BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

Blackburn with Darwen Clinical Commissioning Group Governing Body and East Lancashire Clinical Commissioning Group Governing Body Meeting in Common

The meeting will Wednesday, 13 November 2019, 13:00-15:00 be digitally The ACE Centre, Cross Street, Nelson BB9 7NN recorded AGENDA

PART 1 Item Lead Strategic Report/ Time Objective Category 1 Welcome, Introductions and Chair’s Update Dr R Robinson Verbal 13:00 Chair 2 Patient and Public Involvement 2.1 Patient Story (Prostate Cancer) Mr D Rogers Video 13:05 Presentation 2.2 Public Questions Dr R Robinson Verbal 13:25

3 Governance Arrangements 3.1 Apologies for Absence and Confirmation of Dr R Robinson Verbal Quoracy

3.2 Declarations of Interest Dr R Robinson Verbal Members and Attendees are requested to identify any interests relating specifically to the agenda items (see guide below) and inform the Chair and Governing Body Secretary in advance of the meeting. 3.3 Declarations of Other Business Dr R Robinson Verbal

3.4 Minutes of the previous Governing Body 13:30 Meetings and Matters Arising: a. Blackburn with Darwen Clinical Mr G Burgess Attached Commissioning Group held on 11th September 2019 b. Blackburn with Darwen Clinical Mr G Burgess Attached Commissioning Group Extract from Part 2 held on 11th September 2019 c. Blackburn with Darwen Clinical Mr G Burgess Attached Commissioning Group Annual General Meeting held on 11th September 2019 d. East Lancashire Clinical Commissioning Dr R Robinson Attached Group held on 4th September 2019 e. East Lancashire Clinical Commissioning Dr R Robinson Attached Group Annual General Meeting held on 4th September 2019 3.5 Action Matrix 13:35 a. Blackburn with Darwen Clinical Mr G Burgess Attached Commissioning Group b. East Lancashire Clinical Commissioning Dr R Robinson Attached Group

4 Business 4.1 Integrated Care System Update 13:40 Integrated Care System Strategic Plan Mrs C Richardson Presentation Development 4.2 Integrated Care Partnership Update Mr A Walker To Follow 13:50 Accelerator Report Dr M Dziobon CCG Business 4.3 Joint Chief Officer Report Dr J Higgins Attached 14:00

4.4 Corporate Business Plan Dr J Higgins Attached 14:05

4.5 Performance Report Mr R Parr Attached 14:15

4.6 Finance Report 14:25 a. Blackburn with Darwen Clinical Mr R Parr Attached Commissioning Group b. East Lancashire Clinical Commissioning Mrs K Hollis Attached Group 4.7 Quality Assurance Report Mrs K Hollis To Follow 14:35

Blackburn with Darwen Clinical Commissioning Group Specific Business No specific items East Lancashire Clinical Commissioning Group Specific Business No specific items 5 Reports Presented for Information 5.1 Safeguarding Annual Update Mrs D Ross Presentation 14:40 Mrs S Clarke 5.2 Sub Committee Summary and Stakeholder 14:55 Minutes a. Blackburn with Darwen Clinical Attached Commissioning Group Mrs D Atkinson b. East Lancashire Clinical Commissioning Attached Group 5.3 Accident and Emergency Delivery Board Mr A Walker Attached Chair’s Report 5.4 Pennine Lancashire Emergency Preparedness Mrs K Hollis Attached Submission Blackburn with Darwen Clinical Commissioning Group Specific Item 5.5 Blackburn with Darwen Health and Well-Being Prof D Harrison Attached Annual Report 2018/19 6 Any Other Business 6.1 Items for inclusion on the Corporate Risk Register

7 Date and Time of Next Meeting Wednesday, 15 January 2020, 13:00 hrs Meeting Rooms 1 and 2 at Blackburn Central Library, Town Hall Street, Blackburn BB2 1AG RESOLUTION “That representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.” (Section 1[2] Public Bodies (Admission to Meetings) Act 1960.

Types of Interest Type of Description Interest Financial This is where an individual may get direct financial benefits from the consequences of a Interests commissioning decision. This could, for example, include being:  A director, including a non-executive director, or senior employee in a private company or public limited company or other organisation which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations;  A shareholder (or similar owner interests), a partner or owner of a private or not-for- profit company, business, partnership or consultancy which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations.  A management consultant for a provider;  In secondary employment (see paragraph 56 to 57);  In receipt of secondary income from a provider;  In receipt of a grant from a provider;  In receipt of any payments (for example honoraria, one off payments, day allowances or travel or subsistence) from a provider  In receipt of research funding, including grants that may be received by the individual or any organisation in which they have an interest or role; and  Having a pension that is funded by a provider (where the value of this might be affected by the success or failure of the provider). Non- This is where an individual may obtain a non-financial professional benefit from the Financial consequences of a commissioning decision, such as increasing their professional Professional reputation or status or promoting their professional career. This may, for example, include Interests situations where the individual is:  An advocate for a particular group of patients;  A GP with special interests e.g., in dermatology, acupuncture etc.  A member of a particular specialist professional body (although routine GP membership of the RCGP, BMA or a medical defence organisation would not usually by itself amount to an interest which needed to be declared);  An advisor for Care Quality Commission (CQC) or National Institute for Health and Care Excellence (NICE);  A medical researcher. Non- This is where an individual may benefit personally in ways which are not directly linked to Financial their professional career and do not give rise to a direct financial benefit. This could Personal include, for example, where the individual is: Interests  A voluntary sector champion for a provider;  A volunteer for a provider;  A member of a voluntary sector board or has any other position of authority in or connection with a voluntary sector organisation;  Suffering from a particular condition requiring individually funded treatment;  A member of a lobby or pressure groups with an interest in health. Indirect This is where an individual has a close association with an individual who has a financial Interests interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision (as those categories are described above). For example, this should include:  Spouse / partner;  Close relative e.g., parent, grandparent, child, grandchild or sibling;  Close friend;  Business partner.

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

Item 2.1 Patient Story: Lloyd Pinder: Prostate Cancer

Briefing Notes for Governing Body Members

In the UK, prostate cancer is the most common cancer in men. Across the country, there are more than 333,500 men living with and beyond the disease. Many are dealing with serious side effects from treatment.

Movember is an annual event involving the growing of moustaches during the month of November to raise awareness of men's health issues, such as prostate cancer, testicular cancer, and men's suicide. The Movember Foundation runs the Movember charity event, housed at Movember.com. The CCG actively promotes Movember throughout November!

For prostate cancer this means Movember is about helping men, and their families and friends to know the signs, symptoms and risk factors to ensure early diagnosis, treatment and better outcomes, as well as prevention.

In this video, having been diagnosed with advanced prostate cancer, Lloyd Pinder records his determination to outlive his prognosis for the sake of his young daughters and to help other men avoid his fate.

Key statistics

 Around 363,000 new cancer cases in the UK every year, that's more than 990 every day (2014-2016).  Every two minutes someone in the UK is diagnosed with cancer.  Breast, prostate, lung and bowel cancers together accounted for over half (53%) of all new cancer cases in the UK in 2016.  In males in the UK, prostate cancer is the 2nd most common cause of cancer death.  Incidence rates for all cancers combined in the UK are highest in people aged 85 to 89 (2014-2016).  Over the last decade, prostate cancer incidence rates have increased by around a twentieth (4%) in males in the UK  Around 4 in 10 prostate cancer cases are diagnosed at a late stage in England (2014)  Prostate cancer in England is less common in males living in the most deprived areas  Prostate cancer is most common in Black males, then White males and least common in Asian males  An estimated 280,500 men who had previously been diagnosed with prostate cancer were alive in the UK at the end of 2010

Diagnosis and Treatment

 'Two-week wait' is the most common route to diagnosing prostate cancer  GP referral is the route with the highest proportion of cases diagnosed at an early stage, for prostate cancer  Prostate cancer: diagnosis and management: NICE guideline [NG131]: May 2019  Rapid diagnostic and assessment pathways – Implementing a timed prostate cancer diagnostic pathway (A handbook for local heath and care systems: April 2018: NHSE)

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

 L & SC Cancer Alliance Prostate Pathway: guiding principles (Draft as of October 2019)  Urology NSSG adopting a unified Urgent Referral template for Suspected Urology Cancer (preferred proforma)

New developments at ELHT, in Pennine Lancashire

 One-stop clinic for prostate patients incorporating OP/MRI/TRUSS Biopsy to reduce time to diagnosis and treatment  Clinically agreed protocols for Supported Self-Management Follow-up (SSMFU) for management of stable prostate cancer patients (Draft/Urology NSSG))  Implementation of new procedure – Precision Biopsy, work in progress to identify clinic space and to train clinicians, move from theatre procedure to OPD

Current service provision at ELHT, in Pennine Lancashire

 ELHT have introduced Clinical Nurse Specialist (CNS) follow up for patients as a precursor to Prostate SSMFU: CNS led clinics for; o after radical Prostatectomy o watchful waiting patients o hormone treatment o following radical radiotherapy  E-Books in draft stage to support patients undergoing Robotic Prostatectomy and Radiotherapy for Prostate Cancer

Challenges for commissioners and clinicians:

• Assessing a man’s risk of developing prostate cancer during his lifetime • Understanding whether or not a man is at high risk of the disease • Whether a man should have a test for prostate cancer? (PSA test is not very accurate) • Differential diagnosis and prognosis of aggressive versus non-aggressive cancer. • Should prostate cancer be treated? What treatment should a man have? • The main clinical conundrum for prostate cancer is the pros and cons of PSA testing. Certainly if men have lower urinary tract symptoms a GP should check the PSA and examine the prostate. The challenge comes if a man asks for a test without symptoms. Often this is based on a friend or family members experience and the patient is actually trying to take responsibility for their own health. The medical evidence however is that testing PSA for asymptomatic patients does not save lives. It may pick up more cancers but also subjects men to unwarranted treatments and side effects.

Publicity

An article was published in the Lancs Telegraph around early detection for prostate cancer. https://www.lancashiretelegraph.co.uk/news/18014577.early-detection-key-surviving- prostate-cancer-doctors-warn/?ref=twtrec

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Subject to approval at the next meeting

CLINICAL COMMISSIONING GROUP (CCG) Item 3.4a Minutes of the Governing Body (GB) Meeting held on Wednesday 11th September 2019 at 1 p.m. in Rooms 1 and 2, Blackburn Central Library, Town Hall Street, Blackburn, BB2 1AG PRESENT: Mr Graham Burgess Chair Dr John Randall General Practitioner (GP) Executive Member (Vice Chair) Mr Roger Parr Chief Finance Officer/Deputy Chief Officer Mrs Claire Richardson Director of Population Strategy and Transformation Dr Penny Morris Medical Director Mrs Kathryn Lord Director of Quality and Chief Nurse Dr Zaki Patel GP Executive Member Dr Adam Black GP Executive Member Dr Geraint Jones Secondary Care Doctor (Retired) Dr Nigel Horsfield Lay Member Mr Paul Hinnigan Lay Member – Governance

IN ATTENDANCE: Mr Alex Walker Director of Performance and Delivery, EL CCG Mrs Kirsty Hollis Chief Finance Officer/Deputy Chief Officer, EL CCG Dr Gifford Kerr Consultant in Public Health, Blackburn with Darwen Borough Council (BwD BC) (representing Professor Dominic Harrison) Mrs Debra Atkinson Head of Corporate Business, EL CCG Mrs Pauline Milligan Governing Body Secretary

Min No. Item 19.068 Chair’s Welcome

The Chair opened the meeting by welcoming all attendees and members of the public to the meeting.

19.069 Apologies for Absence and Confirmation of Quoracy

Apologies for absence had been received in respect of the following members:

Dr Julie Higgins, Joint Chief Officer Dr Ridwaan Ahmed, Clinical Director for Quality and Primary Care Dr Preeti Shukla, GP Executive Member Professor Dominic Harrison, Director of Public Health and Well-being, BwD BC.

The Chair also noted that apologies had also been received from Mr Iain Fletcher, Head of Corporate Business.

The meeting was confirmed as quorate. 19.070 Declarations of Interest Relating to Items on the Agenda

The Chair reminded Members of their obligation to declare any interest they may have

on any issues arising at Committee Meetings which might conflict with the business of BwD CCG.

No declarations were made at this point.

Declarations declared by members of the GB are listed in the CCG’s Register of Interests. The Register is available, either via the Secretary to the GB or the CCG website via the following link:

http://www.blackburnwithdarwenccg.nhs.uk/about-us/registers-interests/.

The Chair reminded members that they should, if appropriate, make a declaration should a conflict emerge during the meeting and these would be recorded against the relevant agenda item.

19.071 Questions from Members of the Public

There were no questions from members of the public.

19.072 Minutes of the Meeting held on 10th July 2019

The draft minutes of the meeting on 10th July 2019 were reviewed.

RESOLVED: That the minutes of the meeting held on 10th July 2019 were approved as an accurate record.

19.072.1 Extract from Part 2 of the Minutes of the Meeting held on 10th July 2019

The Extract of Part 2 of the Minutes of the Meeting held on 10th July 2019 was approved as an accurate record.

RESOLVED: That the Extract of Part 2 of the Minutes of the Meeting held on 10th July 2019 was approved as an accurate record.

19.073 Matters Arising/Action Matrix

Matters Arising

There were no Matters Arising which were not listed on the Action Matrix.

19.073.1 Action Matrix

The Action Matrix was reviewed and the following were noted:

Minute 18.026 (ii)/18.075.1/18.096.1/19.007.1 Dr Adam Black provided a verbal update. It was noted that he was not involved in this work, as it had been picked up on a Lancashire wide basis.

Mrs Kathryn Lord informed members that a deep dive into Neurology Services had taken place at the Pennine Lancashire Quality Committee (PLQC) and the minutes and actions from the PLQC would supersede this action. This was agreed. 19.074 Joint Chief Officer’s Report

Mr Roger Parr presented the Joint Chief Officer’s Report in the absence of Dr Higgins. The report provided an overview of work across Healthier Lancashire and South Page 2 of 14

Cumbria (HL&SC) and locally; along with an update on national policy issues.

He drew members’ attention to key items:

 Joint Committee of CCGs;  Advancing Integration;  Better Care Fund Planning;  Lancashire Special Educational Needs and Disability (SEND) Partnership Board;  Journey to Integration;  Patient and Public Involvement;  Policy Updates.

Questions and answers followed.

The Chair referred to the Tripartite work between the CCG, EL CCG and East Lancashire Hospitals NHS Trust (ELHT). He informed members that senior leaders of the organisations planned to meet within the next few weeks to discuss the next phase of the work towards integration and would keep the GB informed of progress.

Mr Paul Hinnigan requested an update on progress in relation to the review of the Integrated Care System (ICS) governance and a formally agreed financial risk sharing agreement and shared single control total.

Mr Parr responded that there was currently no formal agreement in relation to a shared single control total. However, there were governance arrangements in place that allowed the CCG to work with its partners to respond to pressures within the system.

Mrs Kirsty Hollis added that the ICS was being performance managed by the regulators against the delivery of the overall L&SC single control total and, if one of the Integrated Care Partnerships (ICPs) was off plan against the delivery of its single control total, each ICP would take a share of the associated risk in line with guidance from the regulators.

Mrs Claire Richardson explained that some of the points made may be addressed in the Single L&SC ICS Strategy Delivery Plan.

Following a question from Dr John Randall about the Better Care Fund (BCF), Mr Parr explained the purpose of the BCF and how it was used by the CCGs and Local Authorities for integration and transformation.

Mrs Hollis informed members that the next SEND re-inspection in EL was due prior to 25th October. She stated that colleagues were already working to support the next inspection and would be given notice of the inspection 10 days prior.

RESOLVED: That the GB members noted the content of the report.

19.075 Integrated Care Partnership Priorities

Mrs Richardson delivered a presentation on ICP Priorities in order to provide members with an update on the Pennine Lancashire (PL) response to the NHS Long Term Plan (LTP) requirements.

She reminded members of some of the key themes from the LTP. Technical guidance was still being received and the first submission was due by the end of the week. Page 3 of 14

There were still some planning unknowns but it was clear that ICPs were expected to:

 standardised models of care across the NHS with a new delivery model;  focus on Primary Care Networks (PCNs) and neighbourhoods;  maximise resources, whilst improving patient experience and outcomes;  focus on prevention and early intervention;  move towards collaboration, rather than commissioner/provider split.

ICSs were expected to develop, on behalf of their constituent organisations, a 5 year strategy that was:

 clinically led and locally owned;  included workforce, activity and finance;  focused on health inequalities and variation.

Mrs Richardson explained that, for PL, work was progressing towards the establishment of an ICP.

She outlined the planning requirements for PL at ICS level:

 A single L&SC ICS Strategy Delivery Plan: o Describes the 5 year strategy of the ICS and how it will deliver the LTP; 5 year ambitions for transformational change, including interactions between finance, activity and workforce, quality and performance;  Data and metrics: o Setting out 5 year plans at ICS level for finance, activity and workforce; o 5 year trajectories at ICS level for metrics outlined within the LTP;  ICS level assumptions: o Finance, activity and workforce assumptions being developed for ICS wide system change priorities by clinical leads – these will need to be adopted by ICPs.

Mrs Richardson highlighted the PL planning response and referred to the Pennine Plan, which was signed off by the PL GBs last year. The planning requirements and responses were:

 Outline and plan for achieving key transformation priorities: o Refreshed Pennine Plan priorities and year 1 Interim Delivery Plan developed – ICP mirroring CCG/ELHT plans; o Clinical priorities being confirmed via Medial Directors’ Group; o Strategic narrative revised confirming key delivery priorities; o Population Health Management (PHM) approach in development.  System development activities: o Initial Tripartite Board convened to consider direction of travel; o Gateways and building blocks in development;  Key assumptions and supporting narrative for finance, activity and workforce plans: o 2018 System planning assumptions being revised and updated; o Pennine System Planning Group re-convened, meeting weekly – finance, Business Intelligence, workforce.  System financial management: o System Resources Group and System Sustainability Group established to achieve financial control totals and deliver actions to achieve financial sustainability.

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Mrs Richardson displayed an infographic and explained the development of a PL Model of Care; based on the Pennine Plan.

She outlined the key transformation priorities and areas of focus in relation to:

 PHM;  Prevention;  Integrated Community Care;  Urgent and Emergency Care;  Scheduled Care,  Mental Health and Well-being;  Clinical Pathways.

Mrs Richardson referred to the PL system development approach and explained how the CCG would develop the health offer via a stronger alliance with system partners and communities.

She outlined next steps:

 Finalise ICP strategic narrative;  Activity, workforce and finance modelling: o ICS planning assumptions; o ICP commissioner and provider plans.  ICS clinical priority setting;  Staged submissions – 26th September and 15th November.

Questions and answers followed.

Members discussed the shifting left of resources and if it was realistic to reduce secondary care sector spend over a period of time. A discussion followed about potential future investment in primary and community care and how this could transform care; led by the development of the PCNs and neighbourhoods.

RESOLVED: That the GB accepted and noted the update and agreed to receive further detail, which would be provided at the Development Session in October.

19.076 Clinical Commissioning Group Annual Assessment 2018/19

Mr Parr presented the report, which formally informed members of the results of the CCG’s NHS England Annual Assessment for 2018/19 against the indicators in the CCG Improvement and Assessment Framework.

He was pleased to report that the CCG had retained its ‘good’ rating, with the Quality of Leadership and Finance indicators rated as ‘green’.

A formal letter from the Chair and Chief Officer had been sent to all staff thanking them for their efforts and work during the course of the year.

Areas of good practice had been highlighted in the formal notification from NHS England and Improvement and there were also details of key areas for improvement. He explained that the key areas of improvement aligned with the CCG’s priorities and workstreams over the next year.

Questions and answers followed. Page 5 of 14

ACTION: Following an enquiry from Dr Nigel Horsfield, Mr Parr agreed to explore if detailed parameters of the scoring were available.

The Chair congratulated colleagues at EL CCG who had also achieved a ‘good’ rating.

RESOLVED: That the GB received the report and noted the headline rating of ‘good’ for the CCG.

19.077 Governing Body Assurance Framework Update

Mrs Hollis presented the report and reminded members that, as part of the work to align the corporate functions, it had been agreed to align the PL CCGs’ Risk Management Strategies and Policies.

She explained that one of the major differences in the two strategies was how the risks were reported in the individual Governing Body Assurance Frameworks (GBAFs). She stated that only those risks that were directly aligned to the existing BwD Corporate Objectives were recorded in BwD’s GBAF; whereas, in EL, all the risks that were scored at a risk rating of 15 or above were escalated to the GBAF, i.e. those that were considered to be the most serious and have the most potential impact.

She reminded members that the two CCGs had recently agreed a set of Corporate Objectives 2019/20 and this could mean that the existing risks reported on BwD’s GBAF were not aligned to the new corporate objective risks.

Mrs Hollis requested that the GB agree to delegate a review of the risks on the BwD GBAF to the PL Risk Management Assurance Group and to recommend to the PLQC a set of actions. These would determine whether, under the revised Risk Management Strategy, the risk rating meant they were retained as GBAF risks or were downgraded and held on the Corporate Risk Register.

She pointed out that, of the 6 existing risks on the GBAF, only 2 would currently score 15 or above and escalate onto the joint GBAF. She assured the GB that there would be an audit trail of the review and decisions made against each risk.

Questions and answers followed.

RESOLVED: That the GB agreed to:

i. noted the content of the report; ii. supported the work underway to align the GBAF risks across both CCGs; iii. identify any further risks which may prevent the achievement of the CCG’s Corporate Objectives. 19.078 Chief Finance Officer’s Report

Mr Parr presented the month 4 report.

He confirmed that the current year to date position was on plan and, whilst it was early in the financial year, the CCG was continuing to forecast a year end on plan position.

There were pressures within the system in acute, physical and mental health services and these were managed with partners.

The CCG was reporting a slight overspend of £87k in commissioned services and

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some of this pressure was due to referrals to hospitals outside PL.

There was a slight underspend of £8k in Primary Care Services.

The CCG continued to manage risk; however there was a small element of the Quality, Innovation, Productivity and Prevention (QIPP) target still unidentified and the CCG was working towards closing the gap.

He reported that the CCG’s main provider was currently underspending against the contract. Continuing Healthcare and complex packages continued to be a key risk, as these were generally high cost and low volume. Prescribing expenditure was currently volatile and the CCG was working with the GP Federation to expand the number of practices that were part of the prescribing hub, to reduce waste and to sustain the progress that had already been made.

Dr Randall raised a point relating to the unavailability of some medicines, e.g. Hormone Therapy Treatment and increased requests from patients to prescribe alternatives.

Dr Gifford Kerr provided an update on plans in terms of the potential impact of influenza on the system this winter. Mr Parr added that the CCG would continue its efforts to increase ‘flu vaccination rates. Dr Black highlighted some of the difficulties faced by GPs in obtaining the recommended ‘flu vaccine.

Dr Zaki Patel referred to the problem of pork-based gelatine being used as a stabiliser in the ‘flu vaccines, which was an issue for some patients. The issue had still not been solved and he suggested that, in order to encourage an increased uptake of the vaccination, it needed to be addressed. He queried if the national decision to allow Pharmacies to provided ‘flu vaccinations had increased uptake and wondered if many patients would have already had their vaccination by the time the GP Practices received their deliveries due to the Pharmacies receiving their vaccines more quickly.

The Chair responded that the he was did not think that action could be taken in relation to the Pharmacies receiving their deliveries quicker than the GP Practices but he was aware that Dr Pervez Muzaffar, GP Engagement Lead, had been working with the Lancashire Council of Mosques and schools to increase awareness about the content of the vaccine.

ACTION: Members to submit any suggestions to solve the issues and increase the update of ‘flu vaccination to Mrs Lord for her to feed into the ‘Flu Coordination Group.

Questions and answers followed.

RESOLVED: That the GB members present noted the contents of the financial summary and financial position of the CCG at the end of July 2019.

19.079 Performance Report

Mr Parr presented the contracting section of the month 3 report and then deferred to Mrs Lord to highlight the key points related to quality and performance.

Mr Parr highlighted the following:

Lancashire Care NHS Foundation Trust (LCFT) Mental Health Services (MHS) (page

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3):  Psychological Therapies – Mr Parr reported that CCG was slightly behind the Improving Access to Psychological Therapies (IAPT) target;  Referrals – down compared to the previous year;  Admissions – slightly above plan;  Out of Area Placements (OAPs) – were still high; however, there was a trajectory for recovery and a lot of work taking place with the provider to improve the position on QAPs and 12 Hour breaches.

ELHT (page 6):  Elective activity – on plan;  Non-Elective Admissions (including non-emergency) – under plan. However, there was an over performance against plan in relation to Accident and Emergency (A&E) attendances.

LCFT Community Services (page 10):  4 of the CCG’s services lines were over performing and 5 were underperforming.

Other Providers (page 12):  BMI – a small underspend against plan was reported.

Mrs Lord highlighted the following:

LCFT MHS (page 3):  Early Intervention in Psychosis (EIP) – the 2 week target of 56% was not achieved by LCFT at 44.44%. The CCG achieved the target at 66.67%;  Attention Deficit Hyperactivity Disorder (ADHD) Service – there were still long waits within the service;  Memory Assessment Service (MAS) – performance against the access within 6 weeks target for the CCG still continued to be poor at 34.28% against a target of 70%. There were staffing and workforce issues in the service.  Improving Access to IAPT Prevalence – the monthly target of 1.58% for June 2019 was not achieved by LCFT at 1.41%. The CCG achieved the target at 1.60%.

ELHT (page 6):  Referral to Treatment (RTT) – the performance had deteriorated to 89.3% for the Trust and 88.9% for the CCG against a target of 92%;  A&E 12 Hour Breaches – there were 8 breaches in June. Bed availability continued to be the primary cause of delay.

LCFT Community Services (page 10): Mrs Lord informed members that the CCG had been advised of several data input errors and migration issues as a result of the recent implementation of the RiO Patient Administration System (PAS) in June 2019. She explained that the data was being refreshed and revalidated and advised that some of it may change.

Questions and answers followed.

ACTION: Following a question from Mr Paul Hinnigan, Mr Parr agreed to consider including an explanation for fluctuations in ELHT activity, e.g. a rise of 14.3% in the number of outpatient first attendances and 27.2% in outpatient follow-up attendances, in order to improve understanding of the data.

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Mr Hinnigan expressed his frustration about the report that there were several data input errors and migration issues in the Community Service figures as a result of the recent implementation of the RiO PAS. He recalled that data errors had regularly occurred over a prolonged period and had still not been satisfactorily addressed.

The Chair enquired if EL CCG colleagues experienced similar errors in the data they received from their provider. Mrs Lord responded that ELHT did supply more consistent, robust, information.

Dr Black suggested that there were different types of data processing systems that could make data analysis reports easier for members to understand. Mr Parr responded that these systems were already used in reports produced for Right Care for example. It was suggested that the use of the systems could be widened to the GB performance reports.

ACTION: Mr Parr to consider the comments made by members and feed into the work to review the content of the Performance Report that was already underway.

RESOLVED: That the GB noted the content of the report and supported the actions as identified.

19.080 Quality Update Report

Mrs Lord presented the Quality Update Report and highlighted key elements:

 World Sepsis Day;  Centralised Outpatients and PAS;  Radiology – Getting it Right First Time (GIRFT);  Quality Improvement;  Northumberland Tyne and Wear Mental Health Pathway Review;  GP Patient Survey;  Friends and Family Test;  Patient Safety Strategy;  First Contact Practitioner for Musculoskeletal.

Questions and answers followed.

ACTION: Mrs Lord agreed to draft and send a letter of congratulations to the staff of the Radiology Department following the successful GIRFT visit to review the services provided.

Dr Geraint Jones raised a point in relation to the age of the some of the equipment in the Radiology Department and how it would be replaced in the future.

Mrs Lord responded that the equipment was linked to the capital replacement programme. Mr Parr added that the CCG would support the lobbying of the system as it looked to replace its equipment.

Drs Black and Randall updated members on the work taking place in the GP Practices in relation to sepsis awareness.

RESOLVED: That the GB noted the content of the report.

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19.081 Governing Body and Sub-Committees’ Terms of Reference

Mrs Debra Atkinson presented the report in the absence of Mr Iain Fletcher.

Following a review of the GB Sub-Committees’ Terms of Reference (ToR) some revisions had been made to reflect the new arrangements following the appointment of a Joint Chief Officer and move to a single Executive Team across the PL CCGs and updated titles to local and national committees and NHS bodies.

Questions and answers followed.

ACTION: Following a comment from Mr Hinnigan, it was agreed that the quorum section (6.4) would be updated to reflect the new Executive titles and the recording of proceedings section (6.7) would be updated to reflect that the meeting recording would be destroyed following the ratification of the meeting minutes. Mrs Pauline Milligan to action.

Mrs Lord referred to the role of the GB Executive Nurse and stated that the voting rights for the role would be reviewed in the future.

RESOLVED: That, following the above amendments being made in line with discussions, the GB received and approved the GB and Sub-Committees ToRs.

19.082 Midlands and Lancashire Commissioning Support Unit Data Migration

Mrs Hollis presented the report, apologised and confirmed that the title of the report should read ‘Midlands and Lancashire Commissioning Support Unit (M&LCSU) Data Migration’ not ‘Mitigation’.

The purpose of the report was to bring to the attention of GB members the intention of the M&LCSU to migrate the storage of the CCGs’ Secondary User Services (SUS) data from a physical server to a cloud based server.

She explained that the use of virtual servers was one of the proposed future mitigations to resolve any issues related to mass Information Technology (IT) outages.

NHS Digital had worked closely with the M&LCSU on the proposal and there were strict criteria and guidelines that a cloud based server provider had to follow. Details of the relevant policy and guidance were attached to the report.

Mrs Hollis drew members’ attention to the reasons for the need to procure an alternative data storage facility and the benefits, in particular:

 The type of data being stored on the cloud would be no different to that already stored on the physical servers;  The way in which the data was processed would be different;  The hardware and software currently being used to support the physical server was becoming out of date and would no longer be supported by the provider;  A full Data Privacy Impact Assessment had been undertaken and reviewed and signed off by the Data Protection Officer (DPO);  NHS Digital had confirmed that the proposal met all necessary requirements for a cloud based server;  The NHS could use cloud based servers that were based within the European Union and the United States of America provided that they were covered by a privacy shield. The proposed hosting area of the cloud based server was within Page 10 of 14

a United Kingdom (UK) cell; with UK west as the secondary region. There would be no data stored outside the UK.

Questions and answers followed.

Dr Randall stressed the importance of ensuring that IT outages were reduced to a minimum in terms of disruption to patient care.

Mr Hinnigan enquired what impact there would be on the CCG if any data was compromised.

Mrs Hollis responded that accountability for data security rested with the service provider.

Dr Penny Morris enquired if there was any risk that data would be lost. Mrs Hollis assured members that there would still be the same data flow; however it would be stored in a different place.

RESOLVED: That the GB:

i. agreed as Data Controller, to be aware of the use of a cloud based storage solution and the processing and controls put into place by M&LCSU as the CCG’s Data Service for Commissioners Regional Office; ii. noted the actions of the Senior Information Risk Owner and DPO to be able to provide the NHS Digital with the required assurance by the deadline of 31 July 2019.

19.083 Communication and Engagement Update

Mrs Hollis presented the report, which provided an update on Communication and Engagement activity over the last quarter, and highlighted key points:

 Preparations for winter and influenza vaccination campaign well underway;  Social media use had increased;  The CCG received a rating of ‘good’ in the annual Integrated Assessment Framework assessment of Patient and Public involvement – a significant improvement on last year,

Mrs Hollis proposed that the CCG thank all staff involved in the work to improve the CCG’s rating. It was noted that work would continue towards improving the CCG’s rating to ‘outstanding’ next year.

She outlined the key priorities for the coming quarter:

 Support the developing PCNs;  Implement and mobilise “community conversations” following approval by Senior managers and Executives;  Plan for delivery of the Pennine Winter Plan.

Questions and answers followed.

The Chair commented that he was pleased to see the increase in social media use and offered congratulations to EL CCG on its achievement of an ‘outstanding’ rating for its annual Integrated Assessment Framework assessment. Page 11 of 14

RESOLVED: That the GB:

i. noted the contents of the report; ii. agreed to feedback any comments or suggestions in relation to communications and engagement activity and comment on future plans; iii. agreed to receive a further report at its joint meeting in November 2019.

19.084 Pennine Lancashire Medical Workforce

Mrs Richardson provided a verbal update.

She informed members that, following previous discussions at GB, a Workforce Summit had been held last week involving a wide range of health professionals.

Discussions had focused on the workforce challenges in the system and possible solutions.

There were some positive discussions and agreement to progress areas such as:

 PCN workforce design – to be coordinated across PL;  North West Ambulance Services – how to bridge the gaps that could be created if colleagues were brought into the PCNs;  Educational learning;  Create a blueprint for GP Practice workforce development;  Different employment models;  Extending education development programme across primary and secondary care;

As part of the LTP submission there was a requirement to develop assumptions in relation to workforce and these would be completed via discussions with the13 PCN Clinical Directors.

RESOLVED: That the GB noted the content of the update.

19.085 Review of Register of Interests

Mrs Atkinson presented the report in the absence of Mr Fletcher, which provided the GB with an update on its Register of Interests (RoI).

GB members had recently been requested to review their Declarations of Interest and the updated register had been presented to the last meeting of the Audit Committee (AC) and published on the CCG’s website.

Questions and answers followed.

Mr Hinnigan reported that the AC had requested that the CCGs’ RoIs were reviewed and aligned in terms of consistency, e.g. the types of interests declared and this work would be fed back to the next meeting of the AC.

RESOLVED: That the GB noted the content of the report. 19.086 Annual Report of the Audit Committee

Mr Hinnigan presented the Annual Report of the AC for 2018/19 for information.

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There were no questions.

RESOLVED: That the GB noted the content of the report.

19.086.1 External Audit Annual Audit Letter

Mr Hinnigan presented the External Audit Annual Audit Letter for the CCG for 2018/19 for information.

There were no questions.

RESOLVED: That the GB noted the content of the letter.

19.087 Blackburn with Darwen Special Educational Needs and Disability Inspection Main Findings

Mrs Richardson presented the report, which provided details of the main findings of the SEND inspection in BwD.

BwD Local Authority and CCG received a letter from the Office for Standards in Education, Children's Services and Skills (Ofsted) in response to the SEND inspection on 2nd August 2019. The letter outlined the main findings from the inspection which took place in June, where inspectors for Ofsted and the Care Quality Commission spoke with children and young people with SEND, parents, carers and staff from BwD BC, schools, education settings and the CCG.

The Inspectors had confirmed that BwD had made considerable progress in implementing the SEND reforms since 2014 and outlined a number of key strengths.

There were also a number of key areas for development and these were particularly in relation to outcomes and experiences of children and their families.

Mrs Richardson confirmed that a deep dive had taken place in relation to speech and language, occupational therapy and psychology services and meetings were taking place to discuss the improved delivery of services.

She concluded that this was a positive outcome for BwD and a reflection of its partnership working.

There were no questions.

The Chair added that there had been a great deal of work undertaken in relation to the inspection and echoed Mrs Richardson’s comments that it was of great credit to the partnership working in the Borough. He thanked all the staff that had been involved.

RESOLVED: That the GB:

i. noted and formally received the letter outlining the outcome of the Joint Local Area SEND inspection in Blackburn with Darwen; ii. noted areas of key strengths and areas of development, particularly in relation to long waits for neurodevelopmental pathways, therapies and some elements of mental health services, identified within the letter; iii. agreed to receive updates in relation to SEND developments, including escalation of risk, via the PLQC and GB.

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19.088 Governing Body Sub-Committees and Groups’ Minutes

Mrs Atkinson presented the report in the absence of Mr Fletcher, which included the minutes of the GB Sub-Committees and Groups for receipt and note by members; to inform the GB of delegated and key decisions taken and provide information regarding items of particular interest or potential risk.

There were no questions.

RESOLVED: That the GB noted the content of the report.

19.089 Any Other Business

No further business was discussed.

19.090 Date and Time of Next Meeting

The next meeting will be held on Wednesday 13th November 2019 at 1 pm at Walshaw House, Regent Street, Nelson BB9 8AS.

The Chair thanked everyone for their attendance and input and the meeting closed.

EXCLUSION OF THE PRESS AND PUBLIC – ‘That representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest’ (Section1(2)Public Bodies(Admission to Meetings)Act 1960).

Signed ………………………………………………. Chair …………………………………….. Date

Page 14 of 14 Subject to approval At the next meeting

Item 3.4b

Extract from Part 2 of the Minutes of the Governing Body (GB) Meeting held on Wednesday 11th September 2019 at 3 p.m. in Rooms 1 and 2, Blackburn Central Library, Town Hall Street, Blackburn, BB2 1AG

PRESENT: Mr Graham Burgess Chair Dr John Randall General Practitioner (GP) Executive Member (Vice Chair) Mr Roger Parr Chief Finance Officer/Deputy Chief Officer Mrs Claire Richardson Director of Population Strategy and Transformation Dr Penny Morris Medical Director Mrs Kathryn Lord Director of Quality and Chief Nurse Dr Zaki Patel GP Executive Member (Part) Dr Adam Black GP Executive Member Dr Geraint Jones Secondary Care Doctor (Retired) Dr Nigel Horsfield Lay Member Mr Paul Hinnigan Lay Member – Governance

IN ATTENDANCE: Mr Alex Walker Director of Performance and Delivery, EL CCG Mrs Kirsty Hollis Chief Finance Officer/Deputy Chief Officer, EL CCG Mrs Debra Atkinson Head of Corporate Business, EL CCG Mrs Caroline Edwards Lead Nurse – Transformation of End of Life Care (Item D/19 only) Mrs Pauline Milligan Governing Body Secretary

Re-Confirmation of Apologies for Absence and Quoracy

Apologies for absence had been received in respect of the following members:

Dr Julie Higgins, Joint Chief Officer Dr Ridwaan Ahmed, Clinical Director for Quality and Primary Care Dr Preeti Shukla, GP Executive Member Professor Dominic Harrison, Director of Public Health and Well-being, Blackburn with Darwen Borough Council.

The Chair also noted that apologies had also been received from Mr Iain Fletcher, Head of Corporate Business.

The meeting was confirmed as quorate.

Re-Confirmation of Declaration of Interests

The Chair reminded Members of their obligation to declare any interest they may have on any issues arising at Committee Meetings which might conflict with the business of Blackburn with Darwen CCG.

Declarations declared by members of the GB are listed in the CCG’s Register of

Interests. The Register was available, either via the Secretary to the GB or the CCG website, via the following link:

http://www.blackburnwithdarwenccg.nhs.uk/about-us/registers-interests/

The Chair noted a financial Conflict of Interest (CoI) declared for all the GPs present for Item C/19 Adult Community Services – Next Steps and Opportunities, due to them receiving services from the current provider. Their declarations were held on the CCG’s Register of Interests. It was agreed that the GPs present could remain in the meeting and take part in discussions.

The Chair reminded members that they should, if appropriate, make a declaration should a conflict emerge during the meeting and these would be recorded against the relevant agenda item.

A/19 Minutes of Part 2 of the Meeting held on 10th July 2019

The Minutes of Part 2 of the Meeting held on 10th July 2019 were reviewed.

RESOLVED: That the Minutes of Part 2 of the Meeting held on 10th July 2019 were approved as an accurate record.

B/19 Matters Arising

No new matters arising were noted:

B/19.1 Action Matrix

The Action Matrix was reviewed.

There were no new actions to update.

C/19 Adult Community Services – Next Steps and Opportunities

The CoI declared at the beginning of the meeting was noted.

Mr Alex Walker presented a paper further to discussions at the GB Development Session in August seeking approval to extend the Community Contract provided by Lancashire Care NHS Foundation Trust (LCFT).

Mr Walker stated that publication of the NHS Long Term Plan (LTP) had reinforced place based integrated care as a system priority and that the integration of primary and community care within the Primary Care Networks (PCNs) was a key focus for the Pennine Lancashire (PL) Integrated Care Partnership (ICP) and the CCG.

The extension of the contract had enabled commissioners to focus on transforming services and build a new, modernised and integrated service offer to meet the needs of communities. There was clear evidence of stronger and more purposeful relationships across primary and community services since the extension of the contract and this was reflected in the progress made.

A further extension of the contract was requested. Mr Walker remarked that there was broad support for the proposal at the last Development Session; with

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a number of associated requirements.

He stated that the recommendation was for the CCG to extend the contract with the existing provider and agreed to accept quarterly updates on progress, issues and risks.

Questions and answers followed.

RESOLVED: That the GB:

i. agreed to extend the contract with the existing provider in line with the EL CCG contract, i.e. to March 2021; ii. request that a further report be brought back to the GB in two months’ time to include milestones and SMART targets, along with community and PCN based engagement that could be measured.

D/19 End of Life Care Performance Measures – Annual Review

The Chair welcomed Mrs Caroline Edwards, who attended for this item and delivered a presentation on the work undertaken across PL over the last 12 months.

She provided data in relation to the death rates across PL, which were slightly lower than the national average (by 0.84% for BwD and 1% for EL) and the predominant causes of death, i.e. cancer, circulatory disease and respiratory disease. 14% of deaths were recorded as those who had dementia listed as an underlying or contributory cause.

Mrs Edwards stated that 75% of deaths were expected/planned for and this meant that 3736 people across PL need care and support towards the end of their lives; however only a third of people who died last year were registered on GP palliative care registers (1602 people – mainly those suffering from cancer). She explained that there was a focus to try and identify those with LTCs and in the last year of life and potentially in the last year of life to be identified at an earlier stage.

She referred to the Place of Death Measure and advised of a major study that had taken place in 2010 that had concluded that 67% of patients would prefer to die at home; however, she advised that a patient’s wishes were the main priority.

She highlighted end of life care profile data produced by Public Health England and the number of deaths in the usual place of residence. The figures demonstrated that the level in BwD was less than the national average and there were also significant variations in the place of death.

She informed members that over the last year across PL there had been an end of life care design transformation process involving feedback from stakeholders and this had informed a refresh of the PL Integrated Health and Social Care Economy End of Life Care Strategy 2018/21. She outlined the priority areas of focus and the ongoing work to meet each of the three priorities, which were:

 Reducing inequalities and ensuring equitable access;  Communication and coordination;

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 Education and training.

Mrs Edwards reiterated that adherence to patient wishes was incorporated in all the priorities.

Questions and answers followed.

RESOLVED: That the GB noted the content of the update.

The Chair thanked Mrs Edwards for her presentation and she left the meeting.

E/19 East Lancashire Medical Services: Contract Extension for Integrated Urgent Care Update

Mr Walker provided a verbal update on the current position in relation to the development of the Integrated Urgent Care System.

He referred to the East Lancashire Medical Services contract and reminded members that there had been an expectation that there would be an update to the GB when the new contract was put in place.

There were no questions.

RESOLVED: That the GB noted the content of the update.

F/19 Pennine Lancashire Clinical Commissioning Groups’ Confidential Provider Update

Mrs Kathryn Lord presented the report, which provided the GB members with a briefing on new provider performance/quality issues that had occurred since the last meeting.

Mrs Lord highlighted key items.

There were no questions.

RESOLVED: That the GB received the report for information purposes.

G/19 Governing Body Sub-Committees and Groups’ Part 2 Minutes

Mrs Debra Atkinson presented the report, in the absence of Mr Iain Fletcher, which included the Part 2 minutes of the Governing Body Sub-Committees and Groups.

The minutes informed members of delegated and key decisions taken and provide information regarding items of particular interest or potential risk.

There were no questions.

Dr Zaki Patel left the meeting. The meeting remained quorate.

RESOLVED: That the GB received and noted the content of the report.

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H/19 Pennine Lancashire Accident and Emergency Delivery Board Report

Mr Parr presented the report for information.

Questions and answers followed.

ACTION: Following an enquiry from Mr Paul Hinnigan, it was agreed that the report could be presented in Part 1 of the next meeting.

RESOLVED: That the GB noted the content of the report.

I/19 System Update

The Chair provided a verbal system update.

RESOLVED: That the GB noted the content of the update.

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Item 3.4c CLINICAL COMMISSIONING GROUP (CCG)

MINUTES OF THE ANNUAL GENERAL MEETING

WEDNESDAY 11TH SEPTEMBER 2018 AT 11.30 A.M. MEETING ROOMS 1 AND 2, BLACKBURN CENTRAL LIBRARY, TOWN HALL STREET, BLACKBURN BB2 1AG

CONTRIBUTORS: Mr Graham Burgess Chair (Chair) Dr Penny Morris Medical Director (PM) Mr Roger Parr Deputy Chief Officer/Chief Finance Officer (RP)

IN ATTENDANCE: Mrs Pauline Milligan Governing Body Secretary (Minutes)

Min No: 19.001 Welcome and Introductions

The Chair welcomed everyone to the CCG’s Annual General Meeting (AGM).

He gave a short brief on items related to the content of the agenda, housekeeping, catering and the audio equipment.

He informed those present that the Joint Chief Officer (CO) had sent her apologies, due to Annual Leave that had been booked in advance.

The Chair remarked that it was a significant achievement for the two Pennine Lancashire (PL) CCGs to come together and appoint a Joint CO. He explained some of the many reasons behind the decision; e.g. to allow the CCGs to begin to establish a consistency of approach in providing treatment and services across PL. He also referred to the financial challenges faced by the NHS and the savings that had been made by appointing one Joint CO across the two CCGs.

He informed those present that the CO had established a single Executive Team and, whilst the two CCGs remained in their respective bases, staff were working together to maximise resources.

The Chair formally recorded his thanks to the Joint CO, Executive Team and all staff for their work and effort over the past year to maintain the high standards of the CCG.

He also thanked all the CCG’s partners for their work over the last year and, in particular, all those who worked in the Voluntary, Community and Faith (VCF) Sector and neighbourhoods; without who the CCG could not support the developments that the NHS Long Term Plan (LTP) outlines.

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19.002 The Year in View

Dr Penny Morris introduced herself and remarked that she was pleased to present The Year in View for 2018/19; as it reminded her of all the hard work that had taken place, and achievements reached, over the last year.

Dr Morris outlined the impacts of the work of the CCG during 2018/19 and its achievements in relation to:

Primary Care Networks The CCG had four Primary Care Networks (PCNs), East Blackburn, West Blackburn, North Blackburn and Darwen. The PCNs had evolved from ‘localities’, established in Blackburn with Darwen (BwD) over a six year period and, following the publication of the NHS LTP, were now referred to as PCNs.

Dr Morris explained how the PCNs had developed from the localities; from work involving the General Practitioner (GP) Practices, the GP Federation, VCF Services and Therapy Services on specific projects relevant to their area; where people could work together to make a difference. This did not necessary involve the significant spending of resources but was more focused on goodwill and collaborative working. She provided several examples of areas where this approach had made a difference, e.g. the increase in uptake in cervical screening in the North PCN following a targeted campaign.

Dr Morris referred to the new GP Contract issued on 1st April 2019, which directed that every GP Practice should offer extended GP access (i.e. appointments in the evenings and weekends) to its patients. This had been established in BwD for the last three years. She explained that every GP Practice in BwD was a member of the long established GP Federation and this had enabled the Federation to work with the Practices to help them work more closely together, reduce inappropriate referrals to hospital and make significant savings in relation to medicines waste.

Dr Morris referred to an infographic that demonstrated the breakdown of the PCNs and those partners and staff members involved in their shared leadership and Integrated Neighbourhood Teams (INTs). She explained that the health needs of each of the PCNs may be different; so members of each of the PCNs met and coordinated care to address the needs of the communities within their PCN. Members of all professions were involved in their area and this approach was referred to as ‘Population Health Management’.

She explained that the Local Integrated Care Partnership, which involved senior representatives of all the partner organisations, was responsible for overseeing the work of the PCNs.

Dr Morris outlined some of the achievements in Primary Care during the year:

 Darwen Healthcare was successful at bringing in extra funding for a new training scheme for Nurses; Page 2 of 10

 Hollins Grove Surgery in Darwen was nominated for The People’s Choice Award: Surgery of the Year;  Darwen Healthcare Assistant Practitioner, Maria Slater, was announced as a finalist in the 2018 RCNi Nurse Awards.

Mental Health Dr Morris highlighted that, across Lancashire and South Cumbria (L&SC), a specialist Mental Health Service had been introduced for new and expectant mothers with significant mental health needs. She explained how the new eight bedded unit would make a positive difference to the care of new mothers and their babies.

She referred to the current redesign of the Child and Adolescent Mental Health Service (CAMHS) and, as part of this work, there had been a series of listening events, involving children, young people and their carers and parents.

A series of educational broadcasts had been arranged via LearnLive to promote awareness of mental health and other conditions such as asthma to children, young people and Teachers in local schools.

Sport England Dr Morris was pleased to inform the meeting that PL was one of twelve Local Delivery pilot areas chosen by Sport England to look at different ways of working with people who would not normally take any exercise. The aim of the pilot was to make it easier, and encourage people, to become healthier and more active. It was also to understand the reasons why people find it hard to be active; working with partners to try new approaches to help change lives. The pilot had meant that £10m of investment would be available over the next few years within PL to progress this work.

Intermediate Care Dr Morris explained that Intermediate Care was provided to patients who were well enough to be discharged from hospital but were not well enough to be discharged home. The focus of the care was to support patients in the interim until they were well enough to be able to go back to their own home, or be supported in the community.

A joint project between the CCG and BwD Borough Council was being undertaken to redevelop Albion Mill, Blackburn, and utilise the facility to deliver Intermediate Care provision for BwD residents.

The £12.5m Albion Mill extra care facility would provide 109 beds, including 50 extra care apartments, 31 en-suite rooms for Intermediate Care, 24 dementia apartments and 4 rehabilitation apartments.

The new home which was scheduled for completion in summer 2020 would provide state of the art facilities for elderly people in BwD.

Hospital Care Dr Morris stated that, this year, saw the introduction of a more efficient electronic referral system for GPs to refer patients to hospital. Page 3 of 10

She explained that, at the point of referral by the GP (particularly if there is a suspicion that the patient’s symptoms may suggest cancer) the patient would be referred under a ‘two week rule’. The referral was submitted during the patient’s GP appointment and would ensure that the patient was assessed within the following period of two weeks.

She reiterated her earlier comments that the CCG had built on the successful introduction of its INTs in each locality and had begun to integrate more services in the community and, in doing so, brought more hospital services closer to people’s homes. In line with NHS LTP, there should be significant investment into this area in the future.

Children and Young People Dr Morris announced that BwD had officially become a ‘breastfeeding friendly’ Borough; supported by the CCG.

She confirmed that, along with BwD Borough Council, the CCG had been successful in a funding bid to tackle childhood obesity.

As previously mentioned, the CCG had broadcast health messages to all schools in PL; with a particular focus on asthma. The broadcasts had shown young people how to prevent, manage and support asthma attacks.

The CCG had also worked closely with children and young people to find out how it could improve mental health services.

Cancer Dr Morris referred to the focus on the treatment of cancer in the NHS LTP; to improve early diagnosis and access to diagnostic investigations and treatment. The CCG had a shared Action Plan with East Lancashire Hospitals NHS Trust to ensure that any necessary improvements were made.

She referred to the CCG’s successful awareness campaign to encourage 25 year old females to have their first smear test for cervical cancer, called “25 it’s time”.

The CCG had also launched a bowel cancer test, which can be used quickly and easily and can rule out bowel cancer.

Dr Neil Smith, the CCG’s Cancer Lead, and his team, had launched a campaign across PL to raise awareness of cancer and the importance of early detection and diagnosis – “Let’s Talk Cancer”. The campaign was already being adopted across L&SC.

Urgent and Emergency Care Dr Morris informed members that the CCG had invested in and supported the establishment of a new purpose built Ambulatory Emergency Care Unit. She explained that the unit would help treat patients with a range of conditions, e.g. low risk chest pain and pulmonary embolism.

The CCG had led a campaign to raise awareness of the importance of influenza Page 4 of 10

immunisation and Dr Morris explained why it was important in terms of urgent and emergency care. She encouraged the audience to have a ‘flu vaccination and to encourage others to do so; especially those in vulnerable groups, e.g. frail elderly, children and those with Long Term Conditions.

Diabetes Dr Morris stated that, across L&SC, patients with certain types of diabetes, who fulfilled particular criteria, now had consistent access to insulin pumps and glucose monitoring devices. This was a significant development in terms of technology and the management of diabetes.

A structured Diabetes Education Programme had been established called EMPOWER (engage, motivate, plan, ownership, wellness, educate, review), designed to help people with Type 2 Diabetes understand what diabetes was, the effect it had on their body and how to make small, achievable changes to the food they eat and their everyday life. The programme, provided by Spirit Healthcare, was being delivered in community venues across BwD and GP Practices now had the option to refer patients living with Type 2 Diabetes.

19.003 Clinical Commissioning Group Annual Assessment

Dr Morris was pleased to announce that the result of the CCG’s Annual Assessment by NHS England for 2018/19 had been reported as ‘good’ (as last year); with Quality of Leadership and Finance being rated as ‘green’.

She commented that the rating was reassuring and the CCG’s regulators had congratulated it on its work to develop supportive and robust arrangements across PL. NHS England also stated that the CCG had shown focus on overall financial delivery and should be commended for its outstanding performance in dementia and diabetes.

19.004 Financial Accounts 2018/19

Mr Roger Parr introduced himself as the CCG’s Chief Finance Officer and provided an overview of the financial reports for 2018/19.

Mr Parr formally thanked the CCG’s Finance and Governance Teams and Midlands and Lancashire Commissioning Support Unit in producing the CCG’s Annual Accounts and Report; the CCG’s Internal and External Auditors for their scrutiny of the CCG’s systems and processes and the Audit Committee, which approved the Annual Report and Accounts on behalf of the Governing Body.

The CCG achieved each of its three statutory financial duties in 2018/19.

He gave an overview of the following in relation to the CCG’s statutory duties:

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Statutory Duties Target Performance Achieved CCG to remain within its revenue £266,463k £266,463k Yes allocation CCG to remain within its running £3,524k £3,396k Yes cost allocation

Better Payment Practice Code Target Number NHS Payables 95.0% 99.4% Non NHS Payables 95.0% 99.7%

Mr Parr explained that the funding the CCG was responsible for was circa £266m. The CCG had hit its target and achieved a break even position. The breakdown of costs was as follows:

Funding £266,463k Commissioning Costs Staff Costs £907k Other Costs £262,744k

Income (£584k)

Running Costs

Staff Costs £1,623k

Other Costs £1,773k Net Expenditure £266,463k Surplus 2018/19 (target £0k) £0k

He drew members’ attention to the investments and developments in 2018/19, which had focused on out of hospital activities:

 Quality Improvement in Primary Care;  Better Care Fund;  Mental Health;  Child and Adolescent Mental Health Services Transformation;  Resilience.

Mr Parr broke down the overall resource of £266m to the expenditure per head of population and that this equated to £1,504 per head. The majority of spend was in acute care at £782 per head (52%). The breakdown was as follows:

Funding £266m £1,504 per head Acute Care £782 (52%) Primary Care £316 (21%) Community Based Care £105 (7%) Mental Health £135 (9%) Continuing Health Care £60 (4%) Other £106 (7%)

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He explained how the funding was broken down and how the CCG planned to reduce its acute spend and bring some services closer to home.

Mr Parr explained that, in order to deliver the CCG’s financial targets, efficiencies had to be made during the course of the year, as the demand and cost of services increased. The uplifts the CCG received did not keep pace with the increase in demand. The funding gap this generated was known as the Quality, Innovation, Productivity and Prevention (QIPP) gap. The target to be delivered peaked in 2017/18 at £8.6m. The target in 2018/19 was £6m and this was achieved.

He referred to the CCG’s financial achievement since its inception:

Financial achievement year on year Target Actual Variance 2013-14 £1,922,000 £1,924,000 £2,000

2014-15 £2,307,000 £2,311,000 £4,000

2015-16 £2,184,000 £1,589,000 -£595,000

2016-17 £2,232,000 £823,000 -£1,409,000

2017-18 £3,632,000 £3,632,000 £0

2018-19 £6,044,000 £6,044,000 £0

Mr Parr highlighted the financial turnaround and balance that the CCG had achieved over the last two years and remarked that this was a result of work, not only by the CCG itself, but by working with it partners.

Mr Parr reported that the CCG had received its financial allocation for 2019/20. He stated that the CCG had financial plans in place to deliver its target; however, there would be a significant challenge this year to deliver its efficiency savings of £6m.

He explained that a specific funding formula was used to calculate the ‘fair share’ allocation for the CCGs. In 2019/20 BwD CCG had received an allocation increase of 5.7%; however the CCG was still 4.02% under its notional ‘fair share’ allocation (£9,709k) in 2019/20. He added that, whilst the CCG was already in a challenged position at the beginning of the year, over the next few years the gap would close as the CCG’s funding would be slightly higher than the national average.

2019/20 Programme Allocation £241,524k Running Cost Allocation £3,505k

Primary Care Co-Commissioning £24,765k

Total Allocation £269,794k

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Mr Parr reported that the CCG would continue to invest in 2019/20 in:

 Primary Care;  Mental Health Five Year Forward View;  Continuing Health Care and Learning Disabilities;  Child and Adolescent Mental Health Services Transformation;  Better Care Fund;  Primary Care Networks.

In order for the CCG to deliver its financial targets the CCG had to undertake various efficiency projects. He highlighted the significant savings made by General Practice and the Medicines Management Team in reducing prescribing costs and medicines waste by £621k in 2018/19, a significant reduction from the previous year.

He highlighted some areas of CCG performance, some of which involved more work and prioritisation by the CCG:

 The reduction in GP referrals; down by 2.7%;  The 18 Week Referral to Treatment Standard had reached 90.3%, however the target (92%) had been missed;  Cancer 62 Day first definitive treatment standard performance was 84.08% against a target of 85%;  The Accident and Emergency (A&E) 4 Hour Standard performance was 80.0% against a target of 95%;

He concluded his presentation of the CCG’s activity and financial performance in 2018/19.

19.005 Questions and Any Other Business

The Chair thanked Dr Morris and Mr Parr and summarised that the presentations had highlighted a good level of performance in many areas; however, there were still some challenges to be faced and areas where improvements could be made.

He invited questions or comments from the audience.

Q/C I am amazed at how far we have come. From the very first meeting there have been real arguments and debates about how to save money and I’m glad to say that you have listened to what the public had to say as well as some of the GPs. I applaud Dr Morris for what she has done and would like to ask Mr Parr how long he has been doing this in BwD?

RP I came to BwD in 2010. I came to the Primary Care Trust and then transferred into the CCG through the national changes.

Q/C In all honesty in the very beginning it was hard going. I applaud you all for what you

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have done as a user of the system; it has been really good, thank you.

RP Thank you for your encouragement.

Q/C I am delighted from Dr Morris’s point of view to be able to say that she has been cured of cancer after three years. I am surprised at you putting that message out as I was always told that you should never consider yourself cured but should consider yourself in remission for at least five years and I thought that was the message that the medical profession tried to put out but I am delighted that you are cured.

PM That is my positivity. There are lots of people in different situations but, unless someone tells me different, I am cured.

Q/C On topic at the moment is the in appropriate prescribing of opiates – is that an issue in BwD and, if it is, what plans have you to tackle that problem?

PM Just to clarify, opiates are very strong painkillers, e.g. Morphine strength painkillers and in BwD we are an outlier for prescriptions of opiate painkillers. The painkillers are very appropriately used for cancer pain but they are also used for patients with chronic pain, e.g. back pain. Patients may say that the painkillers aren’t working and ask for something stronger and are then prescribed very strong painkillers that, if taken in high doses and with other medications, can become a dangerous cocktail of medications. As part of the CCG’s Quality Scheme for this year, there are some initiatives in relation to the appropriate use of medicines and the prescribing of opiate medicines is one of the initiatives, i.e. reducing the amount of prescribing. This will involve training for GP Practice staff. The CCG is aware of the problem and is planning to address.

Q/C My view on this is that people who take opiate medication then become addicted to them. Are we going to deal with the addictions?

PM That is one of the problems that I did not mention, opiates are addictive; even those medicines that are different from Morphine. Part of the education for professionals is how to deal with this problem and the patients who are taking a higher dose of opiates. It will be looking at how to reduce the dosage slowly, safely and effectively as there will be withdrawal symptoms if patients suddenly stop taking the painkillers. It is a big challenge and all aspects of the issue need to be dealt with. There will be patients who need wider help in coming off the painkillers.

Q/C I have just seen that the CCG will be investing 9% into Mental Health Services and I just wondered what exactly are the CCG’s plans for adult mental health; especially the frequent attenders to A&E, as a massive percentage of that is around adult mental health and social issues.

RP Attendances at A&E are significant in terms of how the system responds to them. It is not just patients with mental health issues; some are those who have substance misuse and alcohol problems and may also have a mental health problem. It is importance to recognise the specific issues. The CCG does not commission Substance Misuse Services but it has been working with third sector organisations this Page 9 of 10

financial year and will continue to do so next year to support them with alternative options for frequent A&E attenders. In terms of the investment during this financial year the CCG is looking to support and improve Community Services to prevent patients from reaching a crisis situation. Patients in crisis can be seen in the community, rather than attending an acute facility and being admitted into a mental health bed.

The Chair added that the CCG did work closely with the Local Authority, i.e. its Public Health and Adult Social Care Services, CAMHS, the VCF Sector and the Hospital Trust in a joined up approach across the Borough to provide alternative options.

Dr Adam Black added that some mental health problems could begin in childhood and a lot of work been undertaken to prevent adverse childhood experiences that could lead to adult mental health problems in the future, e.g. safeguarding training for GPs.

19.006 Closing Remarks

The Chair thanked all those present for their attendance. He reflected that it had been a good last year. He thanked all the CCG’s staff for their work over the year and those who had been involved in organising the AGM.

He acknowledged that there were colleagues present from East Lancashire CCG and a number of staff from both CCGs who were now working together as one team across PL.

He thanked all members of the Patient Participation Groups and Voluntary Sector for their work over the last year and the CCG’s Local Authority partners, e.g. those involved in the obesity pilot, those involved in the CAMHS work in schools and those involved in the leisure and sports activity pilots across PL.

The Chair closed the event by saying that, when the CCG holds its AGM next year, it was hoped that it would be able to demonstrate the improvements it had made in the integration of services across PL.

He thanked everyone for their attendance, once again, and hoped to see everyone again next year.

Signed Date

Page 10 of 10

Item 3.4d

East Lancashire CCG Governing Body Minutes of the meeting held on Wednesday, 4 September 2019, 1pm at Walshaw House

PRESENT: Dr Richard Robinson Chair Dr Santhosh Davis GP Clinical Lead - Burnley Dr Mark Dziobon Medical Director Dr Fiona Ford GP Clinical Lead – Hyndburn Kirsty Hollis Chief Finance Officer Kathryn Lord Director of Quality & Chief Nurse - Interim Dr Tom Mackenzie GP Clinical Lead – Rossendale Michelle Pilling Deputy Chair & Lay Member – Quality & Patient Engagement David Swift Lay Member – Governance Dr Paul Taylor Secondary Care Doctor Alex Walker Director of Commissioning Naz Zaman Lay Member – Equality & Inclusion In Attendance: Debra Atkinson Head of Corporate Business Roger Parr Chief Finance Officer, BwD CCG Claire Richardson Director of Population Strategy and Transformation Adele Thornburn Nursing & Quality Manager - shadowing the Director of Quality & Chief Nurse Anne Holden Corporate Administration Manager

Min ACTION Ref: 19:106 Welcome, Introductions & Chair’s Update

The Chair thanked everyone for attending the Governing Body meeting and introductions were made.

19:107 Apologies

Apologies were received from Dr Julie Higgins.

19:108 Patient Story

The Chair confirmed that September is World Sepsis Month and consideration had been given as to how the Governing Body want to recognise this. He felt that many of the Members will have previously met Julie Carmen, a former PCT employee and survivor of sepsis, who is now working with the Sepsis Trust.

Julie was unable to attend the meeting but her story was shared with Members via a video link. Julie explained how a series of everyday communication failures conspired to create delays in her receiving effective treatment. These delays and the resultant risk to her life led to a slower recovery, and in her view were probably avoidable.

Dr Robinson asked what assurance does the Governing Body have that we are doing the right things. In response, Kathryn Lord. Director of Quality &

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Chief Nurse, confirmed that the Quality Team are working with the Trust and are reviewing documentation that is needed to be completed to ensure the coding is correct, as this has been identified as an issue. Discussions have also been ongoing through the PL Quality Committee.

All information is being aligned nationally to ensure there is one consistent pathway. The Sepsis care bundle is currently being reviewed and audited and has been presented to Junior Doctors to raise awareness in terms of screening and the importance of highlight any concerns as soon as symptoms are recognised. Where a death has been attributed to sepsis, there will be a full review.

With reference to primary care, it is important to ensure practices have a named sepsis champion and an educational session would be held to support general practice, noting there currently is a lot of work ongoing locally.

Michelle Pilling thanked Kathryn for her update. She pointed out that one of the recent headlines in the Lancashire Telegraph highlighted that the numbers of deaths from sepsis are higher than expected over the last six years. She asked if deaths from sepsis are rising, and if so, what is attributable. It was considered that an area for concern is ambulance conveyance time.

Paul Taylor referred to his previous role as Consultant Radiologist in Acute medicine where he was dealing with many different cases. He dealt with many cases of sepsis and made a number of points, particularly that there was no mention of sepsis ten years ago and cases were not recorded, recognising that the method of recording has now changed. He felt there is a need to be clear that every case is caused by delayed diagnosis and the Sepsis Bundle has to ensure people question at an early stage - is it sepsis?

Kathryn outlined next steps and provided assurance that the process will be monitored, with structured reviews received through the PL Quality Committee.

Dr Ford referred to named champions in primary care, as she had not seen any drive for this and asked if they have the necessary training to manage.

The Chair also asked if there are processes for recognising sepsis in the nursing and care homes. Adele Thornburn, Nursing & Quality Manager confirmed that the Regulated Care Sector have a comprehensive educational programme, part of which is recognising early detection and supporting carers to recognise when something is different. Adele advised there is a good relationship with ELHT and their training department and an education programme is also provided through Lancashire County Council’s Infection Prevention Team, dedicated to recognise early symptoms.

The Chair thanked Kathryn Lord and Adele Thornburn for their input to the patient story and would await further developments regarding primary care training.

19:109 Public Questions

There were no public questions.

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19:110 Governance

. Declarations of Interest : The Chair invited members to declare any interests they may have in relation to items on the agenda. There were no further declarations of interest in addition to those already included on the Conflict of Interest Register. . Quoracy : The meeting was quorate

19:111 Declarations of Other Business

There were no declarations of other business.

19:112 Minutes of the Meeting held on 3 July 2019

The minutes of the meeting held on 3 July 2019 were presented and the following points were made:

. There were amendments required to the members listed as present and apologies; . Min 19:90 : Developing a Shared Strategy across L&SC – the meeting was not quorate and the Chair had agreed to contact those clinicians not present to obtain their views. Dr Robinson confirmed that he had made contact with Dr Ford who had shared her views and made contributions which were included in the CCGs feedback. . Min 19:93 : Finance Report - the penultimate paragraph should read past two years.

RESOLVED: that subject to the above changes, the minutes were approved as an accurate record.

19:113 Action Matrix

18.15 : MH Act 1983 Code of Practice It had previously been agreed to retain this issue on the Action Matrix to ensure LCFT meet this requirement. Alex Walker confirmed there was currently no update and the position would be monitored through the Northumberland, Tyne & Wear (NTW) Review Report and Action Plan.

19.88 : Joint Chief Officer Report David Swift referred to discussions at the July meeting when he had highlighted the need to consider how PCNs will be accountable to the CCG as the statutory body, pointing out this had not transferred to the Action Matrix.

In response, Claire Richardson outlined the current position, confirming that discussions are ongoing with ELHT regarding tripartite development and reviewing governance arrangements, recognising the need to have a mechanism in place for PCNs to report into ICPs .

The issue would be transferred to the Action Matrix. AH The remainder of the Actions were now closed and would be removed from the Matrix.

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19:114 Matters Arising

There were no matters arising.

19:115 Sub Committee & Stakeholder Minutes

Debra Atkinson, Head of Corporate Business presented the report which provided Members with minutes of the Sub Committees of the Governing Body. She drew Members attention to the revised Terms of Reference for the Pennine Lancashire Quality Committee (PLQC) which had been reviewed following difficulties in achieving quoracy in terms of clinical representation, and were presented for ratification.

Michelle Pilling, Chair of the PLQC pointed out there remained some minor changes in terms of membership and role outlines.

David Swift was pleased to confirm that the August meeting of the PL Committees in Committee was quorate on both sides.

RESOLVED: that Members receive the report and, subject to minor amends to the membership role outlines, the PLQC Terms of Reference were approved.

19:116 Joint Chief Officer Report

Kirsty Hollis, Chief Finance Officer and Deputy Chief Officer, presented the report which provided an update on major pieces of work, both nationally and locally. Following on from the Special Educational Needs and Disabilities (SEND) inspection in Blackburn with Darwen (BwD), Inspectors had reported that considerable progress had been made in implementing the SEND reforms since 2014, details of which were outlined in the report, together with key areas for development. It was anticipated a Lancashire SEND inspection was imminent during September and the CCG would be notified 10 days in advance, allowing time to prepare. Kirsty pointed out that based on the learning from the BwD inspection, preparation for the inspection will take a significant amount of officers time.

A review of Integrated Care System (ICS) governance had taken place and a set of recommendations were presented to the ICS Board in July. Further iteration of the proposals had taken place and ICPs had provided feedback, with the final draft being presented to the ICS Board earlier that day. It was understood there was a difference of opinion across ICPs and a Task and Finish Group had been established to discuss further.

A number of Policy updates were included in the report with links to further information. The Chair asked if the links had been shared elsewhere and it DR was agreed to include them in the Staff Bulletin.

Michelle Pilling, Lay Member for Patient & Public Involvement, referred to the update in the report relating to the Integrated Assessment Framework for Patient and Public Involvement (PPI). In the previous year, both BwD and EL CCGs received a rating of ‘requires improvement’. This was an opportunity to review processes and approaches to engagement across both CCGs and significant improvements have been made, resulting in a rating of ‘outstanding’ for EL CCG and ‘good’ for BwD CCG.

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Michelle paid tribute to David Rogers, Head of Communications and Engagement and his small team and acknowledged their hard work to achieve this. She advised that EL CCG is in the top 10% of CCGs rated as outstanding for PPI which was testament to the team and the great work taking place.

RESOLVED: that Members receive the report.

19:117 NHS E – CCG Annual Assessment

Kirsty Hollis presented the report which provided confirmation of the annual assessment for 2018/19 and formally reported that the headline rating for the CCG is Good for the second year running, in accordance with the accountability framework as monitored by NHSE. Given the pressures on the service as a whole, she considered this to be an excellent achievement and thanked all concerned. Members were also advised that the PPI assessment forms part of the overall rating too.

In terms of areas for improvement, Dr Taylor asked if a strategy was in place as to how the CCG will respond. Kirsty advised that all areas identified form part of the ongoing work programme and delivery will be picked up through routine work streams.

RESOLVED: that Members receive the report.

19:118 Governing Body Assurance Framework (GBAF)

In presenting the report, Debra Atkinson confirmed that the GBAF holds risks with a rating of 15 or above, noting that the most recent report was presented to the Pennine Lancashire Quality Committee in July. Scrutiny also takes place through Senior Managers and the Risk Management Compliance Group. Following an Audit by Mersey Internal Audit Agency (MIAA) in July, a number of recommendations were made to provide assurance in terms of management of the GBAF.

Debra confirmed that PL CCGs have agreed a shared set of Corporate Objectives and all risks will be aligned to these. Following a review of all corporate risks, the GBAF currently holds six risks which are held on both registers, with the exception of Risk EL 133 relating to the CSU.

It was confirmed there were no new or closed risks during the reporting period and one risk had reduced in rating and was now held on the Corporate Risk Register.

Work is ongoing across the two CCGs to look at a more streamlined approach in terms of handling and monitor risk, with the intention of adopting a tool used in the ICS to ensure a consistent framework.

Discussion followed and it was confirmed that risks that have been on the Register for some time have work streams linked to them.

David Swift queried why the risk rating had reduced for the Initial Health Assessments for Looked After Children. In response Debra provided feedback from discussions at the last Risk Management Group when it was confirmed that when the initial risk assessment had been done, the wrong consequence was listed. There was challenge that it sits outside the scoring

Page 5 of 11 Minutes approved by the Chair: 23.10.19

matrix.

David also considered that some of the targets of the remaining risks on the register were not realistic and requested a review of the targets.

He also highlighted two additional risks relating to the current financial position and the unknown risks associated with Brexit. It was confirmed that both are included on the Corporate Risk Register as they are rated at a lower level.

RESOLVED: that Members receive the report.

19:119 Midlands & Lancashire CSU Data Mitigation

In presenting the report, Kirsty apologised out that the title of the report should be Data Migration and not Data Mitigation.

The report described how the Midlands & Lancashire Commissioning Support Unit (MLCSU) and NHS Digital disseminate and store personal identifiable information and to advise Members of the intention to change the way that data flows from NHS Digital and the CSU and how it is stored.

Kirsty confirmed that data is currently stored on a server, however the hardware is out of date and will not be supported by Microsoft and would incur significant costs to replace. In conjunction with NHS Digital, the proposal is to move to a cloud based solution.

Kirsty has worked with the Information Governance Team and the Data Protection Officer who have been reviewing the information on behalf of the CCG and have provided assurance that all standards have been met. In her role as Senior Information Responsible Officer (SIRO) for both BwD and EL CCGs, Kirsty had provided NHS Digital with assurance, and her statement was outlined at Para 4.2 of the report.

Dr Taylor referred to Annex 2 of the report which referred to data sharing between members of the European Economic Area and the United States. It was noted that once the outcome of Brexit is known, the data sharing agreement will be amended at that point. It was also confirmed that the cloud servers will still be UK based.

RESOLVED: supported the recommendations outlined in the report.

19:120 Confirmation of Delegated Actions

Use of the Seal

The report confirmed that the Chief Officer undertook the signing and sealing of legal documents in respect of the following:

. Section 75 Agreement – Integrated Home Response and Falls Lifting Service between: - NHS Chorley & S - South Ribble CCG - NHS East Lancashire CCG - NHS Fylde & Wyre CCG - NHS Greater Preston CCG

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- NHS West Lancashire CCG - NHS Morecambe Bay CCG - Lancashire Teaching Hospitals NHS Foundation Trust - Lancashire County Council

The commitment was through a pooled budget across Lancashire and the project has been managed through the ICS and Urgent and Emergency Care Network. It was a small contribution from the CCGs for a very useful service.

David Swift queried if the CCG can enter into a formal Section 75 agreement with a Provider. It was confirmed that Lancashire Care NHS Foundation Trust will contribute the NHS digital funding, but are not providing the service and commissioning delegation is through the L&SC Clinical Commissioning Board. It was also confirmed that Blackburn with Darwen CCG are not included as Lancashire County Council are leading the procurement of this service, and BwD CCG already have a service in place.

ACTION: Attach relevant documents to future reports regarding use of the AH Seal.

RESOLVED: that Members confirm the delegated actions as outlined.

19:121 Finance Report

Kirsty Hollis, Chief Finance Officer presented the Finance Report for the four month period to 31 July 2019, advising there had been no change from the previous month. The CCG was still forecasting delivery of all statutory duties, although small pressures were starting to build up on non-contracted activity due to a significant influx of people who have fallen ill in other parts of the country.

Kirsty was confident that the CCG can achieve the statutory duties, however was more concerned regarding the ICP position, including EL CCG, BwD CCG and East Lancashire Hospitals Trust. There is a need to undertake further work to understand what their forecast is likely to be at year end and an emerging picture would be provided in October.

Members requested clarity regarding the financial commitment to the Stroke pathway, advising that the Committees in Common supported further investment. It was noted the Resources Group are working with the provider to bring the investment into the envelope that has been provided.

RESOLVED: that Members receive the report.

19:122 Contracts, Quality & Performance Report

Alex Walker, Director of Performance & Delivery presented the report, pointing out that performance is becoming more of a challenge compared to last year. He highlighted the following key areas:

. A&E identified slight improvements but still continues to struggle against trajectory and tracking where we stand compared to others is ongoing. . Referral to Treatment (RTT) is becoming significantly more challenging this year, with more specialties experiencing difficulties.

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The report outlined the work ongoing to address the issues. . 52 week waiters was becoming more of a challenge, particularly regarding Lancashire Teaching Hospitals. . Cancer continues to perform relatively well. It was recognised that work is ongoing in all areas to try to turn the position around as much as possible.

The Chair considered this has been a similar position for some time. He referred to discussions at the last informal meeting regarding the Ambulance Service and asked if the points raised would help to address some of the statistics.

Alex Walker highlighted the importance of understanding our performance across the Category 1 and Category 2 position across PL, working on a broad NW basis with strong L&SC input. Alex considered there are quite radical changes that we have to work through together. There has been a notable reduction in Ambulance conveyances to A&E in our area over the last 2 months, which highlights that changes are being made in the way we are working together. As we develop some alternatives and properly invest in the community, this is where we will start to improve performance.

Michelle Pilling articulated the same challenges experienced in the PL Quality Committee, where measures are deteriorating over a number of years. There is no reflection of the hard work put in by the staff and asked how do we assure ourselves we are making a difference.

The Chair referred to the huge workforce gaps, which will contribute to the position and also have a knock on effect in terms of expenditure on locums etc. To make improvements in the 4 hour target in A&E, it is about primary care being able to work better and offer different services.

David Swift pointed out that NWAS performance has improved month on month but this is not reflected in the report as all areas are RAG rated Red.

Claire Richardson pointed out that the organisation is still accountable for ensuring that performance is as on track as it can be, through Sub Groups and Partnership Groups, and the Governing Body needs to be assured that there are plans in place. She suggested deep dives be shared with GB members where areas are not improving or measures are changing to provide a higher level of detail.

Dr Davis considered that looking into the future things will be different. Commissioning will be more neighbourhood based and PCN orientated with more collaboration across the system, but the quality standards should not be slipping.

It was recognised there are some fundamental problems that cannot be resolved as a health economy and there is a need to look at different ways of working with providers to address areas of concern.

The Chair noted the potential effect on morale to have a sea of Red against the Quality and Performance Measures.

ACTION: There are a number of hot spots that the PL Quality Committee are reviewing and a resume will be shared with GB to understand the AW amount of work ongoing in specific areas with key actions.

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RESOLVED: that Members receive the report.

19:123 Quality Assurance Report

Kathryn Lord, Director of Quality & Chief Nurse presented the report and drew members attention to key points.

As referenced earlier in the meeting, World Sepsis Day is to be held on 13 September 2019 and the CCG has planned communications to raise awareness.

In terms of provider updates, ELHT Centralised Outpatients & Patient Administration Services have won the Public Sector Paperless Award for ‘Best Use of a Digital Solution’ and have also been shortlisted for the ‘Special recognition Award’. The system allows patients to download their appointment letter to their smart phone. At the end of June, this has resulted in 38% of letters being downloaded, avoiding over 210,000 letters being printed.

The Radiology Department was recently involved in a ‘Getting It Right First Time (GIRFT) review. A lot of good practice was demonstrated through the department and Kathryn paid tribute to all the staff involved, particularly during times of significant pressures.

Following the CQC inspection at Lancashire Care NHS Foundation Trust, it was highlighted that there was not enough patient care involvement. The Trust Experience Team are working on this to promote opportunities to collect service user feedback.

The report also outlined the work ongoing in respect of the Northumberland Tyne and Wear (NTW) Mental Health pathway review.

In primary care, the results of the GP Patient Survey 2019 were published in July and the report provided a summary of the outcome. Areas of focus include Improving Access and implementing Care Navigation as a way to manage demand.

Kathryn advised that revised guidance for the Friends and Family Test is expected by April 2020. A webinar was also scheduled for 20 September to outline the benefits of First Contact Practitioner for musculoskeletal (MSK).

The NHS Patient Safety Strategy was launched at the Patient Safety Congress in July 2019 and describes how the NHS will continuously improve patient safety and work is ongoing to build on the foundations of a safer culture across the whole system.

Roger Parr made reference to the NTW report and the recommendation relating to capability commissioning, confirming that the ICS have devised a programme to support this going forward.

GP colleagues also highlighted the importance of leading the way in terms of managing patient safety and incidents. RESOLVED: that Members receive the report.

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19:123 Integrated Care Partnership Priorities

Claire Richardson, Director of Population Strategy and Transformation gave a presentation outlining the current position in relation to the Integrated Care Partnership (ICP) priorities.

The CCG is in currently the middle of the five year planning round, expected to deliver a response to the Long Term Plan (LTP) and is tasked with providing standardised care within a new NHS delivery model, bringing together provider and commissioner functions. She advised that over the coming months the ICS will develop a strategy across Lancashire & South Cumbria (L&SC) for the next 5 years.

The Chief Finance Officer had previously outlined the financial challenges and there will need to be some assumptions across L&SC in terms of developing the strategy. However guidance has now been received and discussions are ongoing in terms of achieving an aligned view. The ICS priorities were considered at the last meeting of the Governing Body and Claire confirmed there was some consistency of feedback from across the ICS.

In terms of the content and context of how to model this going forward and to consider the ICP Planning Response, discussions are ongoing with the Chief Officer, Medical Directors and other Directors and Teams to focus on the things we are going to deliver on, particularly in terms of culture and ways of working. It is also important to ensure the neighbourhoods have the capacity and understand the needs of the system.

Claire made reference to the report received from the Good Governance Institute (GGI) following the Tripartite meeting which highlighted that the direction of travel is working with health partners and wider partners. Two Task and Finish Sub Groups have been established to manage resources and governance.

In reviewing and developing the Pennine Plan, it is important to look at fundamental building blocks and a system development approach, focusing on work with ELHT as to how to do business more effectively, and how to engage better, particularly on intermediate care and neighbourhoods.

In terms of transformational priorities, a number of Programme Boards are becoming established and work is ongoing to look at how to bring teams together and create some tangible work streams.

In terms of next steps, there is a need to finalise the narrative, building on the work already done and including more detail and more indepth discussion would take place at the GB Development Session in October. Claire confirmed there would be staged submissions to the ICS, once the templates have been received. The two Chief Finance Officers would sign off the finances for the first submission on 26 September and the 15 November submission will be signed off at the 13 November GB meeting.

RESOLVED: that Members receive the report.

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19:124 Any Other Business

Items for inclusion on the Corporate Risk Register.

There were no additional items for inclusion on the Corporate Risk Register.

19:125 Date Time of Next Meeting

The next meeting was confirmed as a Meeting in Common with Blackburn with Darwen CCG Governing Body and was to take place on Wednesday, 13 November 2019 at Walshaw House.

David Swift queried whether BwD CCG can hold their public meeting outside their CCG boundary.

RESOLUTION “That representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.” (Section 1[2] Public Bodies (Admission to Meetings) Act 1960.

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Item 3.4e

East Lancashire CCG Governing Body

ANNUAL GENERAL MEETING Minutes of the meeting held on Wednesday, 4 September 2019 11:30pm at Walshaw House

PRESENT: Dr Richard Robinson CCG Chair Dr Santhosh Davis GP Clinical Lead - Burnley Dr Mark Dziobon Medical Director Dr Fiona Ford GP Clinical Lead - Hyndburn Kirsty Hollis Chief Finance Officer Kathryn Lord Director of Quality & Chief Nurse – Interim Dr Tom Mackenzie GP Clinical Lead - Rossendale Michelle Pilling Deputy Chair & Lay Member – Quality & Patient Engagement David Swift Lay Member – Governance Dr Paul Taylor Secondary Care Doctor Alex Walker Director of Performance & Delivery

In Attendance Debra Atkinson Head of Corporate Business Roger Parr Chief Finance Officer/Deputy Chief Officer – BwD CCG Claire Richardson Director of Strategy and Transformation Anne Holden Corporate Administration Manager

Staff, Member Practices and Organisations Represented: Julie Pollard ) Rachel Watkin ) CCG Staff Kath Clarkson ) Afrasiab Anwar Community Team Leader – Ethnic Minority/Gypsy Roma & Traveller Achievement Service, LCC Barbara Marshall Parkinsons UK Dr Naheed Thursby Surgery Tracy Noon Burnley, Pendle & Rossendale CVS Linda Riley M&L CSU Representatives from the Slaidburn Community APOLOGIES: Dr Julie Higgins Joint Chief Officer Naz Zaman Lay Member – Equality & Inclusion

Min Ref: 19:01 Welcome & Introductions

Dr Richard Robinson, Chair of the CCG welcomed everyone to the Annual General Meeting (AGM). The AGM was a statutory meeting and an opportunity to share the CCGs Annual Report and Accounts. He outlined the content of the agenda and confirmed there was an opportunity to ask questions at the end of the meeting. The AGM was to be followed by the formal Governing Body meeting at 1pm which was to be held in public and visitors were invited to attend if they wished. Page 1 of 7 Minutes approved by the Chair : 29.10.19

Dr Robinson advised that he had been in post as Chair of the CCG since September 2018 and had been involved in the recruitment of the Joint Chief Officer following the retirement of Mark Youlton at the end of December 2018. Mark had previously worked in finance roles, joining the CCG as the Chief Finance Officer for three years before becoming the Accountable Officer and Dr Robinson was grateful to him for all his years of service.

The Chair confirmed that Dr Julie Higgins had been appointed as the Joint Chief Officer (CO) for East Lancashire and Blackburn with Darwen CCGs. Dr Higgins has a background in public health and has held a number of senior roles in the North West. She had sent her apologies for the meeting as she was currently on annual leave.

He advised that the CO had established a single Executive Team across the two organisations, to enable closer working and improve services across Pennine Lancashire (PL) for our population, whilst supporting the national ask for CCGs to reduce running costs by 20%.

Whilst the two CCGs remain statutory bodies, Dr Robinson advised that work had now commenced to map meetings across the two organisations, looking at common ground as there is similar geography and both CCGs share an Acute Trust and many of the services. Having a single Executive Team avoids duplication and work is ongoing to look at aligning various sub committees. The Governing Bodies have also started to work jointly in development sessions and in November will hold the first Meeting in Common with the two CCG Governing Bodies.

The NHS Long Term Plan (LTP) also requires CCGs to work in a different way, with closer working with providers, to join up care and avoid duplication and provide a better patient experience. This is work ongoing.

Dr Robinson handed over to Dr Mark Dziobon, Medical Director with the CCG who came into post in January 2019, prior to which he was the Clinical Director for Performance with the CCG.

19:02 The Year in View

Dr Dziobon introduced himself as a GP in Burnley and Medical Director with the CCG. He presented the Year in View for 2018/19 and highlighted achievements and successes during the year, together with areas of business as usual.

Primary Care: . All 53 registered practices achieved an ‘outstanding’ or ‘good’ rating by Care Quality Commission (CQC) which was commendable and a reflection of the good work of general practice colleagues, also testament to the patients who contribute to the ratings. . The CCG has established extended GP access which is a useful addition to our resource of appointments. . Social prescribing offers non-medical support in the community. EL CCG has been at the cutting edge nationally in securing funding and agreeing grants for organisations to provide some of the services in the community. Almost 11,000 patients have benefitted from non-medical interventions, which has had a significant impact on communities. . Across East Lancashire nine Primary Care Networks (PCNs) have been established, with all practices involved. However it was noted that some areas have struggled to do this and it has not been easy for all.

Mental Health: . The CCG has introduced specialist mental health services for new mums, on a Page 2 of 7 Minutes approved by the Chair : 29.10.19

Lancashire & South Cumbria (L&SC) footprint, particularly to support mums at a significant risk of mental health issues following childbirth. . By listening to children and young people, improvements have been made to child and adolescent mental health services and promoting mental health awareness in local schools with LearnLive Educational Broadcasts.

Care Homes: . The CCG is one of six vanguard sites, based in the Pendle area, working closely with Airedale Hospital. It was recognising that a lot of interventions for patients in care homes do not need a hospital visit and the telemedicine platform was introduced, which allows for video consultations between hospital and care homes. . Music therapy for people in care homes with dementia was introduced which has had a massive impact. . Trainee Nurse Associates have also been introduced in the area to create new career paths.

Hospital Care . The CCG has worked with ELHT to develop and introduce a more efficient electronic referral process, resulting in a 99% GP referral rate by electronic means. . A significant success was the introduction of Integrated Neighbourhood Teams in each locality, where a cohort of District Nursing and Allied Health Professional staff are best placed to provide the care required, reducing hospital admissions and a significant boost for our patients. . The CCG has begun to integrate more services in the community, where it makes sense to do so, by bringing more hospital services closer to people’s homes. Work is ongoing with ELHT to progress this.

Children & Young People . A Paediatric Health Hub was introduced in Rossendale, run by Pediatricians’ to reduce hospital trips and bring children’s services closer to home. This has had a significant impact on patients not needing to attend hospital, with very good reports. This was a pilot site and work is ongoing to look at how this can work in other areas and in other disease specialties. . Blackburn Council were successful in a funding bid to tackle childhood obesity. . Health messages have been broadcast to all PL schools with a particular focus on asthma, showing young people how to manage asthma and prevent and support asthma attacks.

Cancer Services . Dr Neil Smith, a GP in Blackburn and the Cancer Lead across Pennine Lancashire led the ‘Lets Talk Cancer’ campaign to raise awareness and highlight the importance of early detection and diagnosis to ensure the right care is received early. Work has also been ongoing to promote awareness around smear tests, encouraging 25 years olds to have a smear. A bowel cancer screening test had also been launched with significant success.

Urgent & Emergency Care . The CCG has invested in and supported the establishment of an Ambulatory Emergency Care Unit, providing specialist intervention for patients to receive same day treatment/diagnosis where this is the right thing for them. . The flu campaign had remained on the CCGs Risk Register all year to ensure it was promoted early, and following a concerted campaign to raise awareness, there was improved uptake.

Diabetes . Patient with diabetes now have consistent access to insulin pumps and glucose Page 3 of 7 Minutes approved by the Chair : 29.10.19

monitoring devices on the NHS and uptake is excellent. A diabetes education programme for people who are at risk of getting diabetes has also proved successful.

As there were no further questions, the Chair thanked Dr Dziobon for his presentation.

He introduced Dr Naheed, a GP at Thursby Surgery in Burnley and Clinical Director for Burnley East Primary Care Network.

Dr Naheed was leading the project closely with Dr Davis, Integrated Care Clinical Lead, looking at a primary care led community approach to frailty.

She described population health management as an approach aimed at improving the physical and mental health outcomes and wellbeing of people, whilst reducing health inequalities within and across a defined population.

Dr Naheed confirmed that Burnley has two Primary Care Networks and a combined patient population of 100,866. There are a number of vulnerable and deprived areas and there is a need for intervention. She described the difficulties experienced in engaging with residents, as they had other issues to worry about, resulting in significant health inequalities. All communities are proud and have a strong sense of belonging.

She advised that an Expression of Interest was put forward and the area was selected to be part of the pilot across Lancashire & South Cumbria (L&SC) to look at population health management. The pilot used a data approach by focusing target interventions on a cohort of specific patients with the aim of improving the overall health of the population.

It was recognised there was no simple pattern and a very complex picture was identified, with people living with a number of long term conditions. A model was developed that is simple, realistic and sustainable to support an ageing population with increased complex needs. She felt this is an approach that can be used across the patch, to enhance existing services rather than creating something new. By connecting with the communities and building resilience, they can take control.

Dr Naheed described the work involved, making particular reference to the work of the Community Connectors. She felt this is the start of an important journey which continues to be work in progress and work is ongoing to evaluate the findings. She highlighted the importance of having knowledge of the community, with the focus being on what makes a difference, and have the links to achieve this. There is also a need to adapt our approach depending on the community. Dr Naheed considered this has been a very interesting and emotional journey and the knowledge gained will be shared with colleagues across the patch.

A number of Peer Support Groups have been established and a short film had been taken at one of the community events where patients outlined what it feels like living with frailty, which was shared at the meeting.

Dr Robinson thanked Dr Naheed for showcasing the work ongoing which was very interesting and invited questions.

One of the Slaidburn residents highlighted the importance of communities, pointing out that Slaidburn is a real community and they do a lot of the things outlined by Dr Naheed for themselves. She highlighted the importance of GPs being part of the community as they know the people and know their needs. The Practice Manager is also part of the community and knows everyone. She pointed out that we have those connections in Slaidburn and we don’t want to lose them. We are those real people with real problems and a lot of what Dr Page 4 of 7 Minutes approved by the Chair : 29.10.19

Naheed describes is transferrable to Slaidburn.

Dr Dziobon responded by saying that as a GP he wanted to acknowledge what had been said, as he is passionate about the job and his patients and knows when they need to be seen. As Medical Director, the threat of closure of any practice, when there is a relationship with the providers and the community which it serves, is deeply saddening. He felt the biggest threat to any practice is the workforce, particularly the lack of GPs and nurses etc.

19:03 CCG Annual Assessment

Following the CCGs Annual Assessment with NHS England, the headline rating for the CCG is Good for the second year running, with the Quality of Leadership and Finance rated as Green. Given the pressures on the system, NHS England said the CCG should be congratulated on the work undertaken in developing supportive and robust arrangements across Pennine Lancashire. The CCG has shown focus on financial delivery overall and should be commended for its outstanding performance in dementia and good in diabetes.

19:04 Presentation of the Annual Report & Accounts 2018/19

Kirsty Hollis, Deputy Chief Officer and Chief Finance Officer introduced herself and was pleased to present the Accounts for 2018/19. She outlined the process, confirming that the Accounts were signed off in May this year, following a rigorous external audit process in terms of how we produce the accounts and ensure value for money.

She described each of the statutory financial duties and was pleased to confirm that all were achieved. In terms of the Better Payment Practice Code where the target is to achieve 95% of all invoices to be paid within 30 days, the CCG had overachieved in this area resulting in performance achieving 99%. She highlighted that this is a good indication if organisations are getting into financial difficulties, pointing out that EL CCG are healthy from a financial perspective.

In terms of NHS E Measures, the CCG delivered a £15.2m surplus. It was noted that £11m was brought forward from the previous Primary Care Trust (PCT) as NHS E would not allow surplus funding to be spent, due to constraints on resources within the NHS. In December 2018 the Governing Body took a decision to deliver an extra £1m of surplus and delivered a total of £16.2m. NHS E have now given permission to utilise £2m of the surplus, which will be used to invest in PCNs to support some of the developments during 2019/20.

Key highlights outlined how the money is spent, with just over 50% spent on acute services. The ambition for Pennine Lancashire is to shift this to invest more in community and primary care services to enable patients to remain in their own homes in their communities.

The Chair thanked Kirsty for her report and invited any questions.

Q: What is the budget going forward? A: Kirsty advised that nationally the NHS plan put an average 5.2% growth into the NHS for 2019/20, but this will reduce over the next few years. EL CCG is considered to be an over target CCG in terms of the allocation, highlighting that our size and our demographic should receive £600m, rather than getting the average 5.2% uplift.

She highlighted the need to create some significant cost improvement programmes, and the CCG is working with partner organisations to ensure the NHS within our footprint remains sustainable, but shift investment to support community services.

Reference was also made to the Lancashire County Council social care budget and health and wellbeing services and the implications from cuts to other budgets that are likely to have Page 5 of 7 Minutes approved by the Chair : 29.10.19

an impact. EL CCG is one of eight CCGs across L&SC and there is a move to aggregate the budgets, resulting in a risk going forward that growth monies may be sliced to support areas that are not doing so well.

19.05 Questions & Any Other Business

Dr Robinson invited questions from members present.

. Is there a published strategy that links to the budgets and the work going forward?

In response, Claire Richardson referred to the discussions about our neighbourhoods, prevention, mental health work and reducing the demand for A&E and inpatient care. She referred to the Pennine Plan which aligns to the NHS Long Term Plan, and builds on the work already done in partnership with other organisations. There is a focus on our community to support our residents across Pennine Lancashire to make the right choices, to reduce pressure in the acute sector.

She confirmed that the Strategy will be developed at a Lancashire & South Cumbria (L&SC) level and as soon as the PL Plan has been agreed it will be published. The timetable for response to the LTP will be published by end November. Claire highlighted the need to engage with the public and co-produce the plans going forward, working through PCNs and with Healthwatch.

. Mrs Barbara Marshall, a volunteer for Parkinson UK and former HV shared her sadness at the demise of her previous role which is now managed by Virgin Care.

The Chair pointed out the contract was awarded by LCC and was not something the CCG have been able to influence.

Claire Richardson advised that part of her role covers Children’s commissioning across PL and involves working closely with the local authority. She advised that funding moved to the local authorities five years ago and the service went out to procurement. As part of the Virgin contract services are aligned to neighbourhoods, bringing HVs and school nurses back into alignment with primary are. She confirmed the CCG has strong relationships with LCC and BwD Council, working with Virgin Care to ensure alignment with those services.

. Mrs Marshall was attending on behalf of Parkinson’s UK and wished to thank the CCG for their support in appointing a Parkinson’s Nurse. She advised that things have changed over the years in terms of support for patients suffering from Parkinson’s and outlined the position regarding her husband who suffers from Parkinson’s. She expressed her concerns that some consultants suggest moving patients to a care home and she highlighted the importance of making patients lives worth living, and was concerned that if they go into hospital mobile, they are less mobile when they are discharged.

The Chair thanked Mrs Marshall for outlining her concerns and further discussion would take place outside the meeting.

Having listened to the points raised, particularly relating to Slaidburn, Health Visiting and Parkinsons, Dr Dziobon felt there was a common theme in that out of hospital services need to be so much more developed. The CCG and other partners are determined to bring about change out of hospital with good community provision.

19.06 Closing Remarks Page 6 of 7 Minutes approved by the Chair : 29.10.19

As there was no further business, Dr Robinson thanked everyone for attending and invited those present to stay for the Governing Body meeting.

Further discussion also took place outside the meeting with the residents of Slaidburn.

Page 7 of 7 Minutes approved by the Chair : 29.10.19

Item 3.5a

GOVERNING BODY (GB) MEETING - ACTION MATRIX PART 1

Action Origins Action Owner Due Date Status GB Ref 19.050 Any Other Business – Measles Vaccination Professor Dominic Harrison agreed to discuss the issue with Dr Gifford Kerr, Consultant in Public Health, produce a DH NOVEMBER VERBAL UPDATE report on the uptake of vaccinations and screening and NOVEMBER MEETING invite a representative of NHS England to attend a future meeting to discuss. 19.064.1 Neighbourhood Level Data/Mapping Tool Professor Dominic Harrison agreed to organise a live interactive joint Pennine Lancashire GB session to DH NOVEMBER VERBAL UPDATE demonstrate the neighbourhood mapping tool and would NOVEMBER MEETING share the link to the tool prior to the session. 19.076 Clinical Commissioning Group Annual Assessment 2018/19 Following an enquiry from Dr Nigel Horsfield, Mr Parr agreed RP NOVEMBER COMPLETED to explore if detailed parameters of the scoring were available. 19.078 Chief Finance Officer’s Report Members to submit any suggestions to solve the issues and increase the update of ‘flu vaccination to Mrs Kathryn Lord ALL NOVEMBER COMPLETED for her to feed into the ‘Flu Coordination Group.

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19.079 (i) Performance Report Following a question from Mr Paul Hinnigan, Mr Parr agreed to consider including an explanation for fluctuations in East RP NOVEMBER COMPLETED Lancashire Hospitals NHS Trust activity, e.g. a rise of 14.3% in the number of outpatient first attendances and 27.2% in outpatient follow-up attendances, in order to improve understanding of the data.

19.079 (ii) Performance Report Mr Parr to consider the comments made by members and feed into the work to review the content of the Performance RP NOVEMBER COMPLETED Report that was already underway.

19.080 Quality Update Report Mrs Lord agreed to draft and send a letter of congratulations to the staff of the Radiology Department following the KL NOVEMBER COMPLETED successful ‘Getting it Right First Time’ visit to review the services provided.

19.081 Governing Body and Sub-Committees’ Terms of Reference Following a comment from Mr Paul Hinnigan, it was agreed that the quorum section (6.4) would be updated to reflect the PMILL NOVEMBER COMPLETED new Executive titles and the recording of proceedings section (6.7) would be updated to reflect that the meeting recording would be destroyed following the ratification of the meeting minutes. Mrs Pauline Milligan to action.

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Item 3.5b NHS EL CCG : Governing Body ACTION MATRIX Version 51

MIN REF: ACTION OWNER COMMENT RAG 22 January 2018 18:15 A&E Delivery Board Chair’s Report – A revised draft protocol has been signed off by the Mental Health MH Act 1983 Code of Practice Oversight Group at STP level. This now needs to go through the . David Swift felt the Code of Practice recommendations governance processes of all organisations for sign off and Alex did not provide assurance that the protocol is in place. AW Walker is leading on this for EL CCG. He requested this should be presented to the statutory 4.6.18: Alex Walker to provide an update via email SM body. 23.7.18: This was to remain amber until ELHT have signed off the Protocol. AW 26.9.18 : Protocol not yet signed off, further enquiries to be made with ELHT. AW 26.11.18 : Protocol to be signed off at the next meeting of the Patient Safety & Risk Assurance Cttee. 28.1.19 : Still in progress – remain on the matrix until complete. 25.3.19 : Ensure this is finalised through ELHT governance processes. AW 21.5.19 : Ensure the protocol has been signed by ELHT – KL 3.7.19 : Concerns expressed that the protocol had not been signed. Action to remain on the Matrix and ensure it aligns with the NTW Action Plan . 4.9.19 : There was currently no update and the position would be monitored through the NTW Review Report & Action Plan. 4 September 2019 19:88 Joint Chief Officer Report – 4.7.19 David Swift highlighted the need to consider how PCNs will CR Discussions are ongoing with ELHT regarding tripartite be accountable to the CCG as the statutory body, pointing development and reviewing governance arrangements, out this had not transferred to the Action Matrix from the recognising the need to have a mechanism in place for PCNs to July meeting. report into ICPs . 19:116 Joint Chief Officer Report A number of Policy updates were included in the report with Links to policy updates are included in the Staff Bulletin links to further information. The Chair asked if the links had DR been shared elsewhere. It was agreed to include them in the Staff Bulletin.

19:120 Use of the Seal . Attach relevant documents to future reports regarding AH Include as and when required. the use of the Seal. 19:122 Performance Report . The PL QC are reviewing a number of hot spots and a The Performance Report has been reviewed and will look at key resume would be shared with the GB to understand the AW areas and provide more detail regarding performance, through amount of work ongoing in specific areas with key both the PL Quality Committee & Governing Body. actions.

BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

Blackburn with Darwen CCG Governing Body & East Lancashire CCG Governing Body Meeting in Common

Lancashire and South Cumbria Integrated Agenda Report Title: Care System 4.1 No: Strategic Plan Development - Update Report Meeting Date: 13 November 2019 Summary of Report: This paper provides an update to the Blackburn with Darwen Clinical Commissioning Group Governing Body and East Lancashire Clinical Commissioning Group Governing Body on the planning process to respond to the NHS Long Term Plan in Lancashire and South Cumbria.

Report Recommendations: Members are asked to: . Note the approach being taken to develop a Strategic Plan for the Lancashire and South Cumbria Integrated Care System . Note the current position and next steps in the process.

Financial Implications: Procurement Implications: Report Category: Tick Support and recommend/forward the report. x Approve the recommendations outlined in the report. Debate the content of the report. Receive the report for information. Author: Lancashire and South Cumbria Integrated Care System Mrs Claire Richardson Presented By: Director of Population Strategy & Transformation

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Lancashire and South Cumbria Integrated Care System Strategic Plan Development - Update Report Background This paper provides an update to the Blackburn with Darwen Clinical Commissioning Group Governing Body and East Lancashire Clinical Commissioning Group Governing Body on the planning process to respond to the NHS Long Term Plan in Lancashire and South Cumbria. The Lancashire & South Cumbria Integrated Care System (ICS) is required nationally to submit an ICS Strategic Plan by the 15th November, in response to the NHS Long Term Plan (LTP) and the local needs of our population over the next five years. The plan comprises three key components; a quantified delivery plan (finance, activity & workforce), a metrics plan based upon performance and outcomes, accompanied by a written strategic narrative. The ICS drafted a set of early partnership priorities called ‘Our Next steps’ which was circulated to CCG Governing Bodies, Provider Trust Boards and Health and Wellbeing Boards in the of Spring 2019 (Appendix 1). This document acknowledged that further work was required by the partners to support the development of the ICS Strategic Plan. In responding to the priorities set out in the Long Term Plan, the current stage of work also builds upon existing plans in each of our local Integrated Care Partnerships to improve outcomes, join up health and care services and make best use of the resources available.

Overview - Vision and Objectives Our vision for Lancashire and South Cumbria is that communities will be healthy and local people will have the best start in life, so they can live and age well. At the heart of this are the following ambitions:  We will have healthy communities  We will have high quality and efficient services  We will have a health and care service that works for everyone, including our staff The ICS Strategic Plan builds upon the eight partnership priorities set out in the ICS ‘Our Next Steps’ document, to agree the ambition and approach to respond to the strategic challenges facing our ICS. The success of the partnership priorities is vital to enable delivery of plans set out across the system. The strategy also sets out the programmes and plans to deliver against the aims and objectives of the NHS Long-Term Plan and to meet the health and wellbeing needs of our local Lancashire & South Cumbria population. Recognising the significant ambitions in the Long Term Plan to improve the health of the population and transform the delivery of health and care services, the process of developing the Strategic Plan is intended to create a clear set of priorities for the partner organisations to pursue over the next five years.

Our Approach The process to create the ICS strategic plan has been taken forward in three key stages of development. These are: 1. First Draft ICS strategic plan submission – 27th September 2019 2. Refinement and modelling of plans – October-mid November 2019 3. Final Draft ICS Strategic Plan submission – 15th November 2019

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It is expected that there will be further iterations of the ICS plan on the basis of feedback from NHS England/Improvement, continued work on finance, activity and workforce plans and updated action plans for the priority programmes in the ICS.

Stage 1. Draft ICS strategic plan submission The first stage is completed, and a draft of all three components of the ICS strategic plan were submitted for review to the NHSEI regional team on the 27th September. Individual CCG and Provider organisations were asked to submit a draft of their finance, activity and workforce plans to confirm the resources under each of these categories. The metrics plan was a mixture of both ICS level and organisational level submissions for performance and outcome measures. In addition, each Integrated Care Partnership/Multi-specialty Community Provider (ICP/MCP) has provided an updated summary of its plans for integrated health and care in each area. Contributions to this first stage of work were also requested from each of the programmes operating across the whole ICS. Understandably, these at varying points in their development. Several programmes are established (e.g. Stroke, Learning Disability) while others are at a much earlier stage of consideration. For these reasons, system leaders agreed to develop the first draft of the Strategic Plan under a “do minimum” scenario, allowing a period to create a baseline position from which to understand where further work would be required to firm up and model ideas into plans. ICS and local leads worked together to agree the baseline assumptions under which this baseline stage of the plans would be drafted. .The developing narrative has identified a number of clear priorities for the ICS partners to take forwards. These can be categorised broadly into three types:

 Service priorities– responding to service commitments in the Long Term Plan and addressing local needs  Enabling priorities – action designed to strengthen the delivery of front line care, promote innovation and workforce development  Efficiency priorities– programmes devised to improve the financial stability of the Lancashire and South Cumbria system

There is a recognition that the system needs to agree priorities over the whole of the five year period – it is not possible to take action on every issue immediately. On this basis, the submission identifies a number of early priorities for action over the next two years as follows:

Category Priority areas

Service Priorities Healthy neighbourhoods, primary and community services Urgent and Emergency Care Cancer Mental health and learning disability Planned Care Maternity Stroke Fragile specialist services

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Enabling Priorities Workforce Prevention and population health Digital Estates Communications and Engagement Leadership and Organisational Development Efficiency Priorities Reducing demand pressures Remodelling outpatient activity Improving operating theatre efficiency Redesigning Musculo-skeletal services Developing Shared Service models

During stage one, colleagues from the NHS England and Improvement (NHSEI) regional team have conducted two checkpoint reviews to oversee and advise on the development of the draft plan. As a result of the work undertaken at stage one, the ICS partners were able to set out an aggregated baseline position across Lancashire & South Cumbria and where further work was required ahead of the next submission. Plans would need to ensure that:

 The ICS can demonstrate how partners will focus resources on improving population health and taking action to reduce health inequalities;  Assumptions about the availability of the health and care workforce are retested;  Partners make a collective commitment to the efficiency priorities set out above;  These proposals are designed to reduce significant financial deficits in the system which are not in line with the ICS financial control total;  There are realistic expectations about the levels of activity required to meet the needs of the population. This work has been agreed for development in stage two.

Stage 2. Refinement and modelling of plans The objective of stage two is to build upon the baseline position established at the end of September. Planning leads are now modelling the impact of our key priorities (service, enabling, efficiency) on expected outcomes as well as the financial, activity and workforce position. Inevitably for some programmes in the early phases of development, it may not be possible to assess the impact in enough detail to meet the final plan submission date but details will be included within the strategic narrative so that the ICS doesn’t lose sight or commitment to these programmes. Further work is required to set out the ambitious nature of the partners’ plans to improve the health of our communities, whilst at the same time being clear about the workforce, finance and demand challenges the system needs to tackle.

Stage 3. Final draft ICS Strategic Plan submission Stage three pulls together the work from stages one and two to produce a final draft ICS strategic plan for submission as part of a national process on the 15th November. This version of the plan will be shared with all partners and submission will be overseen by the ICS Board.

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In addition to these technical submissions, the ICS is also drafting a public summary document outlining the plans for public, patient groups and other stakeholders. As indicated above, it is expected that there will be further iterations of the ICS plan on the basis of feedback from NHS England/Improvement, continued work on finance, activity and workforce plans and updated action plans for the priority programmes in the ICS. This may lead to a further review of the core assumptions in the plan.

Engagement Throughout the development of the ICS Strategic Plan there has been engagement with wider stakeholders (universities, voluntary, community, faith and social enterprise sector, police, local Healthwatch). There has also been extensive direct engagement with staff, patients, public and partners to involve them in plans within each of the five local areas over the past two years. Between May and September 2019, staff from partner organisations were actively involved in discussions regarding the key messages from the ‘Our Next Steps’ document. This included the development of a toolkit of materials to support system leaders, leaders from ICP/MCPs and Primary Care Networks (PCNs) to hold discussions and collate feedback from staff and partner organisations. A survey for staff working in partner organisations (including NHS, local authority and Voluntary, Community Faith and Social Enterprise and education) regarding the partnership priorities and partnership working received 397 responses in August 2019. At a national level, NHSEI commissioned Healthwatch England to undertake an initial engagement exercise to capture insight from local people to contribute to local plans developing across the country. In Lancashire and South Cumbria, the ICS has worked in partnership with Healthwatch Together, a partnership of the four local Healthwatches, to deliver this activity which included surveys and focus groups with 969 local people. The ICS has ensured that the insight independently reported by Healthwatch is being used to shape plans in relevant areas such as mental health, primary care and maternity services. Evidence from the report shows that access, getting the right treatment, receiving care and support at home and security of personal data are all important issues for local people. A programme of an additional 23 targeted focus groups commenced in August 2019, commissioned and co-ordinated by the ICS and delivered in partnership with ICP/MCPs in partnership with the Healthwatch Together partnership. Audiences for this second wave of focus groups were identified based on local need and included hard to reach groups and members of the public involved in neighbourhood development. These have provided valuable local insight on the ICS vision and partnership priorities along with topics identified by ICP/MCPs, or in some areas, our emerging Primary Care Networks (PCNs). This feedback has been received and is contributing to the plan. The ICS has agreed a further 10 more focus groups at the request of ICP/MCPs to continue the ongoing collaborative cycle of engagement.

Collaborative Working The strategic plan development process has demonstrated positive collaborative working and leadership across Lancashire & South Cumbria. This has been reflected in both the development of plans and the decision making to date.

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Focused workshops and events at various intervals have been held and facilitated, both at ICS and ICP/MCP levels to bring together key stakeholders to share their current plans and ideas to support the collaborative development of the strategy. A Clinical Congress was held on the 17th September to bring together senior clinicians from across the ICS to build upon the emerging ICS clinical strategy and support the delivery of the associated programmes. Clinicians were keen to share examples and commitment to joint working particularly where this supports plans for sustainable, safe services, greater efficiency and reduced waste in service delivery and the wider agenda to improve models of prevention and population health. The Congress acknowledged the importance of continued support for clinical leaders working on the priorities emerging from the Long Term Plan.

Delivery and Next Steps This intensive phase of planning activity will continue for the rest of the autumn period as set out in this paper. Going forward, system leaders are working together to ensure that the priorities agreed to deliver the Long Term Plan are taken forwards with a robust approach to governance, decision-making and resourcing. It will also be vital to ensure that for each of the major priorities, an agreed programme management approach to delivery is set out by the ICS partners confirming the work which will take place across the whole system, in each locality and/or neighbourhood. This will support the management of risks and interdependencies as well as providing oversight and assurance across all partners. The next steps in the process are therefore as follows:  Completion of stages two and three for the final ICS Strategic Plan submission;  Publication of a public summary document accompanied by continued communication and engagement activity by all partners in line with the agreed plans;  Development and subsequent application of the common programme management approach. Recommendations The Board is asked to:  Note the approach being taken to develop a Strategic Plan for the Lancashire and South Cumbria Integrated Care System  Note the current position and next steps in the process.

Mrs Claire Richardson Director of Population Strategy and Transformation

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Appendix 1

ICS Partnership Priorities (Our Next Steps)

1. Maximise the benefits of our work in neighbourhoods 2. Deliver an integrated health and social care workforce for the future with the capacity and capability to provide sustainable care and support to our local communities. 3. Strengthen the resilience and mental health of people and communities 4. Establish a group model for all hospital services in Lancashire and South Cumbria 5. Reinvigorate strategic partnerships across the public sector 6. Establish a public sector enterprise and innovation alliance with our ICS partners, including academic partners and Local Enterprise Partnerships to deliver inward investment and support job creation 7. Bring the entire health and social care system back into financial balance 8. Consolidate commissioning so that our arrangements for planning and prioritising our resources improve our population’s health and the outcomes of health and social care

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BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

Blackburn with Darwen CCG Governing Body & East Lancashire CCG Governing Body Meeting in Common

Agenda Report Title: Integration Accelerator Proposals 4.2 No: Meeting Date: 13 November 2019 Summary of Report: The report provides a detailed overview of the proposals to implement the Neighbourhood Integration Accelerator Pathfinder across Pennine Lancashire. Report Recommendations: Members are asked to:  Note the proposal to develop Neighbourhood Integration Accelerator Pathfinders across Pennine Lancashire as outlined in this report.  Endorse this proposal and offer their support to the project going forward, subject to formal agreement by each of the participating organisations. Financial Implications: Procurement Implications: Report Category: Tick Support and recommend/forward the report. Approve the recommendations outlined in the report. x Debate the content of the report. Receive the report for information. Author: Mrs Collette Walsh, Deputy Director of Commissioning

Report supported & approved by your Senior Lead? Y Presented By: Mr Alex Walker, Director of Performance & Delivery Other Committees Partnership Leaders Forum Consulted: Has a PIA been completed in respect of this report? Data Privacy Impact N Assessment (PIA) If Yes, please attach If No, provide reason below. Has an EIA been completed in respect of this report? Equality Impact Analysis N (EIA) If Yes, please attach If No, provide reason below. Risks: Have any risks been identified / assessed? Y Conflict of Interest: Is there a conflict of interest associated with this report? N Has any clinical engagement/involvement taken place as part of the proposal being presented. Y Clinical Engagement: Yes – co-produced with GPs and Clinical Directors/CCG Medical Director Have patients been involved in the drafting of this report? Patient Engagement: N No – however PPG representation on LCP. Privacy Status: Can the document be shared Y

CCG Corporate Objectives :

To commission the best quality and effective services to deliver optimal healthcare CO1 outcomes for our local population. Ensure the balance of our health investment reflects our population’s needs and keeps CO2 the population well. CO3 Deliver the 10 year strategy by engagement with the population we serve and ensure 1

we commission services that meet local needs with a clear focus on population health management strategies. CO4 We will focus on population health outcomes through helping to deliver successful Integrated Care Partnerships and ensure decisions, provision and access to local services is based on the needs of our population. CO5 As local health leaders, we will focus on increasing life expectancy across Pennine Lancashire to be at, or about, the national average in the next 10 years.

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BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

Agenda Item No: 4.2

Blackburn with Darwen CCG Governing Body & East Lancashire CCG Governing Body Meeting in Common

13 November 2019

INTEGRATION ACCELERATOR

1. Introduction

1.1 This report now provide Governing Body members with a detailed overview of the proposals to implement this Neighbourhood Integration Accelerator Pathfinder across Pennine Lancashire.

2. Recommendations

2.1 Governing Body Members are recommended to:  Note the proposal to develop Neighbourhood Integration Accelerator Pathfinders across Pennine Lancashire as outlined in this report.  Endorse this proposal and offer their support to the project going forward, subject to formal agreement by each of the participating organisations.

3. Background

3.1 PCNs are groups of GP practices working more closely together, with other primary and community care staff and health and care organisations, providing integrated services to their local populations. Clinicians describe this as a change from reactively providing appointments to proactively caring for the people and communities they serve.

3.2 Throughout 2018/19 and the first half of 2019/20, considerable work and clinical engagement has been undertaken across Pennine Lancashire to facilitate the development of thirteen Primary Care Networks. The majority of these networks have recently been independently assessed by the National Association of Primary Care (NAPC) as having exciting, ambitious, yet realistic projects with clear PCN leadership and good CCG support. They have been recognised for their understanding of local need, their planning and collaboration across primary, community, social care, secondary care and the voluntary sector.

3.3 However, despite the success of the PCNs to date, GP Practices are still under inordinate pressure to meet rising demand. Far greater integration and more ambitious service redesign is required to meet the requirements of the NHS Long Term Plan 2019, and fulfil the Pennine Lancashire vision of seamless, high quality, fully integrated place based care.

3.4 There is an opportunity to support all of our 74 Pennine Lancashire GP practices to explore new ways of working within their core practice teams (includes triage, access and patient cohort segmentation). At the same time, we can explore optimal models for integrated neighbourhood team working. Whilst there are currently actions being undertaken in both areas, the GPs in practice cannot work at the top of their skill set 3

and hand over care to a wider multi-agency, multi-disciplinary team, if that team is not fully knitted in and sufficiently responsive at an operational level.

4. Overview of the Neighbourhood Integration Accelerator

4.1 The Integration Accelerator will:

 Accelerate the development of self-directed teams who will provide a timely response for core general practice.  Provide personalised, proactive, responsive care 24/7, to patients who have multiple, complex needs and place a high demand on system resources.  Explore how practices can manage rising demand and the system can jointly respond to fluctuating need.  Move care closer to home and ensure that funding follows.  Ensure that social prescribing is embedded into new ways of working.

4.2 The Integration Accelerator will manage the interface between case management and fluctuating need. This includes the management of exacerbations.

4.3 The challenge to PCNs and community based services (via an Alliance Agreement), within a six month period, is:

a. Using a Population Health Management (PHM) approach, can you identify a cohort of approx. 40 patients per practice per six month period? b. Work with the patients to understand their challenges and life goals and any problems (including social and economic) that are contributing to their ill-health. Identify barriers to engagement. A face to face assessment is required (but can be carried out by a non-medic). c. Starting with core practice, consider all the resources that you have available to meet the needs of the patients. Do systems and procedures at a practice level (including access and triage) meet the needs of the cohort? Where are the gaps? What community assets are available? Are the VCFS involved? How does the wider community integrated neighbourhood team support the offer? Where are the gaps and opportunities? d. What interventions will you use? Is your care planning inclusive and does it draw on all community based assets? Does it respond to patient feedback? How will you work differently within an allocated budget? e. Using a Plan Do Study Act (PDSA) approach, monitor the interventions and their impact on patient care (and resource utilisation). Includes tracking patient journeys in real time and facilitating their movement through the care management cycle. Relevant outcome data must be clinically interpreted and challenged. AQUA will be used to help monitor outcomes (currently in discussion). f. Develop an infrastructure to share risk and reward.

4.4 If the pathfinder was successful then the PCN may have the opportunity to continue with further phases until the 31 March 2021. Adult Community Service Contracts in both East Lancashire and Blackburn with Darwen terminate at the end of March 2021, and it is envisaged that learning from the pilots would assist us with determining next steps. The intention that GP practices would have embedded new ways of working by this point, or at very least, relationships would be sufficiently developed to ensure a fully informed, win-win systems discussion takes place between all key stakeholders regarding the best options for service configuration moving forwards.

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4.5 Within the alliance, all members are equally valued and have equal say in significant collective decisions. The rationale behind applying an Alliance Agreement to the Integration Pilot is that the alliance approach brings additional elements including proactive relationship management and alignment of values and drivers. This maximises the chances of successful integration, as contracts themselves will not change values and cultures.

Flexibility

4.6 The Integrator Accelerator aims to be sufficiently flexible for PCNs/Community Services to develop their own approach to providing, timely, responsive, effective wrap around care, but at the same time, there are specific commissioning requirements that will be built into the pathfinder specification, namely:

i. The Pathfinders can demonstrate patient segmentation based on need and how GPs oversight and direction is embedded in the care planning. ii. Data regarding the patient’s journey is clinically interpreted and challenged iii. Pathfinders explore the optimal level of medical (GP and Consultant) input into INT and IHSS Case Management/Advance Care Planning to ensure integrated care delivery and prevent exacerbation in a crisis iv. Every person in the identified cohort is personally involved in the development of their care plan and every Accelerator Project will share 5 Case Studies where there has been good learning to go into a library of cases for future use v. Social Care, Mental Health Providers and the VCFS can evidence that they have been appropriately engaged

4.7 There is flexibility too in relation to the cohort selection. The CCG has stated that the preferred cohort of patients for the accelerator is: individuals with multiple complex co- morbidities, whose needs fluctuate. This includes people who are towards the end of their life.

4.8 There are many people who have four or more comorbidities whose needs are stable, and these patients are known to INTs but are not within this cohort. The cohort, with which this challenge is associated, have high needs which are changing, therefore active intervention and management is required if we are to stabilise demand and reduce need.

4.9 As long as a Population Health Management Approach (PHM) is utilised (and there is CCG approval), prior to the Accelerator commencing, there is scope to change the cohort based on local needs and clinical discretion. It is also anticipated that patients may be added to the cohort in response to need that has arisen (using clinical discretion), so for example, an individual may be identified by NWAS or Voluntary Services as being in particular need of support.

Outcomes and Evaluation

4.10 Outcomes are required on a patient, neighbourhood and systems level. Again, there is flexibility for the PCN/Community Service to select outcomes or add outcomes, as long as the mandatory outcomes are met (to be determined). Wherever possible, outcomes will be linked to Right Care.

4.11 A baseline assessment will be required.

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4.12 There will be evaluation criteria which must be met, which utilise quantitative, qualitative and economic measures. The criteria will be developed further with PCNs.

4.13 The Integration Accelerator provides an opportunity for clinicians from primary/community and secondary care to work together to develop appropriate pathways (including speciality pathways) to manage more care in the community, mutually up skill to improve effectiveness and productivity. Models for risk, gain share will be explored.

4.14 Based on each practice treating cohorts of 10 patients per week within a cohort and the entire cohort refreshing every six weeks, this means that there is the potential to improve outcomes for 4420 patients in East Lancashire and 1993 patients in Blackburn with Darwen per annum. These numbers are sufficient to make a difference on a population level as shown in Diagram 1, especially since the cohorts will be higher up the pyramid in terms of complexity. However these numbers are illustrative only as rateable values will be applied.

Diagram 1: Pennine Lancashire Whole Population (Long Term Condition Tiers)

4.15 Of course, as Diagram 2 shows, the Integration Accelerator which will last for a period of 18 months only, is part of a bigger long term strategy which will see new ways of working embed before decisions are made regarding the future long term commissioning of community services. The establishment of PCN Social Prescribing Link workers is currently being considered as part of longer term workforce planning and consideration needs to be given to the wider VCFS infrastructure in terms of their capacity to support increased referrals.

4.16 The governance of the pathfinders will be via the Local Community Partnership (EL) and LiCP (BwD), reporting up into the new Integrated Community Care Board.

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Diagram 2: Embedding new approaches now as stepping stones to longer term integration.

Alliance Contracting

4.17 An Alliance Agreement will be utilised to enable providers to work even closer together and maximise the opportunities presented by the Pathfinders. The agreement would be signed by all parties and added as a contract variation to existing contracts; no new legal entity is created.

4.18 Within the alliance, all members are equally valued and have equal say in significant collective decisions. The rationale behind applying an Alliance Agreement to the Integration Pilot is that the alliance approach brings additional elements including proactive relationship management and alignment of values and drivers. This maximises the chances of successful integration, as contracts themselves will not change values and cultures.

5. Conclusion

5.1 Many positive developments have taken place, in terms of neighbourhood integration, in recent years; however, there is now the opportunity for the system to move further, faster. The Integration Accelerator is a means to accelerate the pace of transformational change, embed population health management and ensure that new ways of working are discovered and fully operationalised. As soon as cohorts have been selected utilising a PHM approach, both quantitative, qualitative and economic outcomes will be clearly defined.

5.2 Governing Body Members are asked to endorse this proposal and offer their support to the project going forward, subject to formal agreement by each of the participating organisations. This support is crucial if we are to enable general practice and wider community services to co-design and deliver services which are sustainable, clinically led, fit for the future and holistic in nature.

Collette Walsh Deputy Director of Commissioning (Interim)

7 NHS BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP NHS EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

Blackburn with Darwen CCG Governing Body & East Lancashire CCG Governing Body Meeting in Common

Agenda Report Title: Joint Chief Officer’s Report 4.3 No: Meeting Date: 13th November 2019 Summary of Report: This is a report to the Pennine Lancashire (PL) Governing Bodies (GBs), which provides an update on national and local issues of interest to members Report Recommendations: The GB is requested to receive this report and note the items as detailed Financial Implications: None Procurement Implications: None Report Category: Tick Support and recommend/forward the report. Approve the recommendations outlined in the report. Debate the content of the report. Receive the report for information. Author: Dr Julie Higgins

Presented By: Dr Julie Higgins Other Committees N/A Consulted: Has a PIA been completed in respect of this report? Privacy Impact Assessment N (PIA) If Yes, please attach If No, provide reason below. Has an EIA been completed in respect of this report? Equality Impact Analysis N (EIA) If Yes, please attach If No, provide reason below. Data Protection Impact Is a Data Protection Impact Assessment Required? N Assessment Have any risks been identified / assessed? N/A Risks: Conflict of Interest: Is there a conflict of interest associated with this report? N Has any clinical engagement/involvement taken place as part Y Clinical Engagement: of the proposal being presented. Patient Engagement: Have patients been involved in the drafting of this report? N Privacy Status: Can the document be shared Y CCG Corporate Objectives : CO1 To commission the best quality and effective services to deliver optimal healthcare outcomes for our local population. CO2 Ensure the balance of our health investment reflects our population’s needs and keeps the population well CO3 Deliver the 10 year strategy by engagement with the population we werve and ensure we commission services that meet local needs with a clear focus on population health management strategies CO4 We will focus on population health outcomes through helping to deliver successful Integrated Care Partnerships and ensure decisions, provision and access to local services is based on the needs of our population. CO5 As local health leaders, we will focus on increasing life expectancy across Pennine Lancashire to be at, or abote the national average in the next 10 years. Report of the Joint Chief Officer Page 1 of 10

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

NHS BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP and NHS EAST LANCASHIRE CLINICAL COMMISIONING GROUP

GOVERNING BODIES MEETING IN COMMON

13 NOVEMBER 2019

JOINT CHIEF OFFICER’S REPORT

1. Introduction

I am pleased to present my joint report to the Pennine Lancashire (PL) Governing Bodies (GB) meeting in common (Blackburn with Darwen CCG and East Lancashire CCG), to provide an update on national and local issues of interest to members.

2. System Updates

2.1 Integrated Care System (ICS) Board Update

2.1.1 People Plan

At the ICS Board on 2nd October 2019, a proposal was shared on how the ICS will engage and involve local people in decision making across Lancashire and South Cumbria (L&SC). There is currently a well-developed network of communications and engagement teams working across partner organisations, and the paper described the main approaches that the ICS is already taking, with a number of specific examples where involvement with local people has been evidenced.

The ICS is working to address four objectives in relation to communicating, engaging and involving:

Build relationships  Build relationships for partnership working amongst health and care staff, partner organisations, such as the police, universities, voluntary, community, faith and social enterprise sector organisations so that they can add value and contribute positively to partnership initiatives.

Inform and involve  Inform and involve all stakeholders (including professional bodies and committees, staff representatives, local authorities, staff, partners, patients and the public) in the development of the ICS and our emerging vision for health and care in L&SC so that the plan is the best it can be for patients  Cascading clear decisions and leadership messages to relevant staff, partners  Improve outcome of ICS initiatives by ensuring clinicians and health professionals (including pharmacists, allied health professionals, nurses, dentists and optometrists) are engaged and involved.

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Showcase positive impact  Demonstrate the value of partnership working to audiences at different levels of the system with a particular focus on the impact on local people’s lives and the quality of care they receive  Utilise websites and social media to share information, case studies and messages in an open and transparent way.

Strengthen partnership working in relation to communications, engagement and involvement:  Adopt consistent approaches to managing consultations across the ICS and Integrated Care Partnership(ICP)/Multispecialty Community Providers (MCP) in L&SC, increasing co-ordination of activity, reducing duplication and adopting best practice  Deliver co-ordinated communications and engagement across L&SC by sharing resources, utilising best practice and shared thinking to deliver campaigns and initiatives across the footprint which result in behaviour change and impact  Help staff to understand the ICS, what it means and how they can contribute through clear internal staff communications and engagement.

A small number of ICPs are exploring new initiatives for involving their populations in health and care through Citizen Panels. The ICS Board recognise the need for a strategic and consistent approach to involvement, with clear structures and connected approaches in place across the health and care system for involving and engaging local people, and a Task and Finish Group is being established to take this approach forward.

2.2 Lancashire Better Care Fund Plan 2019/20 In line with national requirements the Lancashire Better Care Fund (LBCF) Plan 2019/20 was completed and submitted by the required date of 27th September 2019. It is now subject to the regional and national assurance process. Following the submission of a small amount of further supporting evidence positive feedback has been received indicating likely approval. Due to the lateness of the start of the process the plan is in effect a bringing together of existing spending plans rather than a more ambitious approach. While the plan covers the Lancashire Health and Wellbeing Board area, it has been developed in partnership with colleagues in Blackburn with Darwen, Blackpool and South Cumbria so as to continue towards greater cooperation and integration at ICP level. 2.3 Better Care Fund 2020/21 On 4th September 2019 the Government set out the results of the 2019 Spending Round. These included the confirmation that the BCF will continue into 2020/21. “As the NHS works with local government on plans for enhanced and improved Primary and Community services, they should also be working together on continued integration of health and social care, as well as alignment to wider local government services such as housing.” The NHS contribution to adult social care through the BCF will increase by 3.4% in real terms in 2020-21 and the improved BCF and Winter Pressures Grant will continue at the 2019/21 level. Having confirmation of the continuation and level of BCF in 2020-21 will allow a much more ambitious approach to integration in its planning. The process of identifying what priorities will be and the opportunities to arrange those priority services in an integrated way is underway. This process will be influenced by the recommendations of the Intermediate Care review carried out across L&SC in 2019, although the full impact is likely to take two to three years to be implemented.

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2.4 Intermediate Care Programme The intermediate care review has been approved and we are commencing the implementation planning for the ICS and each ICP area recommendations in conjunction with the ICS. In terms of the enabling functions, which are being implemented on an ICS level, there is a provisional date of the 29th November 2019 for a workshop with Carnall Farrar, the organisation that carried out the review, around the next steps. It will have representation from NHS, council and Voluntary Community and Faith Sector (VCFS) colleagues at to help shape the plan going forward and ensure that there is a joint approach to intermediate care. 2.5 Special Educational Needs & Disability (SEND) Summary

2.5.1 Lancashire County Council

Following the joint Ofsted and CQC inspection in November 2017, the local area expects a re-visit inspection this autumn. The last SEND Board took place on 16th September 2019 and spent time reviewing its self-assessment in readiness for the inspection. The previous inspection had highlighted 12 areas for action including joint commissioning and working with partners. There has been progress in most areas and the Board heard reports on all areas to seek assurance.

There are four areas that acceleration plans have been produced for to demonstrate the immediate action partners propose to take in order to rectify this. The current acceleration plans are for:

 Quality of Education, Health and Care plans  Diagnostic pathways for autistic spectrum disorder across the local area  Improved outcomes of children and young people who have SEN and/or disabilities  Improved accessible information on the local offer The Neuro-Developmental pathway was considered; local commissioners and providers are now undertaking a gap analysis and developing local implementation plans.

The Board considered work underway for Preparing for Adulthood (transitions) which the previous SEND inspection had highlighted as an area of concern. Although progress has been made in health care transitions the board is seeking greater assurance on the wider collaborative transition agenda.

A new operational group has been set up to drive work in the partnership and link the different workstreams together.

https://content.govdelivery.com/attachments/UKCCC/2019/08/22/file_attachment s/1270814/Cumbria%20SEND%20WSOA%20for%20submission%2021.8.19.pdf

2.6 Pennine Lancashire Integrated Care Partnership (ICP)

2.6.1 ICS/ICP Strategy Development

The ICP Partnership Leaders’ Forum have endorsed the Strategic Narrative for the ICP, which was submitted as part of ICS planning approach. The narrative outlines the delivery priorities of the ICP and sets out how partners in the ICP will work together to deliver improvements to health and care in Pennine Lancashire.

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Partnership Leaders also considered an initial draft NHS Plan Five Year Pipeline of potential deliverables for the Integrated Health and Care Partnership; this outlines some of the strategic developments that are likely to require Partnership consideration over the next twelve months. The pipeline will allow the ICP, with its constituent organisations, to make informed judgements regarding transformation priorities for the next five years and in turn, the alignment of system capacity and capability to deliver the required change. Partnership Leaders endorsed the draft pipeline but agreed that it would be vital to inform and engage the Primary Care Neighbourhoods (PCNs) in discussions regarding the pipeline and gain feedback from them. In this way, organisational leads and PCN leads can form an aligned and coherent approach.

2.6.2 Intermediate Tier Proposition

The ICP has considered the proposition regarding future developments for intermediate care in Pennine Lancashire in response to the Lancashire Intermediate Care Strategy. The Draft Intermediate Tier Strategy oultines actions that could be undertaken to support people to stay out of hospital and help to reduce pressures on the system and on our staff by shifting activity and providing a broader discipline model. This plan will require alliances and collaborative working across the system and in particular between clinical and professional teams. The draft Strategy was endorsed by the ICP, however further details were requested in relation to timescales for development and delivery

2.6.3 Neighbourhood Integration Accelerator

The ICP Partnership Leaders have welcomed the move to implement the Neighbourhood Integration Accelerator and felt this offered an exciting opportunity to realign service provision in neighbourhoods using a population health management approach. The key points of the approach are:

 The most needy patients will be identified and worked with to understand their challenges and goals; interventions will be decided with the patient and effectiveness will be monitored. This will lead to a system being designed with patient involvement  A quantitative, qualitative and economic evaluation will be in operation with metrics to reflect patient and staff outcomes  An alliance approach will be adopted which will maximise the chances of success

2.6.4 Together an Active Future

The Together an Active Future team has recently sent in their submission to Sport England with the aim of securing £3 million for their pathfinder plans. If successful, the funds will be allocated across the districts in Pennine Lancashire and will be used to get residents to move more by introducing them to new activities and ways to combine exercise with their everyday lives. The outcomes of this submission will be known in November 2019.

3. Clinical Commissioning Group Updates

3.1 Patient and Public Involvement

Over the last month the CCG has been actively engaging patients to understand their experiences of bladder and bowel services, heart failure, and the Home First service. In addition to this, extensive fieldwork has been undertaken in Ophthalmology (eye) clinics to understand their experiences of ophthalmology services and to elicit their views about services in the area. Engagement with patients who suffer from age related hearing loss has contributed to the development of audiology services across Lancashire and South Cumbria, and was led by the CCG on behalf of each area.

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3.2 Winter

The Pennine Lancashire-wide winter planning approach builds on a system approach which acknowledges the usual peaks in demand over winter period, plus unusual peaks In demand as a result of adverse weather conditions, flu outbreaks and surges. Historically the winter planning process has primarily been acute focussed, but increasingly it is recognised that winter affects in and out of hospital services and therefore the plan includes system schemes.

The full plan has been developed and approved through the Pennine Lancashire A&E Delivery Board governance structure, and was reviewed and approved in CCG Committees in Common in October 2019. This system winter plan includes ICS and ICP schemes and responsibility for delivery of elements spans various governance structures. A Pennine Lancashire Winter Delivery Group has been established to coordinate and oversee the delivery of the elements within this plan.

Learning from previous years has highlighted that surges and pressures in activity are to some extent predictable, and in response to this a system wide ‘hotspot’ plan has been developed. This analysis includes data from emergency department ambulance attendances, walk-in attendances at urgent care facilities, primary care out of hours, 999 and NHS 111. This provides retrospective analysis of the pressure points in winter 2018/19 and is being used to target resources.

The plan includes a mixture of in and out of hospital schemes with the in-hospital schemes primarily supporting resilience of the Emergency Department and flow through the hospital bed base. The winter plan is aligned with the CCGs strategy to expand the out of hospital offer and shift resources (including financial) to enable this to happen in a planned and sustained way. Specific areas in the winter plan which focus on the out of hospital system include:

 Development of an acute visiting service in East Lancashire CCG. This is a winter development and also a strategic piece of work, which is to support primary care resilience and safely reduce ambulance conveyances to the Emergency Department. Note that an Acute Visiting Service is commissioned by Blackburn with Darwen CCG, and is an embedded service available to practices in Blackburn with Darwen.

 Increase primary care extended access capacity across Pennine Lancashire, including some specific additional capacity in Hyndburn. This will provide additional face to face clinical capacity which general practices and primary care out of hours will be able to access.

 Increase staffing in Intensive Home Support Service in Lancashire & South Cumbria Foundation Trust (LSCFT). This is to enable the team to respond to increased demand (mainly exacerbations on respiratory and frailty pathways) and to extend referral times. Note the equivalent service in East Lancashire has provided assurance regarding capacity and resilience over winter.

 Increase Home First capacity to consistently provide 70+ slots per week across the Pennine Lancashire system. Home First is primarily a step-down pathway from the hospital inpatient pathway and is increasingly being used as a step-up offer from community.

In addition to the above, on a Lancashire and South Cumbria footprint, the ICS is implementing EMS Plus which is a system wide escalation tool and has recently implemented a Falls Lifting Service across Lancashire.

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Mobilisation of the scheme plans is underway and a monthly exception report, risks and mitigation will be presented to the Accident & Emergency Delivery Board (AEDB), and the CCG Senior Management Team as appropriate. The mobilisation process will include the development of scheme KPIs which will be monitored and inform a post winter evaluation.

3.3 Key Commissioning Decisions Taken

At the meeting on the 16 October 2019 between the BwD Commissioning Business Group and the East Lancashire CCG Sustainability Committee Committees in Common (CiC) the following decisions were agreed:

 Telemedicine (East Lancashire CCG) - an extension to the current contract for a period of 12 months was awarded subject to a number of conditions being met including standardisation across East Lancashire and quality and performance indicators.

 Pennine Lancashire Succeed Thrive Empower (STEP) Service – the CiC received assurance that the previously agreed actions in relation to this service have now been implemented. The committees will receive a paper in the new year describing any future provision.

 Children’s Autistic Spectrum Disorder (ASD) – the CiC agreed to the additional funding requested to support a pilot scheme for 18 months, provided by the East Lancashire Children and Adolescent Service (ELCAS) for the 11-16 year old pathway.

3.4 Individual Patient Activity (IPA) Updates

3.4.1 Recovery Actions – Procurement of a Recovery Team In May 2019, the Joint Committee of CCGs acknowledged that the current level of Continuing Health Care (CHC) services provided across Lancashire and South Cumbria needed a substantial review to strengthen the service outputs.

The Committee endorsed a single point of coordination through the IPA Programme Board. The IPA Programme Board was established and has been working together collectively, listening and engaging the views of partners in order to agree areas of improvement focus, actions and timeframes.

The IPA Programme Board has representation from across the ICS and is made up of the 5 Lancashire and South Cumbria ICPs, including representation from the 4 Local Authorities and 8 Clinical Commissioning Groups.

Two broad objectives were agreed for the IPA Programme Board:

 Develop and make formal proposals on the future arrangements for commissioning and operational delivery of IPA services by the end December 2019.

 Deliver the explicit ambition to try to stabilise the current system, accelerate improvement in current performance and provide a more stable platform for future transformation.

Work is underway to complete an outline business case (OBC) to identify a preferred model option and then a full business case to describe and test how the preferred option will work and be implemented.

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The IPA Programme Board received a list of seven options in total. The group held a workshop to undertake a high level options appraisal; two options were shortlisted, in addition to the ‘do nothing/minimum’ option which is required as a comparator. Key outcomes from the workshop were:

 Integration with local authorities is seen as desirable but was felt to be too far a step from the current service model.

 Confirmation that the future vision is for an integrated an end to end service was across Lancashire and South Cumbria.

 Clear recognition that this will need to achieved in two/three phases

The shortlisted options are now being benchmarked against the National 18 point CHC maturity matrix. Work is progressing at pace and exemplar services identified by the national CHC service improvement team are receiving face to face site visits; 3 of these have been completed with a further 3 to be completed in November and early December.

A deep dive has been undertaken across the Pennine ICP footprint and an action plan has been drawn together. To complement this, additional work is being undertaken across the ICP system over three days (11th to 13th November 2019) facilitated by NHS Improvement to map activity in 3 areas, checklists in acute wards (a quality premium target), fast tracks and the complex patient pathway. The outcome of this will be fed back into the ICS work stream for system learning and reported back to the IPA programme board. All of this work is being undertaken by a small group of experts in this field under the leadership (SRO) Jerry Hawker, Chief Officer, Morecambe Bay CCG.

4. Policy Updates

4.1 NHS England

4.1.1 Pre-election (Purdah) Guidance

Pre-election (Purdah) guidance has been issued for the NHS in the run up to the general election. This guidance is effective from 00.01 Wednesday 6 November 2019 until Friday 13 December 2019 (or the date at which a new government is formed). The principles underpinning the guidance are that:

 The day to day operation of the NHS must continue unimpeded  The NHS must act and be seen to act with political impartiality, and its resources must not be used for party political purposes  During the election period, democratic debate between candidates and parties should not be overshadowed by public controversy originating from NHS bodies themselves.

As always during a pre-election period, there should be:

 No new decisions or announcements of policy or strategy  No decisions on large and/or contentious procurement contracts  No particiapation by official NHS representatives in debates or events that may be politically controversialm wheth at national or local level

These restrictions apply in all cases other than where postponement would be detrimental to the effective running of the local NHS or, wasteful of public money.

4.1.2 A Guide to Managing Medicines Supply and Shortages

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This guide aims to support pharmacists, clinicians and other NHS professionals with managing the supply of medicines to their patients and details the national, regional and local management and escalation processes and communication routes for medicines supply issues in order to consolidate existing practice across industry, government and the NHS. https://www.england.nhs.uk/wp-content/uploads/2019/11/a-guide-to-managing- medicines-supply-and-shortages.pdf

4.1.3 Clinically led review of NHS Access Standards

This is the progress report from Professor Stephen Powis, NHS National Medical Director setting out how each of the proposed new standards is being tested and the early learning.

https://www.england.nhs.uk/wp-content/uploads/2019/10/crs-progress-report-v5- 311019.pdf

4.1.4 Antivirals for adults with recent onset (acute) hepatitis C

NHS England will routinely commission antivirals for adults with acute hepatitis C (HCV), including the treatment of acute HCV infection in immunosuppressed adults (e.g. post transplantation patients) in accordance with the criteria set out in this document.

https://www.england.nhs.uk/wp-content/uploads/2019/09/Antivirals-for-adults-with- recent-onset-acute-hepatitis-C.pdf

4.2 Department of Health and Social Care

4.2.1 Section 140 of the Mental Health Act: a briefing for CCGs and local authority partners

Section 140 (S140) of the MHA provides a duty for clinical commissioning groups (CCGs) to notify local authorities of arrangements for the admission of people detained under the MHA. This is in cases of special urgency or when there is a need for appropriate accommodation or facilities designed for children and young people under the age of 18.

4.2.2 Having a child through surrogacy

These documents explain how surrogates and intended parents can start a family through a surrogacy arrangement in England and Wales.

The guidance also sets out best practice for healthcare professionals providing care to people having a child through surrogacy.

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment _data/file/843890/Surrogacy_guidance_for_intended_parents_and_surrogates.pdf

4.2.3 Handbook to the NHS Constitution for England

This handbook is designed to give the public, patients, carers, families and NHS staff all the information they need about the NHS Constitution for England.

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The handbook covers:

 NHS values and the principles that guide the NHS  explanations of the rights and pledges in the NHS Constitution  legal sources of patient and staff rights  the roles we all play in protecting and developing the NHS https://www.gov.uk/government/publications/supplements-to-the-nhs-constitution-for england/the-handbook-to-the-nhs-constitution-for-england

5. Recommendation

The GBs are requested to receive this report and note the items as detailed.

Dr Julie Higgins Joint Chief Officer November 2019

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BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

Blackburn with Darwen CCG Governing Body & East Lancashire CCG Governing Body Meeting in Common

Agenda Report Title: CCG Corporate Business Plan 4.4 No: Meeting Date: 13 November 2019 Summary of Report: Blackburn with Darwen and East Lancashire CCGs’ purpose is to improve health outcomes and reducing inequalities, setting standards to ensure that services are safe and of a consistently high quality and making best use of the Pennine pound.

This report sets out the CCG’s Corporate Business Plan and reflects the CCGs’ move towards alignment of commissioning organisations across Pennine Lancashire, through the appointment of Joint AO and single Executive Team. The long term intended outcome will provide a consistent approach to system leadership with Primary Care and clinical leadership at heart of the decision making and provide opportunities to support Population Health Management, shifting resources into the community. The Corporate Business Plan process will ensure delivery of priorities and inform individuals Personal Development Reviews.

Report Recommendations: Governing Body Members are asked to receive the report.

Financial Implications: Procurement Implications: Report Category: Tick Support and recommend/forward the report. x Approve the recommendations outlined in the report. Debate the content of the report. Receive the report for information. Author: Mrs Claire Richardson / Mr Roger Parr

Report supported & approved by your Senior Lead? Y Presented By: Dr Julie Higgins, Joint Chief Officer Other Committees Consulted: Has a PIA been completed in respect of this report? Privacy Impact Assessment N (PIA) If Yes, please attach If No, provide reason below. Has an EIA been completed in respect of this report? Equality Impact Analysis N (EIA) If Yes, please attach If No, provide reason below. Data Protection Impact Is a Data Protection Impact Assessment Required? N Assessment Have any risks been identified / assessed? N Risks: Conflict of Interest: Is there a conflict of interest associated with this report? N Has any clinical engagement/involvement taken place as part Y/N Clinical Engagement: of the proposal being presented. Patient Engagement: Have patients been involved in the drafting of this report? Y/N Privacy Status: Can the document be shared Y

CCG Corporate Objectives : 1

To commission the best quality and effective services to deliver optimal healthcare CO1 outcomes for our local population. Ensure the balance of our health investment reflects our population’s needs and keeps CO2 the population well. CO3 Deliver the 10 year strategy by engagement with the population we serve and ensure we commission services that meet local needs with a clear focus on population health management strategies. CO4 We will focus on population health outcomes through helping to deliver successful Integrated Care Partnerships and ensure decisions, provision and access to local services is based on the needs of our population. CO5 As local health leaders, we will focus on increasing life expectancy across Pennine Lancashire to be at, or about, the national average in the next 10 years.

2 NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

NHS Blackburn with Darwen and East Lancashire Clinical Commissioning Groups’ Corporate Business Plan

1. Background and Context

1.1. The NHS Long Term Plan, published in January 2019, outlined the future strategy for health services. In summary, this includes taking more action on prevention and health inequalities, delivering new models of integrated care, improving care quality and outcomes for major conditions, using data and digital technology more effectively and ultimately ensuring that the NHS gets best value out of the taxpayers’ investment in the NHS.

1.2. The Plan outlines how Integrated Care Systems (ICS) will be developed to plan for and oversee improvements in care to best meet the changing needs of local populations. The Lancashire and South Cumbria (L&SC) ICS will be responsible for developing the 5 Year strategy, in collaboration with more local Integrated Care Partnerships (ICPs).

1.3. Within this changing landscape, Blackburn with Darwen (BwD) and East Lancashire (EL) CCGs remain statutory bodies accountable for commissioning services for the 531,000 people registered or resident in Pennine Lancashire (PL).

1.4. Our population face a number of challenges:

 Some of the most deprived communities in the country resulting in higher levels of ill health;  People are living longer, with increasingly complex care needs resulting in increased demand for services;  Mental ill-health is more common than elsewhere in the country;  Many children and young people experience poor health.

1.5. The system is currently under pressure financially and health outcomes are poorer than the national average. The levels of deprivation in the area are deteriorating and as such wider determinants of health present a significant risk to the system. Other ICS changes may also create risks going forwards, such as allocations.

1.6. The combined budget across both CCGs is £942m in 2019/20. There are significant underlying financial pressures at the acute provider and we are unlikely to deliver 18 weeks Refer to Treatment (RTT) and 4 hour Accident and Emergency (A&E) constitutional targets. The size of the waiting list has also been growing.

1.7. The PL NHS organisations are working to a single financial control total. To deliver this the CCGs have prioritised financial stabilization of the acute provider in 2019/20 and all three NHS organisations set themselves challenging efficiency targets.

1.8. This means that the CCGs need to have a business plan that prevents these indicators getting any worse and puts plans in place for continuous improvement.

1.9. Creating a single corporate plan across both CCGs reflects our move towards alignment of commissioning organisations across Pennine Lancashire through the Page 1 of 8

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

appointment of Joint Accountable Officer (AO) and single Executive Team. The long term intended outcome will provide a consistent approach to system leadership with Primary Care and clinical leadership at heart of the decision making and provide opportunities to support Population Health Management (PHM), shifting resources into the community.

1.10. The CCGs will continue to take a strong leadership role within the ICP, working with partners to define the future state for local integrated care within the wider L&SC ICS, the likely route map to integration and impact for local people. This will enable us to design and plan services that meet the holistic needs of our population and communities.

1.11. The CCGs priorities and plans are ‘mirrored’ across the ICP, ensuring our common ambitions are translated into tangible programmes of work to ensure we are delivering improvements, transforming care and managing demand effectively.

1.12. The corporate business plan will inform individuals Personal Development Reviews.

2. Purpose

2.1. BwD and EL CCGs’ purpose is to improve health outcomes and reducing inequalities, setting standards to ensure that services are safe and of a consistently high quality and making best use of the Pennine pound. Specifically this means:

2.2. Improving population health:

 Develop and implement a strategy to improve health outcomes and reduce health inequalities for the population we serve;  Involve local citizens and patients in how they want their services prioritised and how they can take responsibility for their own health and well-being;  With primary care networks and neighbourhoods, focus on delivery of strategic objectives and priorities including prevention and early intervention.

2.3. Integrating across health and care to deliver safe and effective services:

 Lead with integrity by holding ourselves and partners to account to deliver effective and efficient primary care, community and hospital services;  Work with and influence partners to bring integration and strong synergy to our collective efforts;  Lead with compassion to motivate, realise and release the potential of our clinical  membership and workforce.

2.4 Make best use of resources:

 Ensure effective stewardship and decision making so resources are in the right place to deliver health outcomes, equity, value for money and high quality.

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

3. Objectives

3.1 The CCGs’ Objectives are:

 To commission the best quality and effective services to deliver optimal healthcare outcomes for our local population;  Ensure the balance of our health investment reflects our populations needs and keeps the population well;  Deliver the 10 year strategy by engagement with the population we serve and ensure we commission services that meet local needs with a clear focus on PHM strategies;  Focus on population health outcomes through helping to deliver successful ICPs and endure decisions, provision and access to local services is based on the needs of our population;  As local health leaders we will focus on increasing life expectancy across PL to be at, or above the national average in the next 10 years.

4. Our Approach

4.1 We have developed a detailed operational plan for 2019-20 which enable us to monitor progress on the delivery of our priorities. This includes setting targets to deliver specific outcomes within clear timeframes. The monitoring of these plans will allow the CCGs to more fully understand its capacity and capabilities within the workforce.

4.2 The CCGs will adopt a population health approach in delivering health improvements and reducing inequalities. A PHM Strategy will look to maximise health outcomes and shift resources into community and prevention by reducing demand, as well as recognising that Acute and Tertiary services need to be adequately funded. Examples include an accelerator programme within Primary Care Networks (PCNs), supporting people with multiple co-morbidities and frailty and whole respiratory pathway redesign.

4.3 The sustainability of the system is a key priority for the CCGs as it is required to deliver statutory financial targets. The CCG will focus on cost reduction and shifting resources ’left’ to gain best value. This means prevention is a priority, which will require the support of the population to change behaviours and how they use health and care services.

4.4 A Performance and Accountability Framework is being developed to ensure that clear metrics and responsibilities are identified in delivering the plan.

4.5 The CCGs recognise the only way it will tackle local problems and improve health outcomes is by working effectively as a system and responding positively to the need to change and transform the way services are planned and delivered. Working with clinical colleagues, across Primary and Secondary Care, the CCGs are developing and agreeing a new clinical delivery model, which will form the foundation of our service transformation. As this model is currently in development, a working draft is reflected below. This model and its principles encompass provision for children/young people, adults and older people, as well as physical and mental health support

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

5. CCG System Leadership and Priorities

5.1 A priority setting process has been undertaken based on local population needs assessments, use of national tools such as NHS RightCare and population health analysis and financial pressures. (Appendix A)

5.2 The CCGs, along with other organisations in Pennine Lancashire can only tackle the problems and improve the health outcomes of its patients by working effectively as a system and responding positively to the need to change. As leading members of the ICP we are clear that our role encompasses:

5.2.1 System Responses – in ensuring partner organisations work together, as a unified system, to respond to immediate and on-going challenges, harnessing collective capability and capacity. Key priorities requiring a system response include managing the financial challenge, through efficiency and management of demand, workforce redesign, recruitment and retention and responses to the ICS. It also includes the development of population health management, digital solutions and the coordinated response to improving the urgent and emergency care system.

5.2.2 System Improvements – in enabling partnership organisations to work together ensuring delivery of tangible improvements in the quality of health and care provision and population outcomes, whilst making the best use of our collective resources, driven through our commissioning and contracting mechanisms.

5.2.3 System Transformation- Following review of the data, a number of priority transformation programmes have been identified, which will specify and deliver significant changes to how current services and pathways are delivered for our population. This large scale change will be delivered over a number of years, across the health and care system and aims to improve quality and outcomes, reduce demand and strengthen integrated community care.

o Intermediate care, including frailty and end of life; o Primary Care Networks and neighbourhood response to managing co-morbidities; Page 4 of 8

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

o Same Day Primary Care; o Respiratory pathway.

These schemes are being managed through the newly established Integrated Community Care Board co-chaired by Dr Julie Higgins and Dr Mark Dziobon It will develop large scale change capability as well as support the implementation of integrated budgets and delegation of budgets to PCNs.

5.2.4 System Development – in enabling partner organisations to work together in developing and managing plans for the journey to a single integrated care provider and fully integrated commissioning in Pennine Lancashire.

System Sysytem System System Response Improvement Transformation Development

 Urgent and Emergency  Individual Patient  Intermediate care,  Towards an Integrated Care Activity including frailty and Care Provider  Financial sustainability  Older People end of life;  Integrated and Economic Strategy  Children and Young  Primary Care Commissioning  Population Health People Networks and  CCG Organisational Management  Learning Disabilities neighbourhood Development  Workforce (ICP) /Autism response to managing  Digital (ICP)  Mental Health co-morbidities  Planned care  Same Day Primary Care  Respiratory pathway

6. System Governance

6.1 System Coordination – providing robust coordination of the ICPs priorities, programmes, plans, engagement and facilitating soft governance, supporting decisions and delivery based on the needs of the system.

6.2 System Wide – Programme Boards are being established to lead the delivery of priorities, supported by clinical leadership and enabler workstreams including estates, workforce and digital. Our voluntary, community and faith sector partners play an active role across the breadth of our partnership delivery and continue to ensure that our plans are as focused on the wider community as it is on health services.

6.3 Clearly difficult choices need to be made and as such ICP governance is being put in place to support this. Sustainability and Resources Groups have been established to support the delivery of the control total and the programme boards will be given savings targets as appropriate.

6.4 Scheduled Care, A&E, Integrated Community Care, Mental Health Boards are taking work programmes forwards that will support the delivery of the transformational schemes.

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

6.5 This structured delivery approach and large scale change approaches have not been delivered at this scale locally before. There are capacity and capability gaps which will be addressed.

6.6 Governance is reviewed regularly by the Pennine System Leaders.

7. Recommendations

7.1 Governing Body Members are asked to receive the report.

Dr Julie Higgins Joint Chief Officer

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

Appendix A

CCG Priorities and Summary of Proposed Outcomes

Priority Summary of Proposed Outcomes Neighbourhood  Reduction in inappropriate hospital admissions; and Community  Improved health and lives saved, with improved outcomes in key at Scale disease areas, for example stroke, heart attacks and cancer;  Reduction in variation at practice and PCN level;  Reduction in General Practitioner referral rates;  Reduction in non-elective A&E attendances;  Reduction in prescribing costs.

Urgent Care  Reduction in inappropriate: - North West Ambulance Service call outs; - Emergency Department attendance; - Non Elective (NEL) admissions to hospital; - Hospital bed days; - NEL admission with diagnosis of Urinary Tract Infection; - Death in hospital <24hours.

Emergency Care  Safeguarding standards incorporated into the procurement, commissioning and assurance systems;  System bed modelling development to be safe and to consider and effectively manage any increased risks to vulnerable patients including children.

Individual  Safeguarding – patients’ identified health needs assessed in a Patient Activity timely manner;  Reviews re-undertaken within locally agreed timescales to ensure changes to patients’ condition and care are addressed;  Safeguarding standards to be fully incorporated into the procurement, commissioning and assurance process, and systems;  Patients’ mental capacity routinely and regularly assessed and the CCG mental capacity policy followed.

Planned Care  30% reduction of face-to-face Outpatient appointments by 2023;  Reduction in inappropriate clinical activity through clinical and threshold policies, meeting requirements of NHS England Statutory requirements for category 1&2 procedures;  Reduced waiting times;  Reduction in capacity clinics;  Increase in nurse lead/Allied Health Professional clinics;  Capacity released in diagnostics to improve cancer pathways.

Older People  Reduction in inappropriate hospital admissions.

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

Priority Summary of Proposed Outcomes Children and  Increased quality of assessments for children and young people Young People with suspected Autism Spectrum Disorder;  Reduction in wait times for diagnosis;  Reduction in wait times for children and young people accessing therapy services;  Reduction in duplication of assessments and support for children and young people;  Reduction in children being admitted to hospital;  Reduction in A&E attendances;  Reduction in admissions to Neonatal Intensive Care Unit;  Reduction in stillbirths;  Reduction in number of women smoking at the time of delivery to 6%;  20% reduction in children and young people being admitted to the Paediatric ward with a mental health issue.

Learning  Reducing the reliance on inpatient beds for patients with a Disability/ Learning Disability/Autism; Autism  Maintain levels of discharge and reduce admissions.

Mental Health  No 12 hour breaches;  Patients being activity case managed;  Timely access to crisis services when needed;  Access to mental health acute and specialist bed;  No stranded patients on wards.

Integrated  Improved outcomes on a wide range of indicators for Independent Commissioning care providers (Care Homes and domiciliary care agencies) through the implementation of improved quality and contract monitoring.

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BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

BLACKBURN WITH DARWEN CCG GOVERNING BODY AND EAST LANCASHIRE CCG GOVERNING BODY MEETING IN COMMON

Agenda Report Title: PERFORMANCE REPORT 4.5 No: Meeting Date: 13TH NOVEMBER 2019 Summary of Report: The Performance Report for the CCGs contains information regarding constitutional targets and indicators relevant to the objectives of the organisations. The focus is on both in and out of the acute hospital settings. Report Recommendations: The Governing Bodies are requested to note the performance reported in the paper and the risks and mitigations identified in the appendices. Financial Implications: None Procurement Implications: None Report Category: Tick Support and recommend/forward the report. Approve the recommendations outlined in the report. Debate the content of the report. Receive the report for information. √ Author: Mr Roger Parr

Report supported & approved by your Senior Lead? √ Presented By: Mr Roger Parr Other Committees Consulted: No Has a PIA been completed in respect of this report? Privacy Impact Assessment N (PIA) If Yes, please attach If No, provide reason below. Has an EIA been completed in respect of this report? Equality Impact Analysis N (EIA) If Yes, please attach If No, provide reason below. Data Protection Impact Is a Data Protection Impact Assessment Required? N Assessment Have any risks been identified / assessed? N Risks: Identified in the report Conflict of Interest: Is there a conflict of interest associated with this report? N Has any clinical engagement/involvement taken place as part N Clinical Engagement: of the proposal being presented. Patient Engagement: Have patients been involved in the drafting of this report? N Privacy Status: Can the document be shared Y CCG Corporate Objectives: To commission the best quality and effective services to deliver optimal healthcare CO1 outcomes for our local population. Ensure the balance of our health investment reflects our population’s needs and keeps CO2 the population well CO3 Deliver the 10 year strategy by engagement with the population we serve and ensure we commission services that meet local needs with a clear focus on population health

management strategies

CO4 We will focus on population health outcomes through helping to deliver successful Integrated Care Partnerships and ensure decisions, provision and access to local services is based on the needs of our population. CO5 As local health leaders, we will focus on increasing life expectancy across Pennine Lancashire to be at, or about the national average in the next 10 years.

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BLACKBURN WITH DARWEN CCG GOVERNING BODY AND

EAST LANCASHIRE CCG GOVERNING BODY

MEETING IN COMMON

13TH NOVEMBER 2019

PERFORMANCE REPORT

1. Introduction

1.1 The Performance Report for the CCGs contains information regarding constitutional targets and indicators relevant to the objectives of the organisations. The focus is on both in and out of the acute hospital settings.

2. Summary Performance

2.1 The table below summarises the performance of the CCGs:

Theme Metric Period BwD EL

A&E 4 Hour Performance [95% Target] [Pennine System] Sep 2019 85.16% 85.16%

18 Week Incomplete pathways for all patients [92% Target] Sep 2019 85.30% 85.30%

18 Week Incomplete pathways for all patients [Waiters ‐ March 2019 Target] Sep 2019 452 1774

(6.3) Patients seen within two weeks for an urgent GP referral for suspected cancer CANCER August 2019 92.11% 93.12% [93% Target] (7.4) Patients receiving first definitive treatment within one month of a cancer CANCER August 2019 96.15% 97.59% diagnosis [96% Target] (8.4) Patients receiving first definitive treatment for cancer within two months [85% CANCER August 2019 76.47% 75.61% Target]

IAPT IAPT Access [4.75% Q1 Q2 Q3 / 5.5% Q4] Q1 1920 4.60% 4.98%

IAPT IAPT Recovery [50% Target] Q1 1920 46% 50%

Smoking Smoking at time of delivery (SATOD) Q1 1920 12.87% 15.02%

80% of eligible women [25‐49] to have adequate screening test within previous 3.5 Cervical Jun‐19 69.03% 73.73% years 80% of eligible women [50‐64] to have adequate screening test within previous 5.5 Cervical Jun‐19 76.95% 77.28% years

The detail supporting the above is contained within appendix A and also includes the measures for the proportion of the population with access to online consultations.

3. Priority Areas

3.1 Appendix B contains the latest performance metrics for mortality. For East Lancashire CCG the districts or Lancashire performance is reflected in most cases as data is not broken down in any other way. The CCG has recognised the key modifiable health risk factors as smoking, obesity and alcohol which impact upon the greatest health risks in our system. There is a significant challenge here to our system.

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Appendix B also contains the CCGs performance on screening, vaccinations and immunisations that are linked to the key areas for improvement for the CCG.

The latest performance in primary care for the CCGs priority in improving outcomes for Cardiovascular Disease (CVD) and Chronic Obstructive Pulmonary Disease (COPD) is contained within the appendix. This shows that whilst there are some areas for improvement there are also some areas where performance is better than the national average.

4. Primary Care Network Indicators

4.1 Appendix C contains a high level indicator of groups of general practices for COPD reported prevalence and emergency admission rates. The CCG is also working with East Lancashire Hospitals NHS Trust to manage the scheduled care system. The appendix shows how referral rates differ between networks taking the Ear, Nose and Throat specialty as an example. The reasons for the differences can then be explored.

5. Recommendation

5.1 The Governing Bodies are requested to note the performance reported in the paper and the risks and mitigations identified in the appendices.

Roger Parr Deputy Chief Officer/Chief Finance Officer 5th November 2019

Page 3 of 3 MEASURE A&E ATTENDANCE NUMBERS AND 4 HOUR PERFORMANCE RISKS GBAF‐259

OWNER Elizabeth Fleming DIRECTOR Alex Walker ICP PB ICCB MHW SCB AEDB Commentary ORG [Apr‐Aug] 2018‐19 2019‐20 Variance % Var • Increased attendances at A&E sites during 2019‐20 over the BwD CCG 25,055 26,821 1,766 7.0% previous year – some of which has been generated following the Accrington Health Access Closure in July 2018. EL CCG 57,040 59,783 2,743 4.8% • Issues, including: • Staffing for both medical & nursing is still a risk; PENNINE 82,095 86,604 4,509 5.5% • Surges in ambulance attendances (delays from high arrivals numbers in short periods); ELHT 75,177 79,242 4,065 5.4% • Mental Health demand and the timely availability of mental health beds; • Trust Flow contributes to reduced performance for Pennine Recovery 2018‐19 2019‐20 admitted breaches. System Target September 81.15% 85.16% 89%

Mitigation Conclusion/Risks • Lack of full system view due to no formal ‘real time’ capacity • System‐wide work plan (Plan on a Page –POAP) agreed by management system. system & being delivered through Accident Emergency Delivery • Surge demand for services can be out of the CCG's control ‐ for Board (AEDB). e.g., RBH is the busiest ED in the North West in terms of • POAP looks to transform work‐streams, including: Access; ED ambulance conveyance (c. 130 a day), mental health bed front door & streaming; Flow; Discharge and recovery; Extended availability Primary Care; resilience and escalation; Mental Health. • Sufficient medical staffing to staff current and future models ‐ • ELHT have recruited a number of sub stantive doctors (now in e.g. use of locum staffing post) and increased the number of internal bank staff (supporting a reduction in locum use); • Opening times for Ambulatory Emergency Care Unit (AECU) to be extended from May 2019 onwards (Nurse‐led) to support enhanced pathways from ED/UCC; • Rapid Assessment & Triage Improvement Plan to support timely patient handover; Working in partnership: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group Appendix A MEASURE 18 Week RTT Performance RISKS GBAF‐262

OWNER Cathy Gardener DIRECTOR Alex Walker ICP PB ICCB MHW SCB AEDB

Mar‐19 BWD CCG [September 19] 2018‐19 2019‐20 Variance Commentary Target • Both CCGs have patients waiting over 18 weeks at ELHT, 18 Week Waiting List 9,994 11,751 1,757 11,299 Lancashire Teaching Hospitals Trust and Manchester University Foundation Trust (with smaller numbers across 18 Week Performance % 89.8% 85.3% multiple providers). • ELHT is one of the national pilot sites for new RTT standard; Mar‐19 EL CCG [September 19] 2018‐19 2019‐20 Variance Target • Waiting lists reported under Trauma and Orthopaedics increased at ELHT in February 2019 with the inclusion of MSK activity. 18 Week Waiting List 24,492 28,464 3,972 26,694

18 Week Performance % 90.4% 85.3%

Mitigation Conclusion/Risks • A Pennine Lancashire Scheduled Care Board has been • The Scheduled Care Board has only recently been formed and established within the ICP Governance Structure; membership there has been no escalation process in place. A Primary Care includes both clinical and managerial membership from all clinical lead has now been identified as part of the membership partners. There is shared SRO responsibility at Director level for of this Board. both ELHT and CCGs and ELHT Chief Executive is the sponsor of • Sufficient medical staffing to staff current and future models ‐ the Board. e.g. use of locum staffing • The Board’s remit includes performance management oversight • Change of pensions has impacted on consultant availability to and active management and transformational /pathway undertake capacity / waiting list initiatives redesign for longer term sustainability. • Outpatient Transformation Group is in place reporting to the Scheduled Care Board. • Every Clinical Division has plans in place to reduce pressures within the RTT pathways including the development and testing of patient triggered reviews, waiting list cleanse exercise, group consultation and telephone clinics. • Each project has a range of outcome measures.

Working in partnership: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group MEASURE DEMAND MANAGEMENT –GP REFERRALS RISKS

OWNER Cathy Gardener DIRECTOR Alex Walker ICP PB ICCB MHW SCB AEDB

% Commentary GP Referrals [Apr‐Aug19] 2018‐19 2019‐20 Variance Variance • There are fewer GP referrals being made for a consultant‐led first OP appointment in 2019‐20 than in the previous year. BwD CCG 13,579 13,457 ‐122 ‐0.9% • 2 Week Rule referrals are showing increases while routine referrals are reducing. EL CCG 33,658 32,580 ‐1,078 ‐3.2%

% Other Refs [Apr‐Aug19] 2018‐19 2019‐20 Variance Variance

BwD CCG 5,832 5,935 +103 1.8%

EL CCG 13,881 13,897 +16 0.1%

Mitigation Conclusion/Risks • A Pennine Lancashire Scheduled Care Board has been • Scheduled Care Board has only recently been formed and there established within the ICP Governance Structure; membership has been no escalation process in place. A Primary Care clinical includes both clinical and managerial membership from all lead has now been identified as part of the membership of this partners. There is shared SRO responsibility at Director level for Board. both ELHT and CCGs and ELHT Chief Executive is the sponsor of the Board. • The Boards remit includes immediate performance management oversight and active management and transformational /pathway redesign for longer term sustainability. • Outpatient Transformation Group is in place reporting to the Scheduled Care Board. • Referral rates by practice and PCN being investigated

Working in partnership: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group MEASURE CANCER –2 Week Rule / 31 Day Diagnosis to treatment / 62 Day referral to treatment RISKS GBAF 239‐1819

OWNER Cathy Gardener DIRECTOR Alex Walker ICP PB ICCB MHW SCB AEDB Commentary CANCER TARGETS [YTD Apr‐Aug 2019] BwD EL • BwD CCG & Blackpool CCG chosen as national pilot sites to participate in a Targeted Lung Health Check programme (patient 2 Week [93% Target] 91.48% 91.37% review for those who are between 55‐74yrs and ex‐smokers); • Focused work with Cancer Research UK working into Primary 31 Day [96% Target] 96.83% 96.44% Care; • Local “Let`s Talk Cancer” campaign; aim to inspire everyone to 62 Day [85% Target] 80.23% 79.86% talk about cancer. A focus on the importance of engaging with screening programmes is a key theme.

Mitigation Conclusion/Risks • Cancer Champions in each practice: Improving / coordinating • Scheduled Care Board has only recently been formed and there care with patients; has been no escalation process in place. A Primary Care clinical • Supporting Primary Care Networks to engage specifically with lead has now been identified as part of the membership of this early cancer diagnosis. Board. • Faecal Immunochemical Tests for symptomatic patients across • BwD frequently having later stage patients with co‐morbidities L&SC Alliance (from Nov 2018) FIT for screening July 2018. resulting in longer and more complex diagnostic pathways. Above expected increase in uptake and positivity rates, • Across both CCGs there are large variations in performance significant impact on waiting times for colonoscopies; between specialities with a couple 'shoring up' some of the • Redesigned hospital cancer pathways to reflect national optimal poorer performing ones. Patient choice has a more significant pathways and improve patients experience (including Supported affect in e.g. urology (prostate). Self‐Management Follow‐up); • Many head and neck need tooth extractions, detox before they • Rapid Diagnostic Centre (RDC) development (NHS Long Term can commence on the pathway proper. Plan): • 28 Day Faster Diagnosis Standard (FDS) Task & Finish Group.

Working in partnership: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group MEASURE IAPT – ACCESS & RECOVERY RISKS

OWNER Cathy Gardener DIRECTOR Alex Walker ICP PB ICCB MHW SCB AEDB Commentary IAPT [Q1 1920] BwD EL TARGET • National expectation that each CCG will achieve a rate of at least 5.5% of local prevalence entering services by quarter 4 of ACCESS 4.6% 4.98% 4.75% 2019/20 and a minimum of 4.75% in all other quarters. • RECOVERY 46% 50% 50% Maintenance of recovery rates at or above the 50% standard during 2019/20 6 Weeks First Treatment 96% 97% 75% • Waiting times from referral to treatment in improving access to psychological therapies (IAPT) services for people with 18 Weeks First Treatment 100% 100% 100% depression and/or anxiety disorders continue to surpass national minimum standards.

Mitigation Conclusion/Risks • The LCFT ‘Mindsmatter’ Clinical Lead is currently reviewing the • Mental Health and Wellbeing Board has only recently been complexity of referrals accepted by the service and the interface formed. between primary and secondary care mental health teams. • Access (prevalence) is not being achieved consistently in each • The review is focused on: month. Q4 requires an even greater number of patients to • Appropriateness of referrals seen by the service; access IPAT services as per the national mandate. • Treatment effectiveness , risk and recovery rates for the ‘non IAPT’ cohort. • Learning from ‘non‐recovered’ patient review ‐ Reasons for non‐ recovery: • Patient complexity ‐ patients are not reaching the full threshold for recovery; • Some interventions have higher rates of non‐recovery; action to address.

Working in partnership: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group MEASURE MATERNAL SMOKING AT DELIVERY / SMOKING QUITTERS RISKS

OWNER Kirsty Hamer DIRECTOR Alex Walker ICP PB ICCB MHW SCB AEDB Commentary SMOKING BwD EL ENGLAND • Pennine Lancs (PL) is one of the more deprived areas of the UK and levels of child poverty vary across the patch – Evidence Smoking at time of delivery [1] 12.87% 15.02% 10.45% shows that quit rates drop in deprived areas. • Smoking Cessation [2] 5,248 6,622 [3] 3,614 Recent LA budget cuts will have impacted smoking cessation services. • Although rates of smokers setting a quit date compare Actual Smoking quitters 331 3,105 [3] favourably to the national position, when the actual number of successful quitters is explored it is clear that in BwD there are [1] Q1 2019‐20 less than half the number of quitters than in 2015‐16. [2] Rate of people setting a quit date per 100,000 smokers aged 16+ • Across BwD and Lancashire, approximately 1/3 of those who set [2018/19] a quit date successfully quit (and this is confirmed) [3] Lancashire position used as a proxy for EL CCG

Mitigation Conclusion/Risks • The East Lancs smoking cessation team (Quit Squad) are working • Smoking Cessation services, commissioned by the Local closely with Maternity Services and provide services aligned Authority (LA) differ across PL. within Maternity at the Trust. • It is currently unclear which of the ICP transformation boards • Blackburn with Darwen’s model signposts patients to Pharmacy will be accountable for raising performance against this metric – services for support. Prevention board ? • Much joint working is taking place including an approach raising the profile with midwives. • In the next year a CCG commissioned service will expand its specification to incorporate Smoking in Pregnancy. This service will cover PL to address the inconsistent approach.

Working in partnership: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group MEASURE CERVICAL SCREENING RISKS

OWNER Cathy Gardener DIRECTOR Alex Walker ICP PB ICCB MHW SCB AEDB Commentary CERVICAL SCREENING – JUN19 BwD EL ENGLAND • Cervical screening rates in the 50‐64 age group are inline with national averages but still below the 80% target 25‐49 – screening test 3.5 Yrs 69.03% 73.73% 70.98% • BwD is below national average screening rates for the 25‐49 age 50‐64 – screening test 5.5 Yrs 76.95% 77.28% 76.70% group whereas EL CCG is performing above national levels. However, neither CCG is meeting the 80% target.

[1] 80% of eligible women [25‐49] to have adequate screening test within previous 3.5 years [2] 80% of eligible women [50‐64] to have adequate screening test within previous 5.5 years

Mitigation Conclusion/Risks • Cervical screening programme has implemented primary HPV screening. • CCG campaigns encouraging uptake of Cervical Screening: 25yr age group and “Clear on Cancer”; “Let`s Talk Cancer”.

Working in partnership: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group MEASURE ED16 ‐ ONLINE CONSULTATIONS RISKS

OWNER Collette Walsh DIRECTOR Alex Walker ICP PB ICCB MHW SCB AEDB Commentary ONLINE CONSULTATIONS BwD EL TARGET • BwD CCG has the pre‐GP functionality of iPlato established in Q1 2019‐20 100% 19.2% 75% each practice and as such has achieved the national target. • EL CCG has iPLATO established in 2 x PCNs and needs further roll‐out • The aim is by March 2020 for all practices in East Lancs to be E.D.16: Proportion of the population with access to online offering online consultations. consultations CCGs are expected to work with their practices to ensure that by March 2020, 75% of practices are offering online consultations to their patients.

Mitigation Conclusion/Risks • Digital Working Group that is overseeing the roll out of iPLATO in East Lancs which is chaired by Kirsty Hollis • Details of how to register with iPLATO have been circulated to East Lancs practices w/c 30th September 2019 • Knowledge sharing events across EL CCG in latter half of September 2019

Working in partnership: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group Appendix B Mortality

Reference Theme Metric Period BwD EL Under 75 mortality rate from all cardiovascular diseases 2015‐17 D Under 75 mortality rate from cancer 2015‐17 D Under 75 mortality rate from injuries 2015‐17 D P01 Premature <75 Mortality Under 75 mortality rate from liver disease 2015‐17 D Under 75 mortality rate from respiratory disease 2015‐17 D Under 75 mortality rate from all other causes 2015‐17 D Under 75 mortality rate: all causes 2015‐17 D Under 75 mortality rate from cancer considered preventable 2015‐17 L Under 75 mortality rate from cardiovascular diseases considered preventable 2015‐17 L P02 Preventable <75 Mortality Under 75 mortality rate from liver disease considered preventable 2015‐17 L Under 75 mortality rate from respiratory disease considered preventable 2015‐17 L Infant mortality 2015‐17 L Mortality rate from lung cancer 2015‐17 L Mortality rate from chronic obstructive pulmonary disease 2015‐17 L Smoking attributable mortality 2015‐17 L Smoking attributable deaths from heart disease 2015‐17 L P03 Other Mortality Smoking attributable deaths from stroke 2015‐17 L Deaths from drug misuse 2015‐17 L Killed and seriously injured (KSI) casualties on England's roads 2015‐17 L Suicide rate 2015‐17 L Rate of Still Births per 1000 Births 2015‐17 Neonatal Mortality ‐ The number of deaths under 28 days, per 1,000 live births 2015‐17 Modifiable Risk Factors

Theme Metric Period BwD EL England Smoking Adult smoking prevalence 2017‐18 Smoking Smoking cessation 2018‐19 5,248 6,622 Smoking Smoking at time of delivery (SATOD) Q1 1920 12.87% 15.02% Obesity QOF BMI>30 prevalence 2018‐19 11.84% 11.88% 10.12% Obesity Childhood weight programme : Obesity ‐ Reception 2018‐19 10.90% 9.9% [L] 9.70% Obesity Childhood weight programme : Obesity ‐ Year 6 2018‐19 22.70% 19.9% [L] 21.50% Falls Emergency hospital admissions for injuries due to falls in persons aged 65+ per 100,000 population 2017‐18 D Diet Proportion of the population meeting the recommended '5‐a‐day' on a 'usual day' (adults) 2017‐18 D Alcohol Admission episodes for alcohol related conditions (narrow definition) 2017‐18 D Alcohol Admission episodes for alcohol specific conditions 2017‐18 D Physical Activity Inactive Adults (%) 2017‐18 D

Worse than National / Local Average DDistrict Level figures used as proxy for ELCCG Similar to National / Local Average LLancashire level figures used as a proxy for ELCCG Better than National / Local Average Updated in this report Screening / Vaccinations / Immunisations

Theme Metric Period BwD EL ENGLAND Cervical CS002: Women, aged 25‐64, with a record of cervical screening (last 5 yrs) 2018‐19 74.63% 76.98% 75.93% Cervical 80% of eligible women [25‐49] to have adequate screening test within previous 3.5 years Jun‐19 69.03% 73.73% 70.98% Cervical 80% of eligible women [50‐64] to have adequate screening test within previous 5.5 years Jun‐19 76.95% 77.28% 76.70% Breast Females, 50‐70, screened for breast cancer in last 36 months (3 year coverage, %) 2017‐18 Bowel Persons, 60‐74, screened for bowel cancer in last 30 months (2.5 year coverage, %) 2017‐18 Flu Population vaccination coverage ‐ Flu, at risk individuals (%) Sep18‐Feb19 Flu Population vaccination coverage ‐ Flu, aged 65+ (%) Sep18‐Feb19 Pneumococcol Population vaccination coverage ‐ PPV (%), aged 65+ [at any time] 2018‐19 71.70% 67.67% 69.16% MMR Population vaccination coverage ‐ MMR for one dose (2 years old) 2017‐18 L MMR Population vaccination coverage ‐ MMR for two doses (5 years old) 2017‐18 L

Worse than National / Local Average DDistrict Level figures used as proxy for ELCCG Similar to National / Local Average LLancashire level figures used as a proxy for ELCCG Better than National / Local Average Primary Care Identification & Management Metric

Theme Metric Period BwD EL ENGLAND IDENTIFICATION Atrial fibrillation: QOF prevalence 2018‐19 1.54% 2.03% 1.98% IDENTIFICATION CHD: QOF prevalence (all ages) 2018‐19 3.60% 3.91% 3.10% IDENTIFICATION COPD: QOF prevalence (all ages) 2018‐19 2.20% 2.61% 1.93% IDENTIFICATION Hypertension: QOF prevalence (all ages) 2018‐19 13.39% 14.95% 13.96%

IDENTIFICATION CVD‐PP001: new hypertension patients, age 30‐74, with CV risk assess >=20% treated w. statins (den.incl.exc.) 2018‐19 68.52% 65.78% 65.32% IDENTIFICATION Obesity: QOF prevalence (18+) 2018‐19 11.84% 11.88% 10.12% IDENTIFICATION % of Cancers Diagnosed at Stage 1 or 22017

MANAGEMENT [CVD] AF006: stroke risk assessed w. CHA2DS2‐VASc (den.incl.exc.) 2018‐19 96.32% 96.74% 93.97% MANAGEMENT [CVD] AF007: treated w anti‐coag. therapy (CHADS2DS2‐VASc >=2) (den.incl.exc.) 2018‐19 87.02% 84.16% 85.68% MANAGEMENT [CVD] CHD002: Last BP reading in last 12mths is <=150/90 (den.incl.exc.) 2018‐19 90.49% 89.66% 88.46% MANAGEMENT [CVD] CHD007: CHD patients immunised against flu (den.incl.exc.) 2018‐19 77.22% 76.28% 78.02% MANAGEMENT [CVD] HYP006: Blood pressure <= 150/90 mmHg in people with hypertension 2018‐19 82.06% 81.31% 79.66% MANAGEMENT [CVD] STIA003: Last BP reading is <=150/90 (den. incl. exc.) 2018‐19 87.34% 86.46% 83.87% MANAGEMENT [CVD] STIA007: Record that an anti‐platelet agent or an anti‐coagulant is taken (den. incl. exc.) 2018‐19 91.92% 92.06% 91.57% MANAGEMENT [CVD] STIA009: Influenza immunisation given 1 Aug‐31 Mar (den.incl.exc.) 2018‐19 75.95% 72.71% 74.74% MANAGEMENT [Cancer] One Year Survival from all Cancers 2016

MANAGEMENT E.H.13: People with a SMI receiving a full annual physical health check and follow‐up interventions Q1 2019‐20 39.70% 37.60% MANAGEMENT E.K.3: Learning Disability Registers and Annual Health Checks delivered by GPs Q4 2018‐19

MANAGEMENT E.D.16: Proportion of the population with access to online consultations Q1 2019‐20 100% 19.20%

MANAGEMENT E.D.20: Citizen facing tools: Proportion of the population registered to use NHSApp 19/08/2019 0.05% 0.06%

Worse than National / Local Average DDistrict Level figures used as proxy for ELCCG Similar to National / Local Average LLancashire level figures used as a proxy for ELCCG Better than National / Local Average Out of Hospital

Theme Metric Period BwD EL ENGLAND EoL Palliative/supportive care: QOF prevalence (all ages) 2018‐19 0.31% 0.46% 0.40% EoL Percentage of deaths that occur in hospital 2018 51.40% 47.40% 45.40% DTOC Delayed Transfers of Care [ELHT] Aug‐19 4.60% 4.60% DTOC % of older people (65+) still at home 91 days after discharge into reablement/rehabilitation services 2018‐19 82.60% 91.70% 82.40% IAPT IAPT Access Q1 1920 4.60% 4.98% IAPT IAPT Recovery [50% Target] Q1 1920 46% 50% IAPT IAPT 6 Weeks First Treatment [75% Target] Q1 1920 96% 97% IAPT IAPT 18 Weeks First Treatment [95% Target] Q1 1920 100% 100% OAP OAPS May‐19 EIP People with first EIP starting treatment within 2 weeks of referral Aug‐19 100% 40%

Worse than National / Local Average DDistrict Level figures used as proxy for ELCCG Similar to National / Local Average LLancashire level figures used as a proxy for ELCCG Better than National / Local Average In Hospital

Theme Metric Period BwD EL CANCER (6.3) Patients seen within two weeks for an urgent GP referral for suspected cancer August 2019 92.11% 93.12% CANCER (7.4) Patients receiving first definitive treatment within one month of a cancer diagnosis August 2019 96.15% 97.59% CANCER (8.4) Patients receiving first definitive treatment for cancer within two months August 2019 76.47% 75.61% A&E 4 Hour Performance [95% Target] [Pennine] Sep 2019 85.16% 85.16% A&E A&E Attendance Numbers August 2019 6.00% 4.70% A&E 12 Hour Breaches Sep 2019 18 Week Incomplete pathways for all patients [92% Target] Sep 2019 85.30% 85.30% 18 Week Incomplete pathways for all patients [Waiters ‐ March 2019 Target] Sep 2019 452 1774 18 Week 52+ Week waiters Sep 2019 0 0 DIAG Diagnostics ‐ 6 Weeks [Target <1%] Sep 2019 0.94% 1.53% GP Referrals GP Referrals against Historic August 2019 ‐0.90% ‐3.20% ADMISSIONS Elective Admissions against Historic August 2019 ‐0.40% 2.10% ADMISSIONS Emergency Admissions against Historic August 2019 23.00% 14.40% ADMISSIONS Zero Day LOS Emergency Admissions against Historic August 2019 56.70% 39.10% ADMISSIONS Emergency Admission Bed Days against historic August 2019 8.80% 2.50%

Worse than National / Local Average DDistrict Level figures used as proxy for ELCCG Similar to National / Local Average LLancashire level figures used as a proxy for ELCCG Better than National / Local Average Appendix C

Primary Care : Exploring Variation by PCN

• QOF Reported COPD Prevalence 2018‐19

• Emergency Admission per 1000 population for COPD [June18‐May19]

• QOF Reported Obesity Prevalence 2018‐19

• PCN GP Referral Rates per 1000 Pop : Ear, Nose and Throat QOF Reported COPD Prevalence 2018‐19

QOF 2018‐19 Adjusted Prevalence : COPD 3.5%

3.0%

2.5%

2.0%

1.5%

1.0%

0.5%

0.0% East East CCG CCG East

East West West West Rural

West

North TOTAL EL

Central

Darwen BWD Ribblesdale Pendle Burnley Pendle Burnley Hyndburn Rossendale PENNINE Rossendale Hyndburn Emergency Admission per 1000 population for COPD [June18‐May19]

DIAGNOSIS : COPD | LOS CATEGORY : (Multiple Items)

Admission Rate (per 1000 pop) Bed Days (per 1000 pop)

3.50 25.00

3.00

20.00

2.50 pop)

Pop) 15.00 2.00 1000

1000

(per

(per

Rate

Rate 1.50 Day

10.00 Bed Admission

1.00

5.00

0.50

0.00 0.00 East CCG East East CCG

East

West West West Rural

West

North TOTAL OTHER OTHER EL

Central

Darwen BWD Ribblesdale Pendle Burnley Pendle Burnley Hyndburn Rossendale PENNINE Rossendale Hyndburn QOF Reported Obesity Prevalence 2018‐19

QOF 2018‐19 Adjusted Prevalence : Obesity 16.0%

14.0%

12.0%

10.0%

8.0%

6.0%

4.0%

2.0%

0.0% East East CCG CCG East

East West West West Rural

West

North TOTAL EL

Central

Darwen BWD Ribblesdale Pendle Burnley Pendle Burnley Hyndburn Rossendale PENNINE Rossendale Hyndburn PCN GP Referral Rates per 1000 Pop : Ear, Nose and Throat

PENNINE PCNs ‐ GP REFERRAL ANALYSIS [Jun18‐May19] : Specialty = Ent

GP Referred Attendances per 1000 pop % Attendances Discharged at First

25.0 40.0%

35.0%

20.0 30.0% pop)

OP

25.0% 1000 15.0 First

(per

at

OP

20.0% First

10.0 Discharged 15.0% % Referred

GP 10.0% 5.0

5.0%

0.0 0.0% BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

BLACKBURN WITH DARWEN CCG GOVERNING BODY AND EAST LANCASHIRE CCG GOVERNING BODY MEETING IN COMMON

Agenda Report Title: Chief Finance Officer Report 4.6a No: Meeting Date: 13 November 2019 Summary of Report: The report outlines the summary financial position for NHS Blackburn with Darwen CCG at September 2019. Report Recommendations: The CCG Governing Body is asked to note the contents of this financial summary and the financial position of the CCG at the end of September 2019. Financial Implications: None Procurement Implications: None Report Category: Tick Support and recommend/forward the report. Approve the recommendations outlined in the report. Debate the content of the report. Receive the report for information. Y Author: Mrs Linda Ring, Finance Manager

Report supported & approved by your Senior Lead? Y Presented By: Mr Roger Parr, Chief Finance Officer and Deputy Chief Officer Other Committees Consulted: None Has a PIA been completed in respect of this report? Privacy Impact Assessment If No, provide reason below: N (PIA) If Yes, please attach not required Has an EIA been completed in respect of this report? Equality Impact Analysis If No, provide reason below: N (EIA) If Yes, please attach not required Data Protection Impact Is a Data Protection Impact Assessment Required? N Assessment Have any risks been identified / assessed? Y Risks: Ref No: 2019/04 & 2019/05 Conflict of Interest: Is there a conflict of interest associated with this report? N Has any clinical engagement/involvement taken place as part N Clinical Engagement: of the proposal being presented. Patient Engagement: Have patients been involved in the drafting of this report? N Privacy Status: Can the document be shared Y

CCG Corporate Objectives :

To commission the best quality and effective services to deliver optimal healthcare CO1 outcomes for our local population. Ensure the balance of our health investment reflects our population’s needs and keeps CO2 Y the population well CO3 Deliver the 10 year strategy by engagement with the population we serve and ensure we commission services that meet local needs with a clear focus on population health management strategies CO4 We will focus on population health outcomes through helping to deliver successful Integrated Care Partnerships and ensure decisions, provision and access to local services is based on the needs of our population. CO5 As local health leaders, we will focus on increasing life expectancy across Pennine Lancashire to be at, or above the national average in the next 10 years.

1 Executive Financial Summary Month 6 – Period Ending 30th September 2019

Year to Date (YTD) Full Year Forecast Budget Actual Variance Budget Actual Variance £000 £000 £000 £000 £000 £000 Funds Available 133,918 133,918 0 273,788 273,788 0

Commissioning 102,895 102,975 (80) 204,342 204,521 (179) Primary Care 27,647 27,715 (68) 56,169 56,216 (47) Corporate 3,278 3,228 50 6,704 6,653 51 Reserves 98 0 98 6,573 6,398 175 Balance 0 0 0 0 0 0

Summary Financial Position – The CCG is reporting a breakeven position in line with the financial plan. The CCG is on plan to deliver its year end forecast breakeven position.

Commissioned Services Risks

 Healthcare Commissioning is reporting a YTD overspend of £80k with  The CCG has a QIPP target of £6.0m and has achieved savings of a year-end forecast overspend of £179k. 43.5% of the target. There is a risk that some schemes will not fully  Primary Care Services are reporting a YTD underspend of £68k with release the planned savings in year and the CCG continues to look for forecast year end overspend of £47k. Prescribing expenditure figures opportunities to mitigate any shortfalls. have been received for April to July with August and September  Acute activity levels continue to be a key factor in 2019/20. Schemes expenditure estimated. A forecast breakeven position is reported at are in place to manage demand this time. An overspend of £112k is forecast on prescribing.  Continuing health care and complex packages continues to be a key  Corporate Services are reporting an underspend of £50k and a year risk as these are generally high cost and low volume. The CCG end forecast overspend of £51k. continues to closely monitor this area of expenditure.  Prescribing expenditure is volatile and is monitored closely by the Capital Medicines Management Team. The prescribing waste scheme and the prescribing hub continue into 2019/20.  A combined budget for hardware replacement of the GPIT estates, provision of infrastructure, mobility working and operating software has QIPP been approved by NHS England on behalf of the CCG. Expenditure of  The CCG has actioned 43.5% of its QIPP savings to date and is on plan £244k is expected in 2019/20. to meet the full year savings of £6.0m.

Recommendation: The CCG Governing Body is asked to note the contents of this financial summary and the financial position of the CCG at the end of September 2019.

2 NHS Blackburn with Darwen CCG APPENDIX A

Summary Governing Body Report ‐ September 2019

Annual Forecast Budget to Date Expenditure to Date Variance to Date Annual Budget Annual Forecast Variance £000 £000 £000 £000 £000 £000

Revenue Resource Limit

Confirmed (133,918) (133,918) 0 (273,788) (273,788) 0 Anticipated 000000 Total Revenue Resource Limit (133,918) (133,918) 0 (273,788) (273,788) 0

Expenditure

Commissioning (Page 2) 130,542 130,690 (148) 260,511 260,737 (226) Corporate (Page 4) 1,599 1,569 30 3,199 3,198 1 Reserves (Page 4) 98 0 98 6,573 6,398 175 Healthcare Sub Total 132,239 132,259 (20) 270,283 270,333 (50)

Running Costs (Page 4) 1,679 1,659 20 3,505 3,455 50 Total Expenditure 133,918 133,918 0 273,788 273,788 0

Surplus/(Deficit) 000000

Better Payment Practice Code YTD Value (%) YTD Volume (%) FOT Value (%) FOT Volume (%) Target (%)

NHS 99.8 99.8 99.0 99.0 95.0

Non NHS 99.6 99.7 99.0 99.0 95.0 NHS Blackburn with Darwen CCG APPENDIX B

Healthcare Commissioning Report ‐ September 2019

Expenditure to Annual Forecast Budget to Date Variance to Date Annual Budget Annual Forecast Date Variance £000 £000 £000 £000 £000 £000

Acute Services

NHS contracts (includes Ambulance Services) 64,997 64,864 133 129,969 129,701 268 Non NHS Providers 3,142 3,410 (268) 6,219 6,752 (533) NHS Contract Exclusions / Cost per Case 299 305 (6) 518 522 (4) Non Contract Activity 1,039 981 58 2,078 1,963 115 Other 272 309 (37) 368 441 (73) Sub Total Acute Contracts 69,749 69,869 (120) 139,152 139,379 (227)

Mental Health Services

NHS contracts 9,104 9,102 2 18,187 18,187 0 Non NHS Providers 444 500 (56) 809 807 2 IPA ‐ Complex Packages 1,324 1,241 83 2,649 2,617 32 Non Contract Activity 403 403 0 450 450 0 Other 546 545 1 759 753 6 Sub Total Mental Health Services 11,821 11,791 30 22,854 22,814 40

Community Health Services

NHS contracts 7,458 7,458 0 14,916 14,916 0 Non NHS Providers 864 894 (30) 1,644 1,728 (84) IPA ‐ Complex Packages 121 121 0 241 242 (1) NHS Contract Exclusions / Cost per Case 190 189 1 380 380 0 Non Contract Activity 000000

Hospices 559 559 0 1,096 1,096 0 Other 000000 Sub Total Community Services 9,192 9,221 (29) 18,277 18,362 (85)

Total Healthcare Contracts 90,762 90,881 (119) 180,283 180,555 (272)

Continuing Care Services

Continuing Care 3,818 3,849 (31) 7,636 7,697 (61) Free Nursing Care 616 538 78 1,231 1,075 156 Sub Total Continuing Care Services 4,434 4,387 47 8,867 8,772 95

Primary Care Services

Prescribing 12,618 12,674 (56) 25,236 25,348 (112) Enhanced Services 1,205 1,140 65 2,491 2,426 65 Primary Care Co‐Commissioning 11,233 11,322 (89) 23,299 23,299 0

Out of Hours 683 682 1 1,365 1,365 0 Commissioning 1,350 1,339 11 2,599 2,599 0 Other 558 558 0 1,179 1,179 0 Sub‐total Primary Care services 27,647 27,715 (68) 56,169 56,216 (47)

Other Programme Services

Other Non Acute 4,573 4,584 (11) 8,939 8,947 (8)

Complex Cases & Individual Funding Requests 3,126 3,123 3 6,253 6,247 6 Sub Total Other Programme Services 7,699 7,707 (8) 15,192 15,194 (2)

Surplus/(Deficit) 130,542 130,690 (148) 260,511 260,737 (226) NHS Blackburn with Darwen CCG APPENDIX C

Main Healthcare Contracts ‐ September 2019

Expenditure to Annual Forecast Budget to Date Variance to Date Annual Budget Annual Forecast Date Variance £000 £000 £000 £000 £000 £000

Acute Contracts Main Provider

East Lancashire Hospitals NHS Trust 55,774 55,775 (1) 111,548 111,550 (2)

Other Lancashire Providers

Lancashire Teaching Hospitals NHS FT 2,847 2,805 42 5,694 5,611 83 Blackpool Fylde & Wyre Hospitals NHS FT 230 277 (47) 448 541 (93) University Hospitals Morecambe Bay NHS FT 69 63 6 138 126 12 North West Ambulance Service NHS Trust (Block) 3,894 3,913 (19) 7,787 7,827 (40) Sub Total Other Lancashire Providers 7,040 7,058 (18) 14,067 14,105 (38)

Greater Manchester Providers

University Hospital South Manchester NHS FT 000000

Salford Royal NHS FT 211 228 (17) 402 437 (35) Royal Bolton Hospitals NHS FT 139 154 (15) 278 309 (31) Wrightington, Wigan & Leigh NHS FT 524 444 80 1,052 891 161 Central Manchester University Hospital NHS FT 1,039 905 134 2,078 1,810 268 Pennine Acute NHS Trust 110 108 2 224 220 4 The Christie NHS FT 105 83 22 211 165 46 Sub Total Greater Manchester Providers 2,128 1,922 206 4,245 3,832 413

Merseyside Providers

Royal Liverpool & Broadgreen NHS Trust 55 108 (53) 109 216 (107) Sub Total Merseyside Providers 55 108 (53) 109 216 (107)

Independent Sector Contracts

BMI Healthcare (Beardwood, Beaumont, Gisburne) 2,906 3,059 (153) 5,732 6,037 (305) Ramsay 236 351 (115) 487 716 (229) Sub Total 3,142 3,410 (268) 6,219 6,753 (534)

Total Acute Contracts 68,139 68,273 (134) 136,188 136,456 (268)

Mental Health Contracts

Lancashire Care NHS FT (Block) 9,079 9,077 2 18,137 18,138 (1) Calderstones Partnership NHS FT (Block) 000000 Greater Manchester West NHS FT 16 16 0 33 33 0 Total Mental Health Contracts 9,095 9,093 2 18,170 18,171 (1)

Community Health Contracts

Lancashire Care NHS FT (Block) 7,458 7,458 0 14,916 14,916 0 Total Community Health Contracts 7,458 7,458 0 14,916 14,916 0

Surplus/(Deficit) 84,692 84,824 (132) 169,274 169,543 (269) NHS Blackburn with Darwen CCG APPENDIX D

Non Healthcare Commissioning Report ‐ September 2019

Annual Forecast Budget to Date Expenditure to Date Variance to Date Annual Budget Annual Forecast Variance £000 £000 £000 £000 £000 £000

Other Corporate Costs (Non‐Running Costs)

CSU re‐charge 000000 NHS Property Services re‐charge 1,327 1,341 (14) 2,653 2,682 (29) Other 272 228 44 546 516 30 Sub Total Corporate Costs 1,599 1,569 30 3,199 3,198 1

Plan requirements & reserves

Reserves 98 0 98 6,573 6,398 175 Sub Total Reserves 98 0 98 6,573 6,398 175

Running Costs

CCG Pay 867 846 21 1,778 1,778 0 CSU re‐charge 570 572 (2) 1,139 1,139 0 NHS Property Services re‐charge 67 67 0 133 133 0 Other 175 174 1 455 405 50 Running Costs Reserve 000000 Sub Total Running Costs 1,679 1,659 20 3,505 3,455 50

Surplus/(Deficit) 3,376 3,228 148 13,277 13,051 226 NHS Blackburn with Darwen CCG APPENDIX E

Statement of Financial Position ‐ September 2019

September Statement of Financial Position £000

Non Current Assets Intangible Assets 9

Total Non Current Assets 9

Current Assets Trade and Other Receivables 2,184 Financial Assets 0 Inventory 803 Cash and Bank 234

Total Current Assets 3,221

Total Assets 3,230

Current Liabilities Trade and Other Payables (4,632) Other Liabilities 0 Provisions (113) Borrowings 0

Total Current Liabilities (4,745)

Total Assets less Current Liabilities (1,515)

Non Current Liabilities Trade and Other Payables 0 Provisions 0 Borrowings 0 Other Liabilities 0

Total Non Current Liabilities 0

Total Assets Employed (1,515)

Financed By General Fund (1,515) Revaluation Reserve 0 Donated Asset Reserve 0 Government Grant Reserve 0 Other Reserves 0

Total Equity (1,515) BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

BLACKBURN WITH DARWEN CCG GOVERNING BODY AND EAST LANCASHIRE CCG GOVERNING BODY MEETING IN COMMON

Agenda Report Title: Finance Report 4.6b No: Meeting Date: 13 November 2019 Summary of Report: The report outlines the financial position for East Lancashire CCG at September 2019. Report Recommendations: The CCG Governing Body is asked to note the contents of this financial summary and the financial position of the CCG at the end of September 2019. Financial Implications: None Procurement Implications: None Report Category: Tick Support and recommend/forward the report. Approve the recommendations outlined in the report. Debate the content of the report. Receive the report for information. Y Author: Mrs Deidre Lewis, Head of Finance

Report supported & approved by your Senior Lead? Y Presented By: Mrs Kirsty Hollis, Chief Finance Officer and Deputy Chief Officer Other Committees Consulted: None Has a PIA been completed in respect of this report? Privacy Impact Assessment If No, provide reason below: N (PIA) If Yes, please attach not required Has an EIA been completed in respect of this report? Equality Impact Analysis If No, provide reason below: N (EIA) If Yes, please attach not required Data Protection Impact Is a Data Protection Impact Assessment Required? N Assessment Have any risks been identified / assessed? Y Risks: Potential Risks are highlighted in the report. Conflict of Interest: Is there a conflict of interest associated with this report? N Has any clinical engagement/involvement taken place as part N Clinical Engagement: of the proposal being presented. Patient Engagement: Have patients been involved in the drafting of this report? N Privacy Status: Can the document be shared Y

CCG Corporate Objectives :

To commission the best quality and effective services to deliver optimal healthcare CO1 outcomes for our local population. Ensure the balance of our health investment reflects our population’s needs and keeps CO2 √ the population well CO3 Deliver the 10 year strategy by engagement with the population we serve and ensure we commission services that meet local needs with a clear focus on population health management strategies CO4 We will focus on population health outcomes through helping to deliver successful Integrated Care Partnerships and ensure decisions, provision and access to local services is based on the needs of our population. CO5 As local health leaders, we will focus on increasing life expectancy across Pennine Lancashire to be at, or above the national average in the next 10 years.

FOR THE SIX MONTH PERIOD TO 30th of SEPTEMBER 2019 Statutory Duties KEY M6 Better/ 1% Better than Plan Worse

On Plan Revenue Resource Limit 1% Worse than Plan Cash Limit

Not Applicable NHS Better Payment Non Neutral awaiting Practice Code NHS information Financial Performance M6 Better /Worse

1% Recurrent Surplus

0.5 % NR Contingency

QIPP Performance – delivery of target - YTD QIPP Performance – delivery against identified schemes

Main Provider Performance Monthly Summary Infographic – September2019  Revenue Resource Limit (RRL) ◦ Expenditure MUST stay within the limits set for the financial year

Limit £’000 On Target Notes The figures reported are the total of both the Commissioning 654,438  notified and confirmed allocations and also Budgets includes the Primary Care Co Commissioning allocation transferred from NHS England. Running Costs 7,772 

 Cash Limit (CL) ◦ Cash spending must stay within the maximum cash drawdown allocated to the CCG for the year

Limit £’000 On Target Notes

The CCG is currently on target as regards spending being within the maximum CCG Total 646,699  allocated cash drawdown. This figure changes subject to any allocation adjustments.  Better Payment Practice Code (BPPC)

◦ The target is to pay ALL invoices within 30 days of receipt of a valid invoice

Cumulative On Target Performance for Year Target to Date End Notes Value 95% 99.8%  NHS Volume 95% 98.6%  With regard to the Better Payment Practice Code, the CCG is currently Value 95% 99.5%  exceeding target levels for both Non- NHS and non-NHS invoices. NHS Volume 95% 99.5%   1% Surplus ◦ The CCG has to plan to deliver a 1% surplus

Month 6 Month 6 Annual Planned Actual reported Surplus Surplus Surplus £’000 £’000 £’000 Confidence Dial Notes The CCG has planned for a surplus of £14,215 million . The CCG is currently on target to achieve the required level of surplus by year end. 14,215 7,107 7,107

Target Surplus 2019-20 15,000 Cumulative Plan £'000 Actual Achieved £'000

10,000

5,000

0 April May June July August Sept Oct Nov Dec Jan Feb March Statutory Duty Summary Financial Position Allocation Annual Plan Actual Performance Annual Plan M6 Plan M6 Actual

800 400 350 600 300

£m 250 400 200 £m 150 200 100 50 0 0 April May June July Aug Sept Oct Nov Dec Jan Feb March Acute Comm CHC MH Other Prog Primary Corporate Prescribing Care

The CCGs statutory duty is for expenditure not to exceed the Revenue In 2019-20 the CCG has planned for a surplus of £14.215m, currently the CCG Resource Limit for 2019-20 which is £662.2m, of which £7.8m relates to remains on target to deliver this surplus. running costs. As at month 6 the CCG is on target to meet this duty.

QIPP Cash Drawdown Annual Plan Cumulative Plan Cumulative Actual Cash Spending Limit 14.0 700

12.0 600 10.0 500 8.0 400 £'m 6.0 300 200 4.0 100 2.0 0 0.0 April May June July Aug Sept Oct Nov Dec Jan Feb March Identified Unidentified Total

For 2019-20 the QIPP target is £12.7m, of which £8.9m has been identified The CCG is permitted a cash drawdown limit £646.699m. in total of which £5.1m is non-recurrent. The balance of QIPP is being delivered via other mitigations i.e. holding back of investments. Significant Currently the CCG is on target to not exceed this limit. new QIPP schemes will need to be identified in order to recurrently achieve the required target. 2019/20 DEBTORS BY VALUE : NHS 2019/20 DEBTORS BY VALUE : NON-NHS 160 5,000

140 4,500 Total Debt 4,000 Total Debt 120 3,500 100 Over 60 Day Over 60 Day Debt 3,000 Debt 80 2,500

60 2,000 1,500 40 1,000 20 500 Total Debtors £'000 Total Debtors £'000 0 0 123456789101112 123456789101112 Total Debt 123 73 117 77 134 131 Total Debt 4,354 1,790 264 843 578 120 Over 60 Day Debt 13 12 10 9 11 15 Over 60 Day Debt 37 34 56 203 43 42

Monies owed to the CCG from NHS Organisations as at 30th of September 2019 Monies owed by Non-NHS organisations to the CCG as at 30th of September total £131k of which £42k is greater than 60 days. The main debtors as at month 2019 total £120k of which £57k is greater than 60 days. The main debtor is 5 are Pennine Acute and BwD CCG with£51k and £48k outstanding respectively. Fresenius Kabi with £40k outstanding.

2019-20 Creditors NHS £'000s 2019-20 Creditors Non NHS £'000s Total Due Amount > 30 days Total Due Amount > 30 days 35,500 33,500 2,500 31,500 29,500 27,500 25,500 2,000 23,500 21,500 19,500 1,500 17,500 15,500 13,500 11,500 1,000 9,500 7,500 5,500 3,500 500 1,500 -500 -2,500 0 April May June July Aug Sept Oct Nov Dec Jan Feb March April May June July Aug Sept Oct Nov Dec Jan Feb March Monies owed by the CCG to other NHS organisations totals £31.835m as at 30th Monies owed by the CCG to Non NHS organisations totals £406k of which of September 2019, £25.104m relates to October ELHT contract invoices which £103k is greater than 30 days outstanding. The largest creditor is Lancashire were paid on 1st of October. County Council at £125k. Annual Budget Year to Date (YTD) Position Annual Budget Actuals Variance Forecast Variance Trend £'000 £'000 £'000 £'000 £'000 Acute Commissioning East Lancashire 247,593 123,852 123,916 (64) (64)  Airedale 14,126 7,063 7,648 (585) (585)  Pennine Acute 6,950 3,475 3,440 35 46  Other Acute Providers 34,417 14,233 14,263 (31) (704)  Independent Sector 12,828 6,431 6,463 (33) (63)  North West Ambulance Services 15,317 7,659 7,664 (6) (10)  NCAS/OATS 2,316 1,158 1,416 (258) (516)  Urgent Care 216 108 107 1 0  Sub Total Acute Commissioning 333,762 163,978 164,918 (940) (1,896) 

Community Health 7,837 3,923 4,168 (245) (565)  ELHT Community Contract 35,758 17,879 17,879 0 0  Better Care Fund ‐ Community 13,038 6,519 6,519 0 7  Better Care Fund ‐ Mental Health14271710 (60)  Better Care Fund ‐ Acute 0000 0 Better Care Fund ‐ LCC Contribution 8,764 4,382 4,382 0 0 

Sub Total Community Services 65,540 32,775 33,019 (245) (618)  Mental Health 65,344 32,683 33,279 (596) (1,142)  Continuing Care 26,216 13,068 13,137 (69) 411  Other Commissioning 6,831 3,416 3,515 (99) (275)  Sub Total Other Commissioning 98,391 49,167 49,931 (764) (1,006)  Primary Care Local Enhanced Services 5,410 2,689 2,689 (0) 0  Co‐Commissioning 52,363 25,034 25,044 (10) (228)  Out of Hours 3,327 1,664 1,652 12 23  Oxygen 472 236 239 (3) 0  Central Drugs 1,800 900 872 28 50  Palliative Care 1376870(2) (4)  Prescribing 56,536 28,268 29,756 (1,488) (1,488)  Primary Care IT 1,438 719 719 0 0  Commissioning Schemes 966 480 433 46 54  GP Forward View 2,309 856 856 0 0  Sub‐total Primary Care Services 124,759 60,914 62,332 (1,417) (1,593) 

Corporate Costs (Non‐Running costs) 5,011 2,506 2,459 47 61  Corporate (Running Costs) 7,772 3,618 3,411 207 212 

Commissioning Reserves 12,760 3,113 0 3,113 4,841 

Reporting Surplus 14,215 7,107 0 7,107 14,215 

GRAND TOTAL 662,210 323,177 316,070 7,107 14,215 

Favourable variances are depicted in black. Adverse variances are depicted in red and in brackets. Mental Health Investment Standard - extract from Non ISFE reported to NHS E

Table 2: Mental Health Spend by Category

£'000s

Core Mental Health Mental Health in Other Areas Total Mental Health

Spend by Category 2019/20 Plan YTD Spend FOT FOT Variance 2019/20 Plan YTD Spend FOT FOT Variance 2019/20 Plan YTD Spend FOT FOT Variance

Children & Young People's Mental Health (excluding LD) 2,089 1,105 2,214 125 3,137 1,556 3,113 (25) 5,226 2,661 5,327 100 Children & Young People's Eating Disorders 748 366 733 (15) ‐‐748 366 733 (15) Perinatal Mental Health (Community) 346 247 494 148 475 (475) 821 247 494 (327) Improved access to psychological therapies (adult) 4,604 2,237 4,704 100 ‐‐4,604 2,237 4,704 100 A and E and Ward Liaison mental health services (adult) 348 387 1,200 852 ‐‐348 387 1,200 852

Early intervention in psychosis ‘EIP’ team (14 ‐ 65) 1,538 737 1,474 (64) ‐‐1,538 737 1,474 (64) Crisis resolution home treatment team (adult) 3,157 1,532 3,325 168 ‐‐3,157 1,532 3,325 168 Community Mental Health ‐ 2,074 4,178 4,178 1,365 494 987 (378) 1,365 2,568 5,165 3,800 Mental Health Act 2,568 1,606 3,497 929 ‐‐2,568 1,606 3,497 929 SMI Physical Health ‐ ‐‐ ‐‐‐‐‐ Suicide Prevention ‐ ‐‐ ‐‐‐‐‐ Other adult and older adult ‐ inpatient mental health (excluding dementia) 35,734 10,850 21,736 (13,998) 504 755 1,510 1,006 36,238 11,605 23,246 (12,992) Other adult and older adult mental health ‐ non‐inpatient (excluding

dementia) ‐ 5,268 9,622 9,622 ‐ 194 388 388 ‐ 5,462 10,011 10,011 Mental health prescribing ‐‐3,997 1,419 2,921 (1,076) 3,997 1,419 2,921 (1,076) Mental health in continuing care ‐‐2,650 407 1,200 (1,450) 2,650 407 1,200 (1,450) Sub‐Total 51,132 26,410 53,176 2,044 12,128 4,825 10,119 (2,010) 63,260 31,234 63,295 35

Learning Disabilities 7,357 5,259 10,759 3,402 4,093 2,047 4,463 370 11,450 7,306 15,222 3,772 Dementia 2,410 1,344 2,752 342 1,759 1,606 3,068 1,309 4,169 2,950 5,820 1,651 Total 60,899 33,012 66,687 5,788 17,980 8,478 17,650 (330) 78,879 41,490 84,337 5,458

As detailed in the above table the CCG is marginally over-achieving against its MHIS plan, overall delivering an additional 5.69% spend compared to 2018-19. Best Likely Worst Case Case Case Area Comment £’000 £’000 £’000

Acute SLA’s As at month 6 the CCG continue to report an overspend within the Acute sector , although there has been a slight improvement overall on the previous month. The CCG still has significant over-trade at Airedale, although month on month the position has marginally improved., the small project team continues to meet and review the position at Airedale to £1,896k £1,896k try and reduce the demand and subsequent over-performance. As at month 5 ELHT are £0k Adv Adv reporting over trade on the non-aligned elements of the contract, the CCG is working with the Trust to validate those forecast outturn assumptions, and until this has been validated the CCG continues to report a breakeven position with the Trust.

Prescribing PPA prescribing data is received two months after the months concerned. Hence only prescribing data for April to July 2019 has been received at the date of this report. The level £2,500k £3,000k £3,000k of charged costs in April to July coupled with the notification of a £1m central charge re Adv Adv Adv category M drugs has led to the forecasting of an adverse financial position re prescribing.

Primary Care For Primary Care currently a breakeven position is forecast for year end.. £0k £0k £0k

Based upon the latest information from NHS England, the Co-commissioning budget is forecast to breakeven. However significantly increased costs from NHSPS and CHP are £300k £500k Co-Commissioning likely to push the Co-commissioning budgets into an overspending position. Discussions £0k Adv Adv are currently ongoing with NHSPS and CHP. Funding has been set aside to mitigate, work is ongoing with both NHSPS and CHP to finalise the budget for 2019-20.

Continuing Care is shown with an overspend at month 6. Due to difficulties with the transition of packages from 18/19 to 19/20 on the ‘ADAM’ system a review is being Continuing Health undertaken with a year end underspend currently forecast. However in September, the (£411k) (£411k) £0k Care CCG saw a significant increase in the number of new packages approved, which has impacted on a deterioration on the forecast outturn.

As at month 6, the CCG is reporting an overspend on Mental Health budgets. The position continues to be reviewed. However any improvement in the position does not contribute to £1,142k £1,142k Mental Health the overall CCG position because we have to maintain delivery of the Mental Health £0k Adv Adv investment standard any reduced spend compared to plan has to be re-invested to maintain the level of investment. ELHT Activity Trend Analysis 7000 Planned Care Activity Trend Analysis 1400 Trend Analyis - Excess Bed Days 6000 1200 DC ELXBD 5000 EL 1000 NELNEXBD

4000 OPPROC 800 NELXBD

Linear (DC) Linear (ELXBD) 3000 600

Linear (EL) Linear (NELNEXBD) 2000 400 Linear (NELXBD) Linear (OPPROC) 1000 200

0 0 Jul-19 Jul-18 Jan-19 Jan-18 Jun-19 Jun-18 Oct-18 Oct-17 Feb-19 Apr-19 Feb-18 Apr-18 Sep-18 Sep-17 Dec-18 Dec-17 Jul-19 Jul-18 Mar-19 Mar-18 Nov-18 Nov-17 May-19 Aug-19 May-18 Aug-18 Jan-19 Jan-18 Jun-19 Jun-18 Oct-18 Oct-17 Feb-19 Feb-18 Sep-18 Sep-17 Apr-19 Apr-18 Dec-18 Mar-19 Dec-17 Mar-18 Nov-18 Nov-17 Aug-19 Aug-18 May-19 May-18

Activity for planned care has shown a decrease in August especially in day cases and outpatient Excess bed-days have shown a reduction in August after a significant increase in procedures. The position is being reviewed. July. The position is being monitored.

Trend Analysis - Unplanned Care A & E Activity Trend 3000 NEL 10000

NELNE 9000 2500 NELSD 8000 AandE 2000 NELST 7000 AANDE_MIU Linear (NEL) 6000 1500 Linear (NELNE) 5000 Ambulatory Care Emergency Unit Linear (NELSD) 4000 1000 Linear (AandE) Linear (NELST) 3000 500 2000 1000 0 0 Jul-18 Jul-19 Jul-19 Jul-18 Jan-19 Jan-18 Jun-18 Jun-19 Oct-18 Oct-17 Jan-19 Jan-18 Apr-18 Sep-18 Feb-19 Apr-19 Sep-17 Feb-18 Jun-19 Jun-18 Dec-18 Dec-17 Mar-18 Mar-19 Nov-18 Nov-17 Oct-18 Oct-17 Sep-18 Feb-19 Sep-17 Feb-18 May-18 Aug-18 May-19 Aug-19 Apr-19 Apr-18 Mar-19 Mar-18 Dec-18 Dec-17 Nov-18 Nov-17 Aug-19 Aug-18 May-19 May-18

As with planned care, unplanned care has shown a drop in August. The Activity within A & E and the MIU overall has decreased in August. position is being monitored. Ambulatory Care Emergency Unit Activity has been incorporated into this report to give a more complete picture. Airedale Activity Trend Analysis 400 300 Trend Analyis - Excess Bed Days 350 Planned Care Activity Trend Analysis DC 250 ELXBD 300 EL NELNEXBD 250 200 NELXBD OPPROC 200 150 Linear (ELXBD) Linear (DC) 150 100 Linear (NELXBD) Linear (EL) 100 50 50 Linear (OPPROC)

0 0 Jul-19 Jul-18 Jul-19 Jul-18 Jan-19 Jan-18 Jun-19 Jun-18 Jan-19 Jan-18 Oct-18 Oct-17 Jun-19 Jun-18 Feb-19 Feb-18 Sep-18 Sep-17 Apr-19 Apr-18 Oct-18 Oct-17 Dec-18 Mar-19 Dec-17 Mar-18 Feb-19 Feb-18 Sep-18 Sep-17 Apr-19 Apr-18 Nov-18 Nov-17 Aug-19 Aug-18 May-19 Dec-18 Mar-19 May-18 Dec-17 Mar-18 Nov-18 Nov-17 May-19 Aug-19 May-18 Aug-18

Despite a drop in May Outpatient Procedures have nearly tripled since the same period last ELXBD had shown a downward trajectory from February , however recent months have year. Airedale has given the reason for the spike in activity as being due to a change in the shown a slight increase. NELXBD has shown a drop in August. The position for both is being way they are counting/coding OPPROC, which had been communicated to the host CCG and monitored. remains a code of conduct query.

Trend Analysis - Unplanned Care A & E Activity Trend 250 1400 NEL 1200 200 NELNE 1000

150 NELST 800 AandE 100 Linear (NEL) 600

Linear (NELNE) 400 50 Linear (AandE) 200 Linear (NELST) 0 0 Jul-19 Jul-18 Jan-19 Jan-18 Jun-19 Jun-18 Oct-18 Oct-17 Sep-18 Feb-19 Apr-19 Sep-17 Feb-18 Apr-18 Jul-18 Jul-19 Dec-18 Dec-17 Mar-19 Mar-18 Nov-18 Nov-17 Aug-19 Aug-18 May-19 May-18 Jan-18 Jan-19 Jun-18 Jun-19 Oct-17 Oct-18 Sep-17 Feb-18 Apr-18 Sep-18 Feb-19 Apr-19 Dec-17 Dec-18 Mar-18 Mar-19 Nov-17 Nov-18 May-18 Aug-18 May-19 Aug-19

Overall unplanned care has remained on the same level in August as in July. Activity will The trend for A & E attendances remains on an upward trajectory despite the drop in March be monitored going forward. and April.  Winter Resilience – Plans are being worked up jointly with ELHT for presentation to the A & E Delivery Board in August, however the latest financial ask exceeds the funding currently set aside, ongoing discussions are being held to identify offsetting mitigations.

 QIPP 2019/20 – based upon the latest financial plan, the CCG will be required to deliver QIPP savings in 2019/20 circa £12.72m. £11.4m of schemes have been identified however £5.1m non recurrently and £3.8m recurrently of the £11.4m. The CCG has mitigations in place for 2019-20. Any shortfall in 2019-20 will be first call on growth monies in 2020-21.

 ELHT – The CCGs have invested significantly into the ELHT contract in 2019-20 to enable the provider to agree their control total, as part of that agreement and also to support managing the ICP system risk an aligned contract has been developed and agreed The aligned contract has been based upon system costs as opposed to income and should support progress towards system balance. Unfortunately there still remains a system shortfall of £2.5m which has been distributed across the 3 ICP partners equitably and still requires closing.

 LD Transformation – in line with the national directive, Learning Disability (LD) services are undergoing a transformation. Our main local provider Mersey Care NHS FT (formerly Calderstones NHS Trust) LD clients will be re-settled within the community and there is a potential risk that the associated costs of re-settlement will be higher than the current service provision. As at September 2019 the majority of East Lancashire CCG clients have been re-settled, however whilst the site remains open the CCG are still required to support the transitional costs. In addition as part of the LD transformation agenda CCGs were set a planned level of discharges for 2018-19, unfortunately this was not achieved and as a result it is likely that funding in 2019-20 will be reduced giving a potential financial pressure.

 Following an announcement by NHS England that CCGs have a responsibility to accept and review cases for periods of care since 1st April 2012 (Retrospective Review Post Cases), initial numbers indicate the CCG currently have 38 cases of which, 5 have been deemed not eligible; 33 are still pending review/outcome, future cases are estimated at approximately 4 per annum. Latest information from MLCSU is that potentially the CCG may have to fund circa £1.674m for these packages, the calculation has been based on an average weekly nursing care rate of £535, should all cases meet the eligibility criteria. The CCG has prudently planned for the majority this risk in 2018-19, early indications are that approximately 27% claims may be successful. The MLCSU are currently reviewing those o/s packages and will provide regular updates on the potential success of those claims. Potential Risks Continued

 The CCG are required to increase their investment in Mental Health spend equivalent to the level of growth they received + 0.7%, for East Lancashire CCG this equates to 5.64%. Funding has been set aside to meet this target. However as a result of the North Tyne & Wear review of LCFT there is a risk that additional investment will be requested over and above the funding currently set aside by the CCG.

 Mental Health Out of Area placements, as part of the planning round CCGs, were requested to set funding aside for OAPs. The latest intelligence indicates that the latest forecast outturn will significantly exceed the funding set aside. The forecast continues to be reviewed for robustness.

 CHC/MH IPA projections from the CSU re future commitments vary significantly month on month making forecast outturn difficult to project. In addition the transition of packages from 2018/19 to 2019/20 was problematic leading to significant cleansing of the ‘Adam’ data by the MLCSU IPA Team. The forecast will continue to be scrutinised and challenged where appropriate.

 Prescribing – due to the challenging QIPP target levied on the prescribing budget plus notification of a significant central charge to prescribing budgets re Category M drugs, the prescribing budget will overspend. The outturn level of overspending suggests an overspend circa £3m however this may increase depending on the extent of the anticipated charge re Category M drugs from October.

 Mental Health Investment Standard – Guidance MH Prescribing In both 2017-18 & 2018-19 the mechanism the CCG used to count Mental Health prescribing spend, was to apportion prescribing costs based upon the programme budgeting % allocated to Mental Health. As part of the Mental Health Audit for the financial year 2018-19 guidance was introduced that stated spend should be identified using specific mental health drugs. This has resulted in an impact circa £1m for the CCG of reduced spend in 2019-20 compared to plan. Should NHS England not re-state the plan for 2018-19, based upon this reduction there is a risk that the CCG may fail its Mental Health Investment Standard unless we are able to identify additional spend to compensate.  Stroke – East Lancashire Hospitals Trust are working towards an improvement in the Stroke pathway. The CCG have agreed to work with the Trust to ensure any changes are in line with CCG strategy and agreed Lancashire wide stroke pathways.

 Pennine Lancashire Transformation Programme Team are working on delivering the ‘Case for Change’ model, focussing on six key areas of enquiry to ensure affordability; health outcomes and inequality gap; current care delivery system; technology and innovation; workforce and citizen participation and empowerment. The CCGs Corporate Business Plan will ultimately feed into the Integrated Partnership Work programme to support delivery of the NHS Long Term Plan and deliver local efficiencies.

 Although the CCG met the required target for Personal Health Budgets in 2018-19 there is an increased trajectory for 2020/21 which the CCG will need to deliver.

 The ICS may require further funding to support transformational schemes including CAMHS, Learning Disability; Mental Health and Stroke which may have an impact upon the CCGs financial position.

BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

Blackburn with Darwen CCG Governing Body & East Lancashire CCG Governing Body Meeting in Common

Agenda Report Title: Quality Assurance Report 4.7 No: Meeting Date: 13th November 2019 Summary of Report: This paper outlines for Governing Body members recent national policy documents, publications and conferences along with quality improvement work to improve the health and care of our population. Report Recommendations: Note the content of the report Financial Implications: None Procurement Implications: None Report Category: Tick Support and recommend/forward the report. Approve the recommendations outlined in the report. Debate the content of the report. Receive the report for information.  Author: Quality and Performance Team Officers

Report supported & approved by your Senior Lead? Y Presented By: Mrs Kirsty Hollis – Director of Finance Other Committees None Consulted: Has a PIA been completed in respect of this report? Privacy Impact Assessment N (PIA) If Yes, please attach If No, provide reason below. Has an EIA been completed in respect of this report? Equality Impact Analysis N (EIA) If Yes, please attach If No, provide reason below. Data Protection Impact Is a Data Protection Impact Assessment Required? N Assessment Risks: Have any risks been identified / assessed? N Conflict of Interest: Is there a conflict of interest associated with this report? N Has any clinical engagement/involvement taken place as part N Clinical Engagement: of the proposal being presented. Patient Engagement: Have patients been involved in the drafting of this report? N Privacy Status: Can the document be shared Y

CCG Corporate Objectives :

To commission the best quality and effective services to deliver optimal healthcare CO1  outcomes for our local population. Ensure the balance of our health investment reflects our population’s needs and keeps CO2  the population well CO3 Deliver the 10 year strategy by engagement with the population we serve and ensure we commission services that meet local needs with a clear focus on population health  management strategies CO4 We will focus on population health outcomes through helping to deliver successful Integrated Care Partnerships and ensure decisions, provision and access to local  services is based on the needs of our population. CO5 As local health leaders, we will focus on increasing life expectancy across Pennine Lancashire to be at, or abote the national average in the next 10 years. 

1 Agenda Item No: 4.7

Blackburn with Darwen CCG Governing Body & East Lancashire CCG Governing Body Meeting in Common

13th November 2019

Quality Assurance Report

1. Introduction

1.1 This paper outlines for Governing Body members recent national policy documents, publications and conferences along with quality improvement work underway across the local health care economy to improve the health and care of our population.

2. Provider Updates

2.1 BMI Healthcare Limited

2.1.1 CQC Inspection BMI: The Lancaster

The CQC published an inspection report on the 15th October 2019, for the inspection carried out at BMI The Lancaster Hospital on the 14th and 15th May 2019.

The rating of the hospital stayed the same with an overall rating of ‘Requires Improvement’. The CQC found that diagnostic imaging and outpatient services required improvement, however found good practice in surgery services.

Following the inspection, the CQC have told the provider that it must take some actions to comply with the regulations and that is should make other improvements, even though a regulation had not been breached, to help the hospital improve. BMI were issued with two requirement notices that affected outpatient and diagnostic services.

The CCG will continue to work with and support BMI with their compliance to the requirement notices.

2.2 East Lancashire Hospital Trust

2.2.1 Chartered Institute of Public Relations (CIPR) Pride Awards

The CIPR Pride Awards are a regional public relations awards which recognise outstanding work being delivered by organisations. ELHT has been nominated for a Best Publication Award for their Share 2 Care publication ‘A focus on Human Factors’. The awards ceremony is scheduled to take place on 29th November 2019.

2.2.2 National Stroke Audit

Stroke services at ELHT have been rated ‘A’ in the national stroke audit for the fourth successive quarter. The audit measures both the processes of care provided to stroke patients as well as the structure of stroke services against evidence-based standards.

2 2.3 Lancashire and South Cumbria Foundation Trust (LSCFT)

2.3.1 Quality Improvement

Listening into Action The Trusts Listening into Action (LiA) programme is underway; improvements have been noted in the response rate for the Staff Pulse Check Survey with a 65% response rate overall and 100% for Doctors. Feedback has highlighted 15 overarching themes that will have 20-week improvement programmes allocated. All programmes are expected to have commenced by the end of October 2019. LiA newsletters are being distributed to ensure effective communication is in place for staff over the 20-week programmes.

A ‘Chat with Caroline’ Staff within the Trust have been given the opportunity to engage directly with Caroline Donovan, Chief Executive, every two weeks. Staff are able to submit questions through a live interactive broadcast, which are then answered by the Chief Executive and other colleagues. Recordings of these sessions are available to view on the Trusts website.

Wellbeing and Mental Health Texting Service LSCFT have launched a confidential texting service for people in Lancashire who may be experiencing issues which affect their wellbeing. Lines are open Monday to Friday 7pm to 11pm and weekends 12pm until midnight.

Excellence in Supply Awards 2019 The Trust has been shortlisted for the NHS in the North Excellence in Supply Awards 2019 in the NHS Procurement category in recognition of the work undertaken in supporting delivery of a new Health and Social Care Network across the Lancashire Integrated Care System.

3.0 Primary Care

3.1 myGP

On 31st January 2019, NHS England published the five-year framework for GP’s which detailed specific digital improvements. Healthier Lancashire and South Cumbria are leading on the development and have invested in myGP, a healthcare application which supports patients to book and cancel appointments with their GP surgery, order repeat prescriptions, care for loved ones by adding dependents and monitor and track their own health.

All practices in BwD CCG are enabled (23), with 13% of the practice population having downloaded the application. Rollout to EL CCG practices is currently underway and there are currently 10 of 49 practices enabled.

A programme of work is underway to support practices in their use of myGP and increase its functionality across the Region.

3.2 Sepsis

The Primary Care Quality Team have been working with Primary Care to improve awareness of Sepsis, supported by a GP Education event which took place in September 2019. Information has been circulated to Practices relating to the requirement for a Sepsis Lead within each GP Practice along with the Royal College of GPs Top Ten Tips for a Sepsis Lead and online training and resources for all practice staff.

3 4. Self-Care Week

Between 18th November 2019 to 24th November 2019 is Self-Care Week across the country, which is an annual national awareness week that focuses on providing support for self-care across communities and families. This year the emphasis is on self-care for life ad the CCGs will be promoting the week via social media.

5. National Clinical Audit and Patient Outcomes Programme (NCAPOP)

There are six recently published clinical audit reports, which ask Commissioners to action recommendations on access to services and treatments, standards and outcomes, workforce development and service delivery networks: - National Clinical Audit of Anxiety and Depression - National Diabetes Audit - National Pregnancy in Diabetes - Medical and Surgical Clinical Outcome Review Programme – Pulmonary Embolism - Maternal, Newborn and Infant Mortality Surveillance and Saving Lives, Improving Mothers Care - National Early Inflammatory Arthritis Audit

All the reports can be found on the Healthcare Quality Improvement Partnership: https://www.hqip.org.uk/

6. Conclusion

This paper outlines information in relation to recent national policy documents, publications and conferences and quality improvements being undertaken by commissioned Providers.

7. Recommendations

7.1 Members are asked to:  Note the content of the report

Mrs Kirsty Hollis Chief Finance Officer November 2019

4 BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

BLACKBURN WITH DARWEN CCG GOVERNING BODY AND EAST LANCASHIRE CCG GOVERNING BODY MEETING IN COMMON

Governing Body Sub-Committees and Groups’ Agenda Report Title: 5.2a Minutes No: Meeting Date: 13th November 2019 Summary of Report: This report presents the minutes of the Governing Body Sub- Committees and Groups for receipt and note by members. Report Recommendations: The Governing Body is requested to receive and note the content of the report. Financial Implications: None Procurement Implications: None Report Category: Tick Support and recommend/forward the report. Approve the recommendations outlined in the report. Debate the content of the report. Receive the report for information. √ Author: Mr Iain Fletcher, Head of Corporate Business, Blackburn with Darwen CCG Report supported & approved by your Senior Lead? Y Mrs Debra Atkinson, Head of Corporate Business, East Lancashire Presented By: CCG Other Committees No Consulted: Has a PIA been completed in respect of this report? Privacy Impact Assessment N (PIA) If Yes, please attach If No, provide reason below. Has an EIA been completed in respect of this report? Equality Impact Analysis N (EIA) If Yes, please attach If No, provide reason below. Data Protection Impact Is a Data Protection Impact Assessment Required? N Assessment Have any risks been identified / assessed? N Risks: Conflict of Interest: Is there a conflict of interest associated with this report? N Has any clinical engagement/involvement taken place as part N Clinical Engagement: of the proposal being presented. Patient Engagement: Have patients been involved in the drafting of this report? N Privacy Status: Can the document be shared Y

CCG Corporate Objectives :

To commission the best quality and effective services to deliver optimal healthcare CO1 outcomes for our local population. Ensure the balance of our health investment reflects our population’s needs and keeps CO2 the population well CO3 Deliver the 10 year strategy by engagement with the population we serve and ensure we commission services that meet local needs with a clear focus on population health management strategies CO4 We will focus on population health outcomes through helping to deliver successful Integrated Care Partnerships and ensure decisions, provision and access to local services is based on the needs of our population. CO5 As local health leaders, we will focus on increasing life expectancy across Pennine Lancashire to be at, or about the national average in the next 10 years.

Page 1 of 2

BLACKBURN WITH DARWEN CCG GOVERNING BODY AND

EAST LANCASHIRE CCG GOVERNING BODY

MEETING IN COMMON

13TH NOVEMBER 2019

GOVERNING BODY SUB-COMMITTEES AND GROUPS’ MINUTES

1. Introduction

This report presents the minutes of the Governing Body Sub-Committees and Groups for receipt and note by members.

The minutes inform members of delegated and key decisions taken and provide information regarding items of particular interest or potential risk.

2. Sub-Committees

2.1 Primary Care Co-Commissioning Committee

The ratified minutes of the meetings held on 23rd July 2019 are attached as Appendix 1.

2.2 Pennine Lancashire Quality Committee

The ratified minutes of the meetings held on 25th July, 28th August and 25th September 2019 are attached as Appendices 2, 3 and 4.

2.3 Blackburn with Darwen CCG Commissioning Business Group and East Lancashire CCG Sustainability Committee meeting as Pennine Lancashire Committees in Common.

The ratified minutes of the meetings held on 21st August 2019 are attached as Appendix 5.

2.4 Information Governance Steering Group

The ratified minutes of the meeting held on 11th June 2019 are attached as Appendix 6.

3. Recommendation

The Governing Body is requested to receive and note the content of the report.

Iain Fletcher Head of Corporate Business Blackburn with Darwen CCG 31st October 2019

Page 2 of 2 Appendix 1

CLINICAL COMMISSIONING GROUP (CCG) Minutes of the Primary Care Commissioning Committee (PCCC) held on Tuesday 23rd July 2019 Board Room, Fusion House PRESENT: Mr Graham Burgess CCG Chair Dr Nigel Horsfield Lay Member (Deputy Chair) Mr Roger Parr Deputy Chief Officer /Chief Finance Officer Mrs Kathryn Lord Director of Quality & Chief Nurse Dr Geraint Jones Lay Member Secondary Care Doctor (Retired) Mr Paul Hinnigan Lay Member Governance

IN ATTENDANCE: Mrs Catherine Lawless Primary Care Support Assistant (Minutes) Mr Peter Sellars Primary Care Transformation Manager Dr Stephen Gunn GP Education Lead Mrs Sarah Johns Blackburn with Darwen Healthwatch

Min No: 1. Chair’s Welcome

The Chair welcomed everyone to the meeting and gave a short briefing with regards to the content of the agenda.

The Chair reminded members that the meeting will be digitally recorded in line with the Primary Care Co Commissioning Terms of Reference. 2. Apologies for Absence and Confirmation of Quoracy

Apologies for absence were received from: David Massey, Dr Preeti Shukla, Sarah Danson and Lysa Hasler

The meeting was confirmed as quorate. 3. Declarations of Interest

The Chair reminded Members of their obligation to declare any interest that they may have on any issues arising at Committee Meetings which might conflict with the business of BwD CCG. The Chair asked members if they would like to declare any Conflicts of Interest (CoI) relating to items on the agenda.

Declarations declared by members of the PCCC are listed in the CCG’s Register of Interests. The Register is available, either via the Secretary to the GB or the CCG website via the following link:

http://www.blackburnwithdarwenccg.nhs.uk/about-us/registers-interests/

The Chair reminded those present that if, during the course of discussion, a CoI became apparent, it should be declared at that point.

Page 1 of 4 4. Questions from the Public

No questions had been received from members of the public. 5. Draft Minutes of the Meeting held on 21st May 2019

The minutes of the previous meeting were reviewed and accepted as an accurate record.

RESOLVED That the minutes of the meeting held on 21st May 2019 were approved as an accurate record. 6. Action Matrix

Actions noted. 7. Matters Arising

Matters to be discussed as agenda items. 8. Primary Care Co Commissioning Terms of Reference – The Chair asked Committee members to note the amendments to the membership which now include the Joint Chief Officer and the Director of Quality & Chief Nurse.

CONCLUSION: That the Committee approved the amendments. ACTION: CL - Terms of Reference to go to Blackburn with Darwen CCG Governing Body. 9. Primary Care Update Report

Mr Peter Sellars presented the Primary Care Update report which brought to the attention of members National and Local Primary Care news and information.

Blackburn with Darwen Primary Care Networks (PCN) – PS advised that all 23 Blackburn with Darwen GP practices have now signed up to the Network Contract Directed Enhanced . Services Directions (DES). The focus for PCN’s in 19/20 is to support the establishment of Primary Care Networks, the recruitment of a new workforce and to develop their governance arrangements with a decision making framework. PS advised that the PCN’s membership across Blackburn with Darwen has been slightly amended and advised that Little Harwood Health Centre is now in the West PCN. It was noted that Little Harwood Health Centre’s Practice Manager works across the two sites and also advised that their practice population is also in the West area. Hollins Grove Surgery is now in the North PCN. PS advised that this is due to Dr Zaki Patel becoming the new contract holder at Umar Medical Centre in the North with plans at a later date to merge both practices.

Digital Update: Apex/Insight Tool – PS advised that NHSE have temporarily paused deployment of the Apex tool until NHS England work through their position on an information governance query. The CCGs Data Protection Officer (DPO) Lead is currently reviewing the equality impact assessments and once validated will go the CCGs Senior Information Risk Owner (SIRO) for final approval. The NHS England funded offer includes the use of both Apex and Insight at ‘Enterprise’ level. The Enterprise tools allow users to conduct workforce planning and activity analysis across a group of practices – these could be Networks, Federations and CCGs . A meeting is planned in August to discuss next steps.

iPLATO/MyGP App – PS advised that deployment is progressing well for Blackburn with Darwen GP Practices. The app allows patients to register remotely and once signed up, they can book and cancel appointments, set medication reminders and make use of a secure instant messaging service. PS further advised that this also assists practices in achieving their NHSE requirements for online consultation. Blackburn with Darwen CCG has purchased SMS credits for Blackburn with Darwen GP Practices for the year for use with iPlato. The credits have been shared out according to practice list size as of 31st March 2019. Practices will be responsible should they exceed their allocation. Practices have been asked to promote the myGP App as much as possible as there is no cost to the practice.

Page 2 of 4 Medicines Management Update – PS advised that despite supply issues driving costs up for a number of key medicines, the prescribing budget was kept under control throughout 2018/19 ending the year with a spend of nearly £1 million less than the previous year.

Prescribing Hub – PS advised that the Blackburn with Darwen Federation run the prescribing hub at Barbara Castle Way Health Centre which started in 2018. There are currently 4 practices involved with the remaining practices to come on board by March 2020. Early analysis of the prescribing data shows a downward trend in prescribing since October 2018.

Community Pharmacy Referral Scheme – PS advised that the Darwen PCN was one of two PCNs across Lancashire and South Cumbria Integrated Care Systems (ICS) to be selected by NHSE to take part in the pilot, whereby patients requesting appointments for minor illnesses are referred digitally to a community pharmacist for consultation. The pilot has shown a considerable shift in helping GP practices to free up appointments to deal with more patients with long term conditions.

West Scheme: Following the last Committee meeting PS advised that the outline business case (OBC) is to be reviewed and will be brought back to the September meeting of the Primary Care Co Commissioning Committee.

Blackburn with Darwen Workforce Data: PS advised that Blackburn with Darwen practices are required on a quarterly basis to input their practice data on to the National Workforce Reporting System. Unfortunately some practices have been unable to log on and as such the data supplied is incomplete. PS advised an accurate data collection on Blackburn with Darwen workforce will not be available until the end of November 2019. KL advised that Anne Greenwood at NHSE has been working on developing a baseline for workforce nationally and could help with data on workforce for Blackburn with Darwen. PS further advised that the next steps for Apex is looking at the Enterprise tools which allow users to conduct workforce planning and activity analysis across a group of practices and could also be used to get a better understanding of workforce requirements. ACTION: Agenda Item November – Baseline Assessment on BwD Workforce. Apex Tool: An update to be provided on what the tool can do and also what the CCG will be able to extract from the tool to help inform on workforce across Blackburn with Darwen.

Questions and answers followed:

Primary Care Networks: The Chair raised concern on how the changes in membership to the West and Darwen PCN’s will effect working arrangements with other local authority services, and asked that a report be written on how they will link together geographically. ACTION: PS to provide a report how other services in the borough will be able to link in with neighbouring PCNs. The Committee asked that key areas/milestones of PCN development be supplied to the Committee in order for them to be assured that Blackburn with Darwen is on target. ACTION: PS to develop a plan of PCN achievement/milestones.

Community Pharmacy Pilot – ACTION: Evaluation of pilot to be brought to the attention of the PCCC.

CONCLUSION: That the PCCC noted the contents of the Primary Care Update Report.

10. Practice Relocation Proposal – PS asked the Committee to note the contents of the report and approve the proposed template business case for use in all other GP practice relocation applications. Committee members made comment that this would be useful document to use

Page 3 of 4 going forward. It was requested that the benefit to patients should form part of the template.

CONCLUSION: That the PCCC approved the business case for GP relocation applications once the amendment is made. ACTION: PS to speak to LH at NHSE. 11. PMS/GMS/APMS Contracts Update: PS advised that there are currently two APMS practices and three PMS practices. The three PMS practices have all been written to and are in the process of receiving their financial statements. It was noted that one practice Hollins Grove wishes to convert to a GMS practice so they can merge at a later date. It was noted that the APMS Contract for extended access runs until 2021 and then the funding will be transferred to Primary Care Networks.

CONCLUSION: That the PCCC noted the update on the PMS/GMS/APMS Contracts 12. Mellor Surgery – PS confirmed that SD has contacted the district valuer with regards to Oakenhurst branch Surgery in Mellor. 13. Primary Care Financial Summary Month 3 – For Information

CONCLUSION: That the PCCC noted financial position for Primary Care Services as of month 3. 14. Physicians Associate Case Studies 14.1 Job description Physicians Associate 14.2 Job description Paramedic

CONCLUSION: Job description Physicians Associate/Job description Paramedic That the PCCC noted the job descriptions for both the physicians associate and the paramedic and made comment there is no information as to the whether the practice offers support and mentorship and that there is also no information on career development. ACTION: PS to feedback comments to Darwen Health Care.

CONCLUSION: That the PCCC noted the case studies for the physician’s associate role and asked that they be shared with other practices as the physician’s associate role has made a positive impact on the practice. ACTION: PS to feedback comments to Darwen Health Care.

15. Primary Care Work Plan – That the PCCC noted the Primary Care Work Plan. AOB There was no any other business noted. 13. Date and Time of Next Meeting The next meeting is scheduled for Tuesday 17th September 12.30 – 2.00 p.m. Board Room, Fusion House.

The Chair thanked everyone for their attendance and input and stated that the meeting would now move into Part 2.

Page 4 of 4 Appendix 2

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

PENNINE LANCASHIRE QUALITY COMMITTEE Minutes of the meeting held on 25th July 2019 PRESENT:

Name and Title Org. 2018 2018 2018 2018 2018 2018 2018 2019 2019 2019 2019 2019 2019 2019 27/06 27/06 25/07 22/08 02/10 24/10 28/11 19/12 23/01 27/02 27/03 24/04 22/05 26/06/ 25/07/ Clinical Representatives (two needed): Lay Advisor: Quality and Patient Engagement – Chair ELCCG   A     A  A     Michelle Pilling Secondary Care Doctor (retired) BwDCCG  A  A   A      L  Geraint Jones: Chair Chair Chair Chair Associate Director of Quality and Commissioning BwDCCG  A  A - A  A A  -  A A Janet Thomas Associate Director of Quality and Nursing / Head of Quality ELCCG E A   A          Kathryn Lord until August 2018; Caroline Marshall from August 2018 Chief Finance Officer ELCCG  A A AR AR AR E AR A A AR A  A Kirsty Hollis Director of Performance and Delivery / Director of Commissioning ELCCG  A    AR E AR A A AR AR AR  Sharon Martin until August 2018; Alex Walker from August 2018 Director of Quality & Chief Nurse (Clinical Post) ELCCG   A   A    A AR   A Jackie Hanson until August 2018; Kathryn Lord from August 2018 Director of Quality and Performance (Clinical Post) BwDCCG       A      A  Dr M Ridgway until October 2018; Dr Ridwaan Ahmed from November 2018 Governance, Assurance and Delivery Manager BwDCCG A  A  A A   A    A  Claire Moir GP Quality Lead (Clinical Post) ELCCG E  A  A  A A     A  Dr Umesh Chauhan GP Representative (Clinical Post) BwDCCG A A A A A A   A    A  Dr Stephen Gunn GP Representative (Clinical Post) ELCCG   A  A  A    A  A A Dr Zeenat Sykes Lay Member BwDCCG               Dr Nigel Horsfield Secondary Care Consultant ELCCG  A      A  A  A  A Dr Paul Taylor Medicines Management Representative (one needed): Senior Operating Officer, Primary, Community & Medicines Commissioning BwDCCG ------A - A - - - - A Julie Kenyon Associate Director of Research, Medicines & Clinical Effectiveness ELCCG   A    A   A     Lisa Rogan Safeguarding Representative (one needed): Head of Safeguarding (Adults) and MCA Leads PLCCG -   A -   -      A Peter Chapman Head of Safeguarding (Children) PLCCG  - - -  ------A Susan Clarke Head of Safeguarding (Children) PLCCG - - - -  - -  - A - - -  Debbie Ross Clinical Representatives: : present A: apols L: arrived late E: left early R: representative in attendance

In Attendance:

Ruth Administration, BwD CCG Simon Bradley Quality & Performance Manager (Pennine) MLSCU Vanessa Morris Infection and Prevention Control Nurse (Pennine) Lewis Wilkinson Quality and Performance Office MLSCU Deirdre Lewis Deputy CFO, ELCCG Jillian Wild DGM Medicines and Emergency, ELHT Travis Peters Equality and Inclusion Business Partner MLSCU Kirsty Hamer Commissioning Lead Childrens, Family and Maternity (Pennine) Adele Thornburn Nursing and Quality Manager (Pennine)

Quoracy shall consist of 50% of the Committee and must include 1 Non-Executive Governing Body Member / Executive Governing Body Member from each CCG, and one clinical representative from each CCG, one of whom must be a GP.

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REF: ACTION 19.145 Welcome & Chair’s Update

The Chair opened the Pennine Lancashire Quality Committee and welcomed all attendees. 19.146 Apologies

Apologies were received as above. 19.147 Declarations of Interest

No declarations of interest noted. Any that transpire during the meeting are to be declared.

The meeting was quorate. 19.148 Minutes of the Meeting held on 26th June 2019

Two amendments were requested for the minutes of the meeting held on 26th June 2019.

19.125 Neurology Update: “S Flynn to share the NHS England Peer Review Report on Neurosurgery” should read “Neurology”.

19.133 Medicines Management Update

The paragraph needs to be amended to read: “Dr L Rogan provided a brief summary of the patient safety work undertaken on DOAC prescribing with a focus on checking renal function and Hb levels and highlighted some of the findings discussed at the Eclipse Conference. A template has been developed by the Medicines Management Team that has been embedded in EMIS to improve the safety of anticoagulation prescribing in Primary Care.”

The comment was made that Katherine had just flagged up that the wording should be changed to read “… to try and contact patient representatives who have substance misuse” rather than “… to try to contact patient representatives that have struggled with opioid use.”

With the above amendments, the minutes were recommended for approval as an accurate record of the meeting.

19.149 Action Matrix

19.083.2 Pennine Lancashire Referral to Treatment Neurology Performance Report SB commented that the specialty pressures are now included in the report and cover the actions being taken to address the wider position. J Wild has covered some of the urgent care issues in her presentation. The Chair thanked the team for this information as it is helpful to have the additional narrative within the report.

19.084.1 Pennine Lancashire Primary Care Update The Chair spoke of the issue concerning the Friends and Family test, She informed the members that she had received a letter that went out to all Chief Executives of all Trusts, Accountable Officers of CCGs and Primary Care Professional Bodies on 10th July 2019 announcing the forthcoming changes to the Friends and Family test following extensive consultation and research. It concerned the feedback regarding the mandatory question which they felt could be clearer and more accessible, which lead to the formulation of a new universal mandatory question. She read the letter to the members and commented that she believed the conversations previously held in this committee meant members were already sighted on the issues, which was positive. More information will be available in September 2019 about how this will change before it comes into force in April 2020. The intention is that the same principles across the Lancashire area. The Chair confirmed she was happy to

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close this action; she has spoken to Katherine and will get the third report from the Workshops.

19.086.3 Pennine Lancashire Quality and Performance Report Month 11 LCFT: IAPT JJ The Chair advised that J Johnston would be able to provide an update in her scheduled Aug report for August 2019. 2019

19.103: Minutes of the Meeting held on 27 March 2019 The Chair confirmed this action was complete.

19.062 Pennine Lancashire Quality and Performance Report Month 10 ELHT: A&E Breaches J Wild has agreed to present her report to committee in July 2019. This action to remain open until her presentation.

19.108.1: Pennine Lancashire Quality and Performance Report Month 12 52-week Waits It was advised that this action is with Specialised Commissioning and not Blackpool CCG. C Marshall has been in contact with Spec Comm and is awaiting a response. It was confirmed that the patient awaiting cardiology surgery had not experienced any harm or adverse consequences as a result of awaiting surgery. The patient is now 8-weeks post-surgery and had recovered well. This action can be closed once Spec Comm have been in contact with C Marshall

19.108.2: Pennine Lancashire Quality and Performance Report Month 12 CQC The staffing pressures will be discussed at the Scheduled Care Board, once it is established. A Demand Management review is being undertaken to ascertain what services could be moved to a community setting. The outcome of this will be reported in the Quality Report when available. This is being supported with NHS Improvement. This action can be closed.

19.108.5: Pennine Lancashire Quality and Performance Report Month 12 CQC The Chair confirmed this action could be closed

19.112: Pennine Lancashire Complaints Report 2018/19 Quarter 4 Sarah Harrison, Head of Patient Feedback Team at LCFT, was to have attended the meeting today, but needed to send her apologies. She has been rescheduled for September 2019. This action to be kept open until complete. The Chair asked that S Harrison be informed about the issues with 12-hour patients, as discussed with J Wild today, so that this could be covered within the report.

19.124 The Terms of Reference This action has been completed. The ToR are on the agenda today for final comments. N Horsfield advised that his title was incorrect. These are to be amended.

19.125.1 The NHS England Peer Review Report on Neurosurgery SF Steve Flynn to be reminded to share this report.

19.125.2 Presentation: Neurology Pathway K Hollis had provided an update, advising that the ICS has included Neurology as a workstream, and it is being considered as a priority area, although no specific timescales have been provided. It was stated that the ICS has set its work programme for this year and this was not included, so members asked that this be expressed to the ICS as an area of

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high concern. It was confirmed that this action can be closed.

19.132 CCG Safeguarding Strategy This will be included as part of the quarterly safeguarding update, and does not need a separate agenda item.

19.133.1 Prescribing and Medicines Optimisation Annual Report 2018/19 The Chair advised she has liaised with Dr L Rogan regarding review of the pathway around opioid prescribing. The Chair has also in contact with the Drug and Alcohol Services who have advised there is a user group that could be contacted.

19.134 Pennine Lancashire Primary Care Update C Wright and M Pilling are taking the FFT Test to the PPG meetings. The action can be closed.

19.150 4 Hour Flow

J Wild, ELHT, attended to present the latest update around the 4-hour trajectory at A&E. The challenging position concerning the A&E Department performance trajectory highlighting how we are performing in terms of 4 hour performance. The admitted breaches up to 8th July 2019 demonstrated that 56.8% of patients got to a bed within 4 hours. In terms of admitted and non-admitted performance, the position is below the 82% target trajectory. . Currently, we have dipped slightly and today we are at 81.33% - we are trying to improve this.

The highlighting of the problem on Monday 8th July 2019 at the Royal Blackburn site was discussed, when there were 738 attendances with 41% of cases presenting at A&E arriving between 4.00 p.m. and midnight.

There were also issues concerning medical staffing with 3 gaps in the evening/overnight due to sickness and the failure to attend by an agency doctor. There are no consequences to the failure of the agency doctor to attend other than a request not to use that agency doctor again, but it was felt there should be some accountability.

Another, more recent date, was shown as a counter example with 393 attendances and performance at 92.11% for most of the day This report showed that the majority of patients, 138, attended between 7.30 pm and midnight; performance dropped to 82%. Many breaches occur overnight and some of this is linked to medical staffing, but also how demand has moved to later in the day. The Trust has tried to mitigate this with changes to the rotas so that from 5th August there will be 7 doctors on overnight which should help increase the flow through. However, the main issue is flow through the system which impact on the ability to meet the 4 hour standard.

On 08 July the Primary Care IT issue also occurred. Whilst it is say whether this also had any impact, it is notable. There will be a question asked in Parliament by one of the local MPs regarding that day and what the waiting time was and the Trust have been asked to provide some information across the system, as they are asking about plans to manage the waiting time.

Action: The Chair has asked to see that escalated onto the Risk Management Group.

It was stated that 08 July 2019 was further compounded by a reported respiratory issue on the same day. There has been a spike in respiratory conditions because of the present weather conditions and work is being done around hot spots and days when there is extra

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pressure to support forward planning. This would link through to community services, as well as flow through the hospital. Urgent care also performs better than ED because of the urgent care path of non-admitted patients, which are simpler cases, rather than the more complex cases at ED, including those with comorbidities and frail elderly.

In order to try and manage the 12-hour breaches, and improve flow through the system, patients are being moved in the early hours of the morning from one ward to another; however this has had consequences with vulnerable patients.

There was discussion regarding the level of vacancies and the plans to fill these. It was noted that ELHT has largest A&Es in the North West, and there was comparison about the staff vacancies compared to other local A&E departments. J Wild confirmed that new staff rotas will be published in August and September 2019, and that there is a lot of work ongoing to improve the staffing complement.

In June there were 8 mental health breaches of 12 hours of patients waiting for a bed to admit; to-date there have been 13 cases in July so there is a deterioration which has an impact within the department. It is not the right environment for patients, and it means cubicles become blocked; there are 28 cubicle spaces available so a reduction in availability will impact on ED performance.

The Chair raised the question of whether it is understood what endeavours are being used to capture patients’ experiences in the 12 hour breach pathway. It was noted that the friends and family feedback has not shown feedback from patients with mental health concerns in that department; this is raising concerns that there must be some issues. The Chair reiterated if there are any proactive endeavours to capture the experiences of people from that 12 hour breach pathway. J Wild confirmed that feedback is usually received from family because the patients are acutely unwell which make it very difficult to get feedback directly from them. The Chair observed that a report was received that stated there were no complaints which, given the environment, was a concern.

Action: J Wild will review the process of capturing feedback from patients on the 12- hour breach pathway and ascertain how this can be clearly identified and reported.

These are a plethora of actions being taken to improve performance. These discharges before 1.00 p.m, although there are a number of challenges being faced with this. The Chair queried the involvement of pharmacy, as late discharges are often as a result of waiting for medications. J Wild assured members that this is another area of focus, and that this also forms part of trying to improve discharges over the weekend rather than waiting. The Trust is currently monitoring the weekly discharge rate, and it was agreed that this review would be shared with the CCG.

Action: J Wild agreed to circulate the weekly discharge rate review

A new building will be opening in December 2020, but is recognised that this will not help to improve performance on its own. Therefore there is also a piece of work underway to change the medical model and try to improve the identified inefficiencies in the system. There are a series of workshops that are going to happen over the next 12 months to develop that model of care, test it out and do some bed modelling so that when the Unit opens it will start working very differently.

A discussion followed concerning the same day primary care work-stream, working together with primary care colleagues to deflect patients from the front door and ensure the patients get to the right places. Patients are not turned away, as often there is nowhere to turn the patients away to. It was emphasised that co-operation with primary care was needed to

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deliver a different model to serve the patients.

A Walker pointed out that there were two issues to be looked at. Firstly, there has been a change from the walk-in centre in terms of activity and access, particularly people accessing RBH and UCC, so there is some work needed around re-designing the family care pathways to make it more obvious and intuitive for them to use. Secondly, the avoidance of some of those more complex needs and the issue about shared care rather than it being about building ever bigger assessment areas and ED capacity.

Dr U Chauhan commented that it was not clear why there is a demand around 4.00 until 12.00 and what the causes can be attributed to.

Action: J Wild could pick this point up and whether it would be possible, particularly where the weekend was concerned, to ascertain any known external causes that could explain the change in demand

It was stated that the high conveyance was also an issue that needs addressing. This may be connected to population change in terms of whether people are not coming out of work for example and therefore accessing the health system at different times. There may well be some softer issues that are going on there. A Walker assured the meeting that he felt this was being addressed to understand the patterns. It was emphasised that it was helpful that the Trust and the CCGs have a really good working. However, it was pointed out that where the change in patient behaviour is concerned, it is very difficult to put it down to one thing, especially as lifestyle has completely changed.

A Thornburn commented on the slide around nursing vacancies and asked whether there was an opportunity to look at the skill mix differently. It was confirmed that training opportunities are available, and a bid for funding has been put forward to support ED with a different staff mix.

V Morris provided a personal case study of her experience of going through the system recently with her sick father and having to call 111. The process took hours with her first call to 111 taking place at 7.30am and finally getting a call back at 3.00pm instructing her to go to ED. It was queried whether this is contributing to patients presenting at hospital after 4.00pm.

Action: MP asked if we could do a brief update at the next meeting. It was agreed that there would be a brief feedback on this issue.

J Wild was thanked for her presentation.

Dr G Jones emphasised that there was no single answer but there were concerns around the demand. The number of cubicles available do not support the number of ambulance conveyances happening.

Dr L Rogan discussed a joint approach with primary care across Blackburn for the self-care approach with a view to directing people away from GPs and directing them to pharmacies. She highlighted a situation which had occurred recently where a GP had directed the patient to the pharmacy, but they had chosen instead to present at ED where they were treated for something which the patient could have easily obtained over the counter at the pharmacy, and which the GP had asked them to go and get. The patient was told at ED that they should have gone to the GP for this. This illustrates the need for consistent messages across the system to prevent a breakdown of trust.

Action: Consistent messages need to be extended to the wider system

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MP thanked the team for their hard work and acknowledged the severe amount of pressure they were all working under.

19.151 NHS Patient Safety Strategy

L Wilkinson attended to provide the committee with a summary of the changes to the NHS Patient Safety Strategy.

The intention of the new strategy is to emphasise learning to prevent incidents, share safety insight and improve patient safety. There are a number of changes to the Patient Safety Incident Response Framework as a result of the refreshed strategy, with a broader scope for incident management and less of a focus on the current threshold for ‘Serious Incidents’. The intention is to develop a risk-based approach, with transparency and support for patients, relatives and staff. This will include a change in the governance and oversight provided by commissioners. The 60 working day deadline will be removed, with the adoption of timelines based on an investigation management plan, agreed with those affected. Investigations will be led by those with safety investigation training, and with the dedicated time and resource to complete the work. There will be greater involvement of patients, families, carers and other lay people.

For primary care, there will be a replacement of the NRLS system with a more responsive and interactive reporting system. This will improve the dissemination and implementation of Patient Safety Alerts through PCNs.

A full timeline is in place for implementation of the strategy by Summer 2021.

The Chair thanked L Wilkinson for this update, noting that the involvement of patients and relatives in the investigation process was positive. There are a number of challenges with the new strategy, but these will be reported through as they arise.

Members noted the update

19.152 Pennine Lancashire Quality and Performance Report Month 02

S Bradley presented key points from the Pennine Lancashire Quality and Performance Report for Month 01. Full details are available within the report.

ELHT: A&E Breaches In May 2019 both CCGs did not achieve the 95% target. Work is focussed on reducing length of stay in the Trust to improve flow through the system and an action plan has been agreed to support this.

Ambulance Calls At the time of writing performance for May 2019 was not available

Referral to Treatment (RTT) Incomplete The referral to treatment (RTT) incomplete pathway target was not met by either CCG in May 2019. For BwD CCG of the patients with a wait over 18 weeks, 734 were at ELHT, 293 were at Lancashire Teaching Hospitals Trust (LTHTr) and the remainder were lower numbers across multiple providers.

For EL CCG of the patients with a wait over 18 weeks, 1,678 were at ELHT, 427 were

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at LTHTr, 171 were at Manchester University Foundation Trust (MUFT) and the remainder were lower numbers across multiple providers.

For ELHT there were 10 underperforming specialties in month.

52-week Waits In May 2019, there were 1 patients reported with a wait of over 52 weeks for EL CCG and 1 patients for BwD CCG. These have both been seen.

Cancer Patients seen within 2-weeks of an Urgent Referral for Breast Symptoms where Cancer is Not Suspected In May 2019 the target was not met by either CCG, with 7 breaches for BwD or 19 breaches for EL.

There has been an increase in the number of referrals into the service from an average of 175 referrals per month in 2017/18 for Pennine Lancashire Patients into ELHT to 202 per month in 2018/19.

A new revised breast referral template has been distributed to GP Practices and uploaded to EMIS to support the discussion on the importance of attending appointments.

Cancer - % of patients receiving definitive treatment within 31 days of a cancer diagnosis In May 2019 the target was not met by EL with 9 breaches. Surgical capacity continues to be a pressure in a number of tumour sites, relevant Directorates are working day to day to ensure sufficient capacity is available and where not, exploring all options to increase the number of surgical lists provided.

Cancer Patients Receiving First Definitive Treatment for Cancer within 2-months In May 2019 the target was not met by either CCG, with 6 breaches for BwD and 21 breaches for EL. The CCG continues to work closely with the Trust on Cancer pathway efficiencies to progress the 28 Day Project, to allow compliance with the Day 28 target by April 2020.

A one stop clinic model was trialled in June 2019 from Prostate. Findings are currently being evaluated.

A review of 62 Day patient escalation processes has been carried out on behalf of Lancashire and South Cumbria Cancer Alliance Board. The report is currently going through factual accuracy checks and will be shared more widely in its final version.

Diagnostics with 6-Weeks The target for <1% of patients to have a wait within 6 weeks for diagnostic tests was not met in May 2019 with performance at 1.8%.

Methicillin Resistant Staphylococcus Aureus (MRSA) In May 2019 there were zero cases of MRSA bacteraemia identified within the population of EL CCG and zero cases in BwD CCG; the total number of cases of MRSA BSI for 2019/20 remains at zero. The numbers are not changing. The EColi work group, with ELHT, LCC and the community is going well, with positive feedback.

C-Diff

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Each CDI case continues to be assessed through the PIR process to determine whether it was linked to a lapse in the quality of care provided to patients. For each community apportioned case the registered General Practitioner (GP) completes a case review prior to being reviewed by the CCG infection prevention team. For each acute apportioned case the relevant acute trust initiates the PIR process. Some cases require input from a variety of providers. The findings are shared and discussed at the Pennine Lancashire HCAI meeting with representation from the acute trust, EL CCG, BWD CCG and Lancashire County Council (LCC). Any lessons learnt are shared with the provider.

LCFT: Early Intervention Psychosis (EIP) The target for 56% of service users to receive treatment within 2 weeks was not achieved at Trust level in May 2019, with performance at 46.34%. The target was not achieved for EL CCG with performance at 44.44%, but the target was achieved for BwD CCG with performance at 100.00%

Duty of Candour There have been 5x breaches of Duty of Candour in May 2019.

Memory Assessment Service The 70% 6-week target was achieved at Trust level in May 2019 with performance at 71.04%. However, BwD CCG and EL CCG failed to meet the target with performance at 12.50% and 20.73% respectively.

IAPT In May 2019, the applicable notional monthly prevalence target was not achieved at Trust level with performance at 1.38%. The target was also not met for BwD CCG with performance at 1.36%, however was achieved for EL CCG with performance at 1.41%. Regarding Recovery, the overall Trust target of 50% was achieved with performance being reported at 52.50%. The target was achieved for both BwD CCG and EL CCG with performance at 53.80% and 52.90% respectively.

CPA The target for 95% of service users on CPA to be followed up within 7 days of discharge from psychiatric inpatient care was achieved at Trust level in May 2019, with performance at 97.91%. The target was achieved for BwD CCG (100%) and EL CCG (97.50%).

Referral to treatment Incomplete (LCFT) For BwD CCG the overall RTT target was not met with performance at 72.7%.

There were 2 underperforming specialties: Children's Occupational Therapy Service (52.8%) and Children’s Speech and Language Therapy (59.1%)

Lewis is working with the LCFT Community team and will keep us updated.

The Committee formerly received the report for information 19.153 CONFIDENTIAL: Provider Update

This paper was tabled for reference. The content of this item is for Committee members and attendees only and is not for wider distribution. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received and acknowledged this report.

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19.154 CONFIDENTIAL: GP Quality Group Minutes for BwD and EL CCGs: June 2019

This paper was tabled for reference. These were distributed prior to the meeting for information. No comments were raised. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received these minutes.

19.155 CONFIDENTIAL: ICS – LCFT Mental Health Oversight Group Minutes: June 2019

This paper was tabled for reference. These were distributed prior to the meeting for information. No comments were raised. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received these minutes.

19.156 Serious Incident Review Group Recommendations

This report is provided to the Pennine Lancashire Quality Committee to provide an analysis of incidents. It aims to provide assurance of a robust process of scrutiny, challenge and shared learning undertaken by the Quality Team along with outlining the developments of these processes over the financial year.

CCG Performance In Q1 of 2019/20 48 x RCA reports have been submitted by providers hosted by EL CCG and BwD CCG. These reports have been reviewed by the CCG Serious Incident Review Groups (SIRG) in line with the Serious Incident Framework (2015). Information from these reports has also been used to produce themes and trends of incidents reported by providers.

East Lancashire Hospital Trust The chart exhibited on page 2 of the report show a similar number of incidents reported in April and June in 2018 and 2019; however a higher number were reported in May 2019 compared to the previous year.

In May 2018 there were 0x pressure ulcers reported by ELHT however in May 2019 4x have been reported. This may be reflective on the new pressure ulcer reporting guidance that was implemented in April 2019.

Pressure ulcers remain in the top 5 incident types reported in Q1 2018/19 and 2019/20, however an increased number were reported in Q1 2019/20.

The number of slips trips and falls reported has reduced in Q1 2019/20 compared to Q1 2018/19, which reflects the falls prevention programme of work.

Treatment delay was the 2nd highest reported incident type in Q1 2019/20There seems to be a common factor that patients are not following the advice given and ELHT are to undertake a thematic review of these incidents.

There has been 1 x Never Event reported by ELHT in Q1 2019/20, relating to a retained foreign object post procedure.

Lancashire Care Foundation Trust

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Apparent/actual/suspected self-inflicted harm remains the highest incident type in Q1 2019/20 as expected from a Mental Health Trust. However, there has been an increase of 9x of these incidents in Q1 2019/20 from Q1 2018/1. Date has been published by the National Confidential Inquiry into suicide and homicides which shows that LCFT are below the nation median suicide rate.

Harm to LCFT staff has gone down in this quarter and we are currently piloting a body camera scheme.

The position for reports that have been reviewed by the CCG and returned to LCFT for further work has now improved significantly and LCFT should be commended for the work done to improve this position within the agreed timeframe.

The serious incident positions for providers hosted by East Lancashire and Blackburn with Darwen CCGs continue to be positive in Q1 2019/20, and providers are continuing to implement several improvements as highlighted in this report. The Quality Team continues to work closely with providers to aid in these improvements.

Members received and acknowledged this report

19.157 Pennine Lancashire E & I Quarterly Report

Travis Peters presented the paper, and assumed that it had been read. The paper is a joint report reflecting on the Equality and Inclusion work undertaken across Blackburn with Darwen CCG and East Lancashire CCG, providing updates between the months of April and June 2019.

He discussed the work programme for the year ahead, and the EDS goals. The workforce race equality standards introduced by NHS England, aims to tackle race discrimination across the NHS, in 2019 as in 2018, the date will be reported separately for each CCG however this year a joint report will also be compiled. HR has been asked to provide the data required by 31st August 2019 for national analysis and publication.

Since April 2019, the Equality and Inclusion Business has met with commissioners to support the following Equality Impact and Risk Assessments. The annual report was approved at the PLQC in April 2019, and has subsequently been published on the Equality and Inclusion pages on each of the CCG websites.

There has been some changes to the structure of the MLSCU Equality and Inclusion Team, and Gemma Aspinall will support Travis in ensure quality of work delivered on behalf of Blackburn with Darwen CCG and East Lancashire CCG is maintained.

Members received and acknowledged this report

19.158 Pennine Lancashire Risk Management Update

C Moir presented the Pennie Lancashire Risk Management Update. The Committee receives the Corporate Risk Register (CRR) and Governing Body Assurance Framework (GBAF) from both CCGs in order to enable members to evaluate the assurance on the management of corporate risks.

It was reported at the last PLQC meeting that a composite risk register would be developed in support of the aligned systems. This will replace the need to maintain 2 separate risk

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registers, therefore reducing duplication and supporting a more streamlined approach to managing and reporting on risks

As previously reported, within NHS Blackburn with Darwen CCG (BwD CCG) there were 11 operational risks and 6 strategic risks held on the register.

Within NHS East Lancashire CCG (EL CCG) there were 16 risks on the CCG Risk Register with 7 of these with a risk rating >15 escalated to the GBAF.

Across Pennine Lancashire there were 10 risks which were included on the risk registers of both CCGs.

1. (259/2015.05) Accident and Emergency 4 Hour Standard 2019/20 2. (157) Failure to adhere to standards outlined in the Ambulance Response Programme (ARP) 3. (239 18-19) 62 Day Cancer Waiting Times Target 4. (262) Failing to deliver the 18 Week Incomplete Pathway (Referral to Treatment) NHS Constitutional Standard 5. (264) Mental Health system pressures 6. (227) Initial Health Assessments for Looked After Children 7. (263) Failure to meet the reforms for children with Special Educational Needs and Disabilities (SEND) 8. (265) UK’s exit from the EU (with a ‘deal’ or ‘no deal’) presents unknown risks that may adversely affect healthcare delivery across Pennine Lancs. 9. (256/2018.05) Loss of Residential and Nursing Home Beds from Care Home Sector and impact upon system resilience (under review) 10. (243) Re-procurement of 0-19 services

All the 7 extreme risks on the register, rating 15 have all been reviewed and action plans updated.

Following review at the RMCG meeting on 9th July 2019, Risk 227 has reduced in rating (“12”) and therefore is no longer held on the GBAF.

All the 10 significant/moderate risks have been reviewed and updated and action plans have been updated for existing risks.

There are no new risks for addition to the CRRs, however Risk ID 131 will be re-assessed and a new entry added at the next presentation of the CRR to the PLQC

Claire Moir recommended that the following four risk be closed:

1. (243) Re-procurement of 0-19 services (This is one of the 10 joint risks noted above) 2. (131) Lack of Access to Inpatient Beds for Children and Young people with Mental Health issues (Tier 4 beds) 3. (EL 143) Current IPA commissioning packages of care fails to adhere to the Mental Capacity Act 2005 in relation to Deprivation of Liberties and CCG Responsibilities 4. (EL 245) Increased risk of legal challenge and consequent financial impact relating to legal Deprivation of Liberty Challenges by CHC funded patients and their legal

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representatives.

The Chair asked for assurance that there was no issue with the Tier 4 risks, which was given from Kirsty Hamer in the Children and Young Peoples Team.

The chair agreed the recommendation.

19.159 Pennine Lancashire Safeguarding Dashboard

Debbie Ross presented the Safeguarding Quarterly Dashboard, to ensure that the Pennine Lancashire quality Committee was sighted on the key safeguarding priorities and aware of the safeguarding activity which has taken place within the last 3 months.

1. Development of the Pan Lancashire Safeguarding Arrangements and ICS A paper has been taken through Blackburn with Darwen and East Lancashire’s joint Governing body in relation to the new Multi-agency Safeguarding arrangements (MASA) for children and the proposed modelling for safeguarding Designated function in the ICS and ICP. The plans had to be submitted by 29th June and a paper was formulated and signed off by the CCGs. The plans are expected to be in place by September 2019.

2. CCG Safeguarding Resource

The CCG Safeguarding team is currently holding a number of vacancies : 1x WTE B7 1X WTE B5 Proposals for reconfiguring hours with other staff members. B7 – has been out to advert with no successful applicants. This has been re-advertised closing date 9th July 2019 B5 – recruitment will commence w/c 29th July 2019

3. Looked after children (LAC) BwD and East Lancashire The LCC and Health Looked After Children Health assessment project has now moved into the redesign phase and a joint action plan has developed to address the project findings. An improvement action plan is in place for Initial Health Assessments in PL which is led on by the Pennine CCG Safeguarding Team and Children’s Commissioner.

East Lancs performance has improved.

4. GP Development

An event was held at the Dunkehalgh on the 12th June, which was attended by 160 participants. The event was very well received by all Penning GPs.

5. BwD CQC Safeguarding and LAC Review April 2019

The CQC Safeguarding and LAC review was carried out 29th April 2019 – 3rd May 2019. The final report was published on the CQC website on the 2/7/19.

The key learning points were discussed and questions and answers followed. Debbie Ross agreed to update as required.

Members received and acknowledged this report 19.160 Pennine Lancashire SEND Update

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Kirsty Hamer presented a paper updating the committee on the progress to implement reforms for children and young people with special education needs and/or disabilities following the previous update in April 2019.

Both CCGs had be identified that progress had been made, however further work is required to implement consistent outcomes. An outcomes framework for children and young people is being developed across the ICS and due for completion in March 2020.

Discussed followed on the areas of progress and the areas for improvement, and Kirsty confirmed to the committee what the RAG ratings meant, i.e. Green – Compliant etc.

It was confirmed that everything was on track for commissioning for September.

Members received and acknowledged this report 19.161 BwD CQC Safeguarding and Looked after Children Review – Final Report published June 2019

A review was carried out between 29th April 2019 and 3rd May 2019, and the final publication had been distributed to the committee.

The review findings and key areas were discussed. This had been shared with the designated nurses for safeguarding who completed a factual inaccuracy check, which was returned to CQC on 3rd June 2019, allowing for the final report to be published.

An action plan now needs to be completed and submitted by 31st July 2019 and the key issues needing to be included were confirmed.

It was agreed that the complete action plan will be received by the committee once Sept completed. 2019

Members received and acknowledged this report 19.162 Quality Contract Meeting Draft Minutes: June 2019 East Lancashire Hospitals NHS Trust BMI Lancashire Quality Review

These were distributed prior to the meeting for information. No comments were raised.

Members acknowledged the minutes.

19.163 ELCCG Risk Management & Information Governance Group Draft Minutes – June 2019

These were distributed prior to the meeting for information. No comments were raised.

Members acknowledged the minutes.

19.164 Cancer Tactical Meeting – June 2019

These were distributed prior to the meeting for information. No comments were raised.

Members acknowledged the minutes.

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19.165 Items for Inclusion of the Corporate Risk Register

Flu in Australia (Discussed during the Quality and Performance Report)

The current flu reports from Australia are the worst recorded incidents for a decade. This is peaking 2 months earlier than usual and we need to prepare for the consequences.

Vanessa Morris commented that this will follow to the UK and there is already a Flu Locality Group in place which NHS England Chairs. She does attend this group and will regularly feedback.

The current vaccines and their effectiveness were discussed and Vanessa is to put together VM a comprehensive paper for the August Meeting. Aug 19

It was agreed that this needed to be added to the Risk Register. CM Aug 19 16.166 Date & Time of Next Meeting

The next meeting has been scheduled on Wednesday 28th August 2019 at 1pm Meeting Room 1, Walshaw house, Nelson

Deadline for papers is 5pm on 19th August 2019.

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

PENNINE LANCASHIRE QUALITY COMMITTEE Minutes of the meeting held on 28 August 2019 PRESENT:

Name and Title Org. 2018 2018 2018 2018 2018 2019 2019 2019 2019 2019 2019 2019 2019 2019 22/08 22/08 02/10 24/10 28/11 19/12 23/01 27/02 27/03 24/04 22/05 26/06/ 25/07/ 28/08/ 25/09/ Clinical Representatives (two needed): Lay Advisor: Quality and Patient Engagement – Chair ELCCG A     A  A      Michelle Pilling Secondary Care Doctor (retired) BwDCCG  A   A      L   Geraint Jones: Chair Associate Director of Quality and Commissioning BwDCCG  A - A  A A  -  A A A Janet Thomas Associate Director of Quality and Nursing / Head of Quality ELCCG   A           Caroline Marshall Chief Finance Officer ELCCG A AR AR AR E AR A A AR A  R  Kirsty Hollis Director of Performance and Delivery / Director of Commissioning ELCCG    AR E AR A A AR AR AR  A Alex Walker Director of Quality & Chief Nurse (Clinical Post) ELCCG A   A    A AR   A A Kathryn Lord Director of Quality and Performance (Clinical Post) BwDCCG     A      A  A Dr M Ridgway until October 2018; Dr Ridwaan Ahmed from November 2018 Governance, Assurance and Delivery Manager BwDCCG A  A A   A    A   Claire Moir GP Quality Lead (Clinical Post) ELCCG A  A  A A     A   Dr Umesh Chauhan GP Representative (Clinical Post) BwDCCG A A A A   A    A   Dr Stephen Gunn GP Representative (Clinical Post) ELCCG A  A  A    A  A A  Dr Zeenat Sykes Lay Member BwDCCG              Dr Nigel Horsfield Chair Secondary Care Consultant ELCCG      A  A  A  A A Dr Paul Taylor Medicines Management Representative (one needed): Senior Operating Officer, Primary, Community & Medicines Commissioning BwDCCG - - - - A - A - - - - A A Julie Kenyon Associate Director of Research, Medicines & Clinical Effectiveness ELCCG A    A   A     A Lisa Rogan Safeguarding Representative (one needed): Head of Safeguarding (Adults) and MCA Leads PLCCG  A -   -      - - Peter Chapman Head of Safeguarding (Children) PLCCG - -  ------ Susan Clarke Head of Safeguarding (Children) PLCCG - -  - -  - A - - -  - Debbie Ross Clinical Representatives: : present A: apols L: arrived late E: left early R: representative in attendance

Jacquie Allan Executive Assistant, BwDCCG (Minutes) Gemma Aspinall Equality and Inclusion Officer, MLCSU (1 item) Kim Ciraolo Quality & Performance Manager (Pennine), M&LCSU Kirsty Hamer Commissioning Lead – Children, Family and Maternity Services (1 item) Judith Johnston Head of Clinical Commissioning, ELCCG Vanessa Morris Infection and Prevention Control Nurse (Pennine), PLCCGs Angela Thornton Head of Mental Health and Cancer Commissioning Teams (1 item) Anita Watson Infection, Prevention and Control Lead, LCC (1 item) Catherine Wright Primary Care Quality Lead (Pennine), PLCCGs (1 item)

Pennine Lancashire Quality Committee 28 August 2019 Page 1 of 12 Minutes Approved by the Chair: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

REF: ACTION 19.167 Welcome & Chair’s Update

The Chair opened the Pennine Lancashire Quality Committee and welcomed all attendees.

19.168 Apologies

Apologies were received as above.

19.169 Declarations of Interest

No declarations of interest noted. Any that transpire during the meeting are to be declared.

The meeting was quorate.

19.170 Minutes of the Meeting held on 28th August 2019

Any minor amendments to be sent to J Allan

With the minor amendments to be sent to J Allan, the minutes were recommended for approval as an accurate record of the meeting.

19.171 Action Matrix

19.108.1 Pennine Lancashire Quality and Performance Report Month 12 52-week Waits It was confirmed that no harm had been caused to the patient and long waits in Blackpool Hospital are being monitored. This action is now closed.

19.108.5 Pennine Lancashire Quality and Performance Report Month 12 CQC This action is complete as of last month.

19.112 Pennine Lancashire Complaints Report 2018/19 Quarter 4 This has been deferred by S Harrison to the September 2019 meeting. To be included on the September 2019 agenda.

19.124 PLQC Terms of Reference These were formally ratified; this item is now complete.

19.125.1 Presentation: Neurology Pathway This has not been received from S. Flynn, therefore will be chased for inclusion in the September 2019 meeting.

19.150.1 4 Hour Flow The risks, actions and mitigations around recent IT disruptions in Primary Care were reviewed by the Risk Management Group and do not meet the threshold to be added to the risk register – concerns have been captured with communication going out to practices and other concerned stakeholders. This action is now complete.

19.150.2 4 Hour Flow These are being looked at by J. Wild who is linking with S. Bradley and the Friends and Families survey regarding 12hour waits. S. Bradley will bring an update to a future meeting.

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19.150.3 4 Hour Flow Weekly Discharge Rate Review C. Marshall to check that E. Fleming has received this report.

19.150.4 4 Hour Flow 111 Redesign Considerable work has been done around this and an update to be given at the October 2019 meeting.

19.155 Flu in Australia An update was included on the July 2019 agenda; this is now complete.

19.161 Safeguarding Looked After Children The action plan has been through the management committees and comments have been received from the inspectors. This will be reviewed and an updated action plan will be discussed at the September 2019 meeting.

19.172 Northumberland, Tyne and Wear Peer Review

A. Thornton gave an overview of the presentation and advised that the Northumberland, Tyne and Wyre (NTW) Trust review was initiated in April 2018 with a substantial outcome report which is available should Committee members require a copy/link. The report was due to be published in January 2019 but was not available until May 2019. Service user and primary care feedback were essential to this report. The review was around the urgent care pathway in acute and Emergency Departments. Section 136 is used by the police for a place of safety and Lancashire is seen as an outlier nationally. A ‘frequent flyer’ pilot is being undertaken in East Lancashire by a SPN and a policer officer which is enabling some people to be appropriately managed at home. Relationship management is an area to be strengthened across Lancashire stakeholders.

Over the next three weeks assessments will be undertaken by Price Waterhouse Cooper regarding Commissioner capabilities and capacity with a number of workshops taking place. There is a focus on bed management and local bed base across Pennine Lancashire with a lot of work being undertaken on in the background with Lancashire Care Foundation Trust (LCFT). A local Mental Health Improvement Board has been set up which will drive forward local actions. A Thornton updated Committee members on the recent CQC inspection and the decision taken by LCFT/wider system in relation to the closure of Mental Health Decision Units by 8th October 2019; it is reported that staff will be redeployed into mental health liaison teams.

East Lancashire Hospitals Trust (ELHT) Mental Health CQC registration remains an outstanding area and the ICS are discussing this with ELHT and LCFT.

The CCG and the Pennine Mental Health teams are meeting regularly where good relationships are being fostered leading to proactive notification of areas of concern. A Thornton proceeded to outline work underway across Pennine Lancashire in respect of the urgent care pathway. There is an intention to undertake a full review including older adults and to link closer with Primary Care Networks (PCNs) and a more stable approach is required for an integrated neighbourhood service.

The NTW-Integrated Care System (ICS) work is being led by Dr J Higgins and will commence next week focussing on Pennine Lancs as a key transformation piece of work. Over the next 6 - 12 months focus will be on community health provision and learning will then be replicated across the ICS. Dr J Higgins has been linking with A Bennet and A Doyle to enable a system wide approach and there have already been improvements seen in the

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crisis team and mental health liaison team, with extra investment put in locally and into the Richmond Fellowship who are supporting the crisis teams. Local teams have good ideas around efficiency and case load management which should be embraced.

It was noted that M Nelligan, Director of Nursing is due to commence in post in September 2019 with a cross/hand over period intended with the current interim Director of Nursing, P Lumsdon.

Dr S Gunn questioned the work that was to commence in September 2019 by the Transformation Team. A Thornton advised that they are to commence with recommendations and actively assist the local teams to facilitate change.

Dr S Gunn also questioned the current state of the local service. A Thornton advised that a conversation has taken place at a recent Mental Health Commissioners meeting around national scrutiny of the commissioning of the mental health service. It was felt that the Lancashire and South Cumbria CCGs needed a more global system in place as it was chaotic in the provision at the present time. Emerging issues have been identified and it is not always clear who is responsible for what; this needs to be addressed through the PWC work described earlier. It was felt that governance and accountability had been lacking as identified by this committee; these deficits are being addressed.

Dr G Jones enquired how are we going to change what we are doing around mental health as a Committee. LCFT have requested a significant amount of money across the system and locally yet it is felt that there is investment that is not understood as there are no service lines and it would be interesting to see what PWC would come up with.

Dr Jones queried the timescales for the delivery of this work?. A Thornton advised that the Pennine Lancashire Mental Health Delivery Board will provide assurance, direction and leadership and hold organisations to account. This Board is a Pennine Lancashire Integrated Care Partnership (ICP) group; minutes will be presented to Governing Body meetings to ensure appropriate oversight.

Action: Quarterly updates to be brought to the meeting by Cathy Gardener. C Gardener

Dr Gunn questioned how this will work better than before as the Committee do not seem to have influence to resolve the initial problem. A Thornton advised that all stakeholders need to fully embrace the NTW report and work collaboratively to implement the changes needed, at pace, to deliver the right services, in the right place at the right time. Committee members all agreed that there needs to be regular oversight on this to be re-assured positive changes are having a positive impact.

The Chair thanked A Thornton for her presentation and detailed information.

A Thornton left the meeting.

19.173 Pennine Lancashire Quality and Performance Report – Month 03

K. Ciraolo advised that the key exceptions within the report would be presented on slides in an attempt to facilitate debate and discussion. The key highlights were presented, discussed, debated and challenge provided in line with the slides:

Ambulance service performance For BwD CCG the Category 1 target was met, however there was underachieved against all other categories in June 2019. For EL CCG there was underperformance against all ambulance response programme targets in June 2019, response times for Category 2-4

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have improved in month. In order to improve performance, NWAS has increased provision of See and Treat, with the aim of reducing conveyance to A&E. In June 2019 27.4% of calls resulted in See and Treat. The entire qualified paramedic workforce is now trained in the application of the Manchester Triage System and training is scheduled for the Newly Qualified Paramedics cohorts due to qualify in August 2019.

Referral to Treatment and 52 week wait patients For BwD CCG of the patients with a wait over 18 weeks, 822 were at ELHT, 311 were at Lancashire Teaching Hospitals Trust (LTHTr) and the remainder were lower numbers across multiple providers. For EL CCG of the patients with a wait over 18 weeks, 1,907 were at ELHT, 470 were at LTHTr, 166 were at Manchester University Foundation Trust (MUFT) and the remainder were lower numbers across multiple providers. The main pressure at LTHTr remains in Neurology, where there are 129 BwD CCG and 298 EL CCG patients with a wait over 18 weeks. As previously reported Greater Preston CCG will be taking service redesign of neurosciences forward as a programme of work in 2019/20.

Cancer performance There continue to be a high number of breaches relating to patient-initiated delays, which makes up 54% of all the Pennine Lancashire Breaches in month. The Pennine Lancashire public campaign ‘Let’s Talk Cancer’ is highlighting the importance of attending appointments and there are plans to roll out the campaign across the Cancer Alliance footprint and to support GP participation in the National Cancer Diagnosis Audit process. There were a large number of breaches relating to outpatient capacity, with a majority (76%) under suspected skin. Recruitment is currently underway to replace a Consultant Dermatologist and the service are looking to appoint a locum consultant in the interim. Capacity and demand is being modelled for skin referrals into Maxillofacial to ensure appropriate capacity for outpatient and biopsy demand to manage 2 week wait patients. Trial one stop clinics for dermatology patients took place in June 2019, this is being evaluated. Surgical capacity continues to be a pressure in a number of tumour sites, relevant Directorates are working day to day to ensure sufficient capacity is available and where not, exploring all options to increase the number of surgical lists provided. The CCG continues to work closely with the Trust on Cancer pathway efficiencies to progress the 28 Day Project, to allow compliance with the Day 28 target by April 2020. The Trust has increased workforce to support the 28 day faster diagnosis standard and will evaluate if this will translate into achievement of the target or if other factors are impacting on performance. A workshop is planned for October 2019. ELHT have undertaken a process mapping exercise which the CCG Cancer Team attended. Pathway analysis is currently underway. A review of 62 Day patient escalation processes has been carried out on behalf of Lancashire and South Cumbria Cancer Alliance Board. The final report has been circulated and ELHT are carrying out a gap analysis against the recommendations in the report.

Clostridium Difficile Infection Each CDI case continues to be assessed through the PIR process to determine whether it was linked to a lapse in the quality of care provided to patients. For each community apportioned case the registered General Practitioner (GP) completes a case review prior to being reviewed by the CCG infection prevention team. For each acute apportioned case the relevant acute trust initiates the PIR process. Some cases require input from a variety of providers. The findings are shared and discussed at the Pennine Lancashire HCAI meeting with representation from the acute trust, EL CCG, BWD CCG and Lancashire County Council (LCC). Any lessons learnt are shared with the provider.

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Memory Assessment Service The 70% 6-week target was achieved at Trust level in June 2019 with performance at 70%. However, BwD CCG and EL CCG failed to meet the target with performance at 34.28% and 29.24% respectively. In June 2019 there has been a continued increase in the number of referrals received and accepted by the Pennine MAS teams. There continues to be sickness and vacancies in the team and bank staff are being utilised where possible. The additional support from other teams had to be stepped down as they were experiencing their own resource issues.

To assist in the continuous improvement of the position the current measures are in place:  Additional assessment slots for current clinicians to fill days that were previously protected for other MAS work, such as duty work, diagnostic and consultation days.  A vacancy has been recruited to and is now seeing a full capacity of assessment slots per week.  Daily courtesy calls are made to help reduce the number of DNAs.  Additional support from bank staff is being secured to provide extra assessment slots and weekend home visits if required.  A trajectory remains in place for September and it has been noted that there has been a further increase in performance in July 2019, and that the trajectory should be met.

IAPT LCFT are currently working towards a prevalence target of 16.8% for EL CCG and 19% for BwD CCG for 2019/20. Actions are in place to increase performance against the prevalence target:  A redesign of the assessment stage to improve efficiency and patient experience  The screening and telephone assessment PDSA are now in progress in the East locality to test out new assessment models, with an aim to roll this out across all teams in quarter 3.  Several referrals are not translating into first appointments as the appointment is not attended. LCFT are currently looking at a communications strategy to achieve more appropriate referrals. With an aim that more appropriate referrals will reduce the number of DNAs and patients dropping out of treatment.

It was highlighted in PEG on 1st August 2019 that the nationally only one area is achieving the prevalence target and that LCFT are doing well when compared to other areas including exemplar Trusts. However, work is still required to achieve the target in Lancashire and South Cumbria.

Committee members all agreed that the slide presentation was helpful and facilitated constructive challenge and discussion.

The Chair thanked K Ciraolo for the update.

19.174 CONFIDENTIAL: Provider Update Paper

The content of this item is for Committee members and attendees only and is not for wider distribution. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received and acknowledged this report.

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19.175 CONFIDENTIAL: Pennine Lancashire General Practice Quality Group Minutes – 28 August 2019

The content of this item is for Committee members and attendees only and is not for wider distribution. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received and acknowledged this report.

19.176 CONFIDENTIAL: ICS Mental Health Oversight Group Minutes – 28 August 2019

This paper was distributed prior to the meeting for information. No comments were raised. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received these minutes.

19.177 CONFIDENTIAL: NHS England – LCFT Quality Oversight Group Minutes – 18 July 2019

This paper was distributed prior to the meeting for information. No comments were raised. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received these minutes.

19.178 Pennine Lancashire Primary Care Update

C. Wright provided an overview of the report as below:

An overview of the most recent complaints information as provided whilst acknowledging that as complaints are reported to NHS England, trying to gather information is difficult due to their capacity.

The Primary Care web tool is being accessed, with 9 practices that have a review identified. These have been mapped onto the dashboard to determine if a quality visit is required.

Human factors training is being undertaken and will be evaluated.

Friends and Family Test (FFT) results are being submitted via a bulletin and information is being shared with practice staff. FFT will change in April 2020. Different data sets are being categorised and a review will be analysed by the two clinical leads.

Annual GP patient survey has been published, this can be circulated with the minutes and a link provided. Analysis has been undertaken on East Lancashire and Blackburn with Darwen comparing response rates, which are similar. This has been compared to national averages – 6 are better for EL and 11 for BwD, this is a snapshot of information. There is a need to understand how practices are achieving, this learning can then be shared.

ACTION: Learning to be brought to the next meeting. C Wright

ACTION: Apex/IPlato/Digital position update to be presented at the next meeting C Wright including virtual GP appointments.

The Chair thanked C Wright for her update.

Members received and acknowledged this report

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19.179 Pennine Lancashire CQUIN 2019/20 Q1 Payments

K Ciraolo provided an overview of the CQUIN report for Quarter (Q) 4 2018/19 and Q1 2019/20 with recommendations for Committee provided in the report along evidence of achievement.

Attention was brought to the Q4 2018/19 submission from Mersey Care where further evidence has been provided.

For LCFT CQUIN 3a there are discrepancies between the LCFT data and national clinical data that has recently been published. This hinders the reconciliation of the indicator therefore the Trust have been requested to submit a narrative to explain the discrepancies to allow Committee to debate and discuss. Members questioned the value of CQUIN 3a for the Trust and K Ciraolo advised she would ascertain this and advise.

ACTION: To ascertain the value of CQUIN 3a for LCFT

The Chair thanks K Ciraolo for the update.

Committee members supported the recommendations as outlined in the paper.

19.180 Pennine Lancashire IPA and CHC Update

J Johnston presented the paper highlighting the 2 positive points across Lancashire and South Cumbria which are the future states and future models.

J Johnston highlighted the Continuing Healthcare (CHC) local staffing issues and explained the difficulties within Midlands and Lancashire Commissioning Support Unit (MLCSU) in recruiting suitable candidates and retaining them within the team. It was outlined that the matter has been escalated to CCG Directors and a meeting is scheduled to take place this Friday to discuss and address these issues with MLCSU. The recovery action plan is to be looked at by Executive Team given the level of investment into the service. A number of complaints are being received from family members andMPs around delays on Retrospective Reviews. K. Hollis has been asked to draft a letter on behalf of Dr Higgins to request a meeting with Mr Derek Kitchen, Managing Director of MLCSU.

ACTION: Update required next month around CHC complaints.

The Chair thanked J Johnston for the update on activity.

Members received and acknowledged this report.

19.181 Pennine Lancashire Complaints Report 2019/20 Q1 Report

C Marshall provided an overview of the report drawing members attention to key areas.

Focus has been given on the analysis of activity as there has been an increase in the EL CCG complaints for medicine management (associated with the implementation of the self- care policy); work is being undertaken to address this by the Medicine Management Pharmacists. There has also been an increase in complaints for both CCGS regarding CHC as highlighted in the previous agenda item.

There have been 11 letters from MPs during Q1 2019/20.

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C Marshall outlined that nationally the CCGs are held to account to acknowledge, investigate and respond to complaints within 60 days.

Locally the CCGs have set their own target at 40 days, to ensure they are all closed within the 60 days. Response times in Q1 2019/20 for some complaints are disappointing; in particular in May 2019 for BwD CCG. The reasons for the delays was provided along with an assurance that improvement work is being targeted in this area.

The Chair thanked C Marshall for the report.

Members received and acknowledged this report.

19.182 Infection Prevention Team Report Healthcare Associated Infections Update Q1 2019/20

The Chair welcomed A Watson to the meeting and invited her to provide an overview of the circulated report.

It was reported that 4 MRSA incidents had been reported across Lancashire with no themes identified following detailed analysis. A Watson advised that Hospital onset of clostridium difficile targets are now two days rather than three days.

Committee members were advised that the ICS has the lowest performance around E.coli in the North West and lot of work is to be undertaken to compare the differences between the ICSs nationally.

As part of the national priority for early identification and treatment of sepsis a lot of work is being undertaken with care homes and hand hygiene in schools. This work will complement the work underway with primary care and providers.

Dr G Jones questioned the origins of the sepsis and E.coli. V. Morris agreed to forward the data, but sometimes the cause is not identified. V Morris advised that it can be difficult to collect the data as it may not always be logged in the GP data. Data is being collected for Q2 and Q3 2019/20 and the acute trust are undertaking work around gall bladders. NHSI have organised an event to discuss this.

Action: V Morris to forward the data around the origins of sepsis and E.Coli to V Morris Dr G Jones

The chair thanks A Watson and V Morris for the update.

Members received and acknowledged this report

A Watson left the meeting

19.183 Pennine Lancashire Seasonal Influenza Planning Report 2019

V. Morris presented the previously circulated paper and highlighted the flu planning report which has an action plan that will be updated every month. The Pennine Lancashire Flu Locality Group is well attended and there is very positive input. Terms of Reference for the group are at the back of the report.

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V Morris advised that if there is an outbreak of flu there is a Standard Operating Procedure in place to follow regarding prescribing antivirals. If antivirals are to be used, access to the correct dosage is required and there are now 5 pharmacies in the area that will hold the stock with out of hours distributing to specific care homes.

Messages that are sent by out the Communications team are to be kept clear and evidence based with the message that flu vaccines should not be given too early. Dr N Horsfield raised concerns that the risks around flu vaccination are not explained to patients. V. Morris explained that patients should be given the opportunity for informed consent around the risks prior to the administration of the vaccine. Dr U Chauhan asked how much informed consent is given when the vaccine is administered to residents in Care Homes. V Morris advised that residents are encouraged to receive the vaccination in care homes and the workforce are also required to have the vaccination.

V Morris was thanked for the report.

Members received and acknowledged this report

19.184 Workforce Race Equality standard Report for ELCCG and BwD CCG

The Chair welcomed G Aspinall to the meeting.

G Aspinall provided an overview of the report which summarises the WRES report. Both EL and BwD CCGs have increased the number of BME staff and have seen an increase in the number of staff self-reporting. All gaps in reporting are being addressed as outlined in the action plan.

NHSE have asked for raw data to be submitted to NHS Digital, this has been undertaken and once it has been approved can be reported to NHSE.

The issue of Executive and Board representation will be flagged to the Governing Body and is on the action plan.

Members received and acknowledged and approved this report.

G Aspinall left the meeting

19.185 SEND Inspection

K Hamer provided an overview of the report and advised that since the last meeting the outcome letter has been received which was positive and highlighted some areas for improvement around health. There is a contrast between the BwD and Lancs position and K Hamer advised Committee members that the 12 areas of concern are being monitored and addressed.

The Chair requested that a RAG rating be presented at subsequent meetings. K Hamer advised the Committee that there is an audit tool in place for SEND reforms and the12 areas are RAG rated.

Members acknowledged the report

K Hamer left the meeting

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19.186 LD Transforming Care, STOMP and LeDer Update

J. Johnston provided an overview of the report.

She explained that there is continued good process to reduce the number of admissions, with a number of patients are being stepped down from secure units. There has been a recent visit from the lead psychiatrist at NHSE (Transforming Care Programme) to review patients and consider how their future needs can be met on the former Calderstones site. This was to support the original plan to transfer patients to social landlords and provision of care by the existing staff. This will enable the site to be de-regulated. There is a planned programme of work around community services to look at this.

J Johnston advised that the STOMP plan has been implemented and officers are continuing to look at options for annual health checks.

There is a pilot with Pendle PCN which is looking at stopping over medicating and is funded by the NHS. It was pointed out that some of the reds on the action plan have now turned to green.

ACTION: An updated report around STOMP to be presented at the October 2019 J Johnston meeting.

LeDer reviews will be undertaken as outlined in Section 5; from a governance perspective it has been agreed that the completed review will be presented to the Serious Incident Review Group panels to ensure sufficient scrutiny and learning/theming/trending. There is a backlog of cases, therefore extra panels will be required to facilitate timely presentation of the cases.

The Chair thanked J Johnston for her update.

Members acknowledged the report.

19.187 Quality Meetings Draft Minutes

9.1a ELHT Quality Review Meeting 9.1b LCFT Joint MH & Community Performance & Quality Meeting 9.1c LCFT Quality and Performance Group

These minutes were presented for reference purposes only. They were distributed prior to the meeting for information. No comments were raised.

Members received these minutes

19.188 Risk Management and Compliance Group Minutes

The minutes were presented for reference purposes only. These were distributed prior to the meeting for information. No comments were raised.

Members received these minutes.

19.189 Pennine Lancashire Cancer Tactical Group Minutes – July 2019

The minutes were presented for reference purposes only. These were distributed prior to the meeting for information. No comments were raised. Members received these minutes.

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19.190 Pennine Lancashire Research, Innovation and Clinical Effectiveness Committee Minutes July 2019

The minutes were presented for reference purposes only. These were distributed prior to the meeting for information. No comments were raised.

Members received these minutes.

19.191 Items for Inclusion on the Corporate Risk Register

There were no new risks identified.

19.192 Date & Time of Next Meeting

The next meeting has been scheduled on Wednesday 25th September 2019 at 1pm Meeting Room 1, Walshaw House, Nelson.

Deadline for papers is 5pm on 16th September 2019.

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancs Clinical Commission Group

PENNINE LANCASHIRE QUALITY COMMITTEE Minutes of the Meeting Held on 25th September 2019 PRESENT: 2019 2020

Name and Title Org 22/05 26/06 25/07 28/08 25/09 30/10 27/11 22/01 26/02 25/03 00/04 00/05 00/06 00/07 00/08 00/09 00/10 00/11 00/12 *25/12* Clinical Representatives (two needed): Lay Advisor: Quality and Patient Engagement - Chair - ELCCG      Michelle Pilling Secondary CareDoctor (Retired) - Chair - Geraint BwDCCG  L    Jones Associate Director of Quality and Commissioning - Janet BwDCCG  A A A A Thomas Associate Director of Quality and Nursing/Head of Quality - ELCCG      Kathryn Lord, Caroline Marshall Chief Finance Officer - Kirsty Hollis ELCCG A  A  A Director of Performance and Delivery/Director of ELCCG AR AR  A AR Commissioning - Sharon Martin, Alex Walker Director of Quality and Chief Nurse (Clinical Post) - Jackie ELCCG   A A  Hanson, Kathryn Lord Director of Quality and Performance (Clinical Post) - Dr BwDCCG  A  A  M Ridgway, Dr Ridwaan Ahmed Governance, Assurance and Delivery Manager - BwDCCG  A   A Clair Moir GP Quality Lead (Clinical Post) - Dr Umesh Chauhan ELCCG  A   

GP Representative (Clinical Post) - Dr Stephen Gunn BwDCCG  A   

GP Representative (Clinical Post) - Dr Zeenat Sykes ELCCG  A A  L

Lay Member - Dr Nigel Horsfield BwDCCG     

Secondary Care Consultant - Dr Paul Taylor ELCCG A  A A A

Medicines Management Representatives (one needed): Senior Operating Officer, Primary, Community and BwDCCG - - A A A Medicines Commissioning - Julie Kenyon Associate Director of Research, Medicines and Clinical ELCCG    A  Effectiveness - Lisa Rogan Safeguarding Representative (one needed): Head of Safeguarding (Adults) and MCA Leads - Peter PLCCG   A -  Chapman Head of Safeguarding (Children) - Susan PLCGG - - A  - Clarke Head of Safeguarding (Children) - Debbie PLCGG - -  - - Ross RATIFIED : Present A: Apologies L: Arrived Late E: Left Early R: Representative in Attendance

In Attendance:

Debra Atkinson - Head of Corporate Business Judith Johnston - Head of Clinical Commissioning deputising for Alex Walker Simon Bradley - quality and Performance Manager Sarah Harrison Vanessa Morris - IPC Lead Nurse Travis Peters

Quoracy shall consist of 50% of the Committee and must include 1 Non-Executive Governing Body Member/Executive Governing Body Member from each CCG and one clinical representative from each CCG, one of whom must be a GP. NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

REF: ACTION 19.193 Welcome & Chair’s Update

The Chair opened the Pennine Lancashire Quality Committee and welcomed all attendees.

19.194 Apologies

Apologies were received and noted as above.

19.195 Declarations of Interest

No declarations of interest were noted. Any conflicts that transpire during the meeting are to be declared and managed appropriately.

The meeting was quorate.

19.196 LCFT Complaints Team

Sarah Harrison from LCFT was welcomed to the meeting. Sarah advised Committee members that she is responsible for the patient experience element of the quality agenda at Lancashire Care, especially around listening and engaging with patients. This information is then shared with the quality improvement team. Patients are encouraged to talk about their individual experiences with work also being carried out with hard to reach groups. To support, this, a two day training package has been put in place for all staff.

Level 1 complaints and rapid resolution are dealt with within five to ten days. There are a low number of level 2 complaints, which are around safeguarding and suicide concerns. The complaints graph circulated, addressed issues in the Pennine area. Face to face meetings will take place unless it will be detrimental to a patient’s health. All complaints are assigned to a case officer and this enables any themes to be picked up in a specific location.

It is hoped the patient meetings will be volunteer led and that the meetings will trigger changes on the wards at the point of care. Patient meetings will feed into team meetings to share and learn from experiences. The first star for “Triangle of Care” was awarded to the Trust in July 2019 and was for a self-assessment of inpatient settings and crisis teams across Lancashire. Actions plans are in place on how to improve engagement with carers. Every area has a carer’s information board; Champions are being identified for each area to share up-to-date information with colleagues. The “Triangle of Care” process will constantly evolve due to the involvement of family members and information gathered through listening. It will take two years to complete the Triangle of Care exercise for the whole area.

Sarah also outlined how a film of people’s experiences of seclusion is available to share with staff. Seclusion leaflets are now accessible for families and patients. Work has been undertaken around nicotine management, and this is an ongoing piece of work.

The Meridian System is an additional to the Friends and Family Tests to improve on feedback from engagement to improve care. The new Executive team has brought new ideas to instigate change.

Kathryn Lord thanked Sarah for the presentation and believed that there have been a lot of positive improvements regarding transparency with staff, patients and carers and that this positive improvement should be widely shared.

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Dr Geraint Jones thanked Sarah for the presentation and for listening to people. He asked if there was any evidence of changes that have taken place following a complaint theme. Sarah outlined a national award had been received for the “Always There Event” that had been developed at The Guild Lodge.

Following this a meeting had taken place with staff and service users. This resulted in the installation of ligature safe patient feedback post boxes, which are emptied by admin staff. A complaint had been received regarding the way information around diversity was being received from patients. This has now been improved and the issue has been addressed.

Dr Umesh Chauhan queried the complaints from MPs, as the majority are patient focused.

Peter Chapman asked what the link was between complaints and safeguarding; Sarah confirmed that any mention of safeguarding or complaints which referenced harm or abuse triggers a phone conversation with the safeguarding duty team and the case officer, who will request a check is made on the person if required.

Caroline Marshall thanked Sarah for the positive work that has been undertaken around complaints. Caroline advised Committee members that there is a positive closer working relationship between the Trust and the CCGs .

The Chair asked how proactive the Trust are in gaining feedback from people in significant mental health distress. Sarah confirmed that they do not approach these patients regarding their experiences until they are out of distress. The complaints received in relation to Section 136 suites specifically highlight the delays in waiting for beds across the county.

Work is being undertaken on the experiences of people in Mental Health Decision Units specifically focusing on care needed to enable the individual to remain at home. The Synergy Project on the Fylde Coast enables a police officer, ambulance crew and mental health professional to attend a person in mental health distress and try and support them at home; the initial feedback has been positive and the work is being formally evaluated externally.

The Chair thanked Sarah for her presentation and welcomed the approach to involving patients and carers.

Sarah Harrison then left the meeting.

19.197 Minutes of the Meeting held on 28th August 2019

The date of the meeting was highlighted as incorrect therefore is to be amended. If there are any further amendments to the attendees stated, the meeting administrator is to be informed.

With the date of the meeting to be amended the minutes were recommended for approval as an accurate record of the meeting.

Dr Zeenat Sykes joined the meeting.

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19.198 Action Matrix

19.086.3 Pennine Lancashire Quality and Performance Month 11 LCFT: IAPT Any crisis services will be reported by Judith Johnston at future meetings; this action is now closed.

19.112 Pennine Complaints Report 2018/19 Quarter 4 A presentation has been delivered; this action is now closed. In addition, the action is to be amended to remove incorrect information.

10.125.1 Presentation: Neurology Pathway The Neurology peer review report and action plan has been received from Steve Flynn and to be circulated. A summary report is to be completed by Simon Bradley and then shared with the Governing Bodies.

19.150.4 4 Hour Flow Verbal update to be given at the October meeting

19.161 BwD CQC Safeguarding and Looked After Children Review – Final Report published June 2019 This report and actions undertaken by Kirsty Hamer was circulated at the meeting. Item now closed.

19.172 Northumberland Tyne and Wear Peer Group Item now closed as quarterly updates will be given in the regular reports to Committee.

19.178.1 Pennine Lancashire Primary Care Update Update to be given at the October 2019 meeting.

19.178.2 Pennine Lancashire Primary Care Update Update to be given at the October 2019 meeting.

19.179 Pennine Lancashire CQUIN 2019/20 Q1 Payments CQUIN update on the agenda. Item is now closed.

Vanessa Morris joined the meeting.

19.180 Pennine IPA and CHC Update Update to be given at the October 2019 meeting through the scheduled Committee paper.

19.182 Infection Prevention Team Report Healthcare Associated Infections Update Q1 2019/20 Action: Vanessa Morris to forward the report to Dr Geraint Jones.

19.186 LD Transforming Care, STOMP and LeDer Update To be presented at the October 2019 meeting through the scheduled Committee paper.

VM 19.199 Pennine Lancashire Quality and Performance Report – Month 04

A PowerPoint presentation of the performance report was given by Simon Bradley. The key highlights presented were:

A&E four hour performance remains static. There has been an increase in Type 1

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attendances, adding further pressure to the position however there are times when the performance is at 95% or above. It has been recognised that the 4 am SITREP often shows a reduction in performance, which is a key area of focus. When compared nationally, the Trust’s position has improved.

Conversations around staffing caps need to take place to ensure consistency across the system. Discussions took place on increased demand; this may be due to inappropriate attendances and there are many factors which may impact on this. Simon Bradley will review data from 111 to ascertain if there is a link to demand increases.

Action: Simon Bradley to review the data from 111 to ascertain if there is a link to demand. SB

Ambulance performance is seeing an increase in the number of calls being received. The service is focussing on See and Treat. Paramedics are trained in the Manchester Triage technique and there is a rolling programme for new starters. It should be noted that there has been an improvement in ambulance handover times which impacts on crews being able to return onto ‘the road’. SB Action: Simon Bradley to amend the performance trajectory arrows to an extra context box to indicate trends graphs (pages 3, 7 and 8).

The new RTT performance pilot measure commenced 1 August 2019 with an average waiting time set at 8.5 weeks. The current performance is 11 weeks. Different ways of working and recruitment are being addressed to improve performance. There are concerns regarding the downward trajectory; for example due to Consultant staff reluctance to undertake overtime due to additional pension liabilities. Focus is on reducing the waiting times by maximising the skill mix available and where activity can be undertaken in the community. This is a test phase and the Trust have been given some the different ways of working to try and reduce the waiting lists.

A patient waiting more than 52 weeks for surgery has now received treatment; this was a complex procedure requiring two Consultants as previously reported. As of month 5 2019/20 there are no breaches for either CCG.

The pressure on the two week cancer breaches are predominately around patient choice. Work continues with GPs around emphasising the need for patients to attend the two-week appointments. The “Let’s Talk Cancer” campaign will focus on the screening programmes. The Trust has produced an information leaflet on diagnosis tests. 31 day breach numbers are struggling due to surgical capacity. 62 days is seeing improvements on performance and there is support to help with pathways. Diagnostics will hopefully be undertaken on the day to reduce appointments.

Early Intervention and Psychosis (IAPT) has seen improvements for July. The National Team have visited and looked at the processing policies. The changes have potentially helped with the improvements and referrals processes need to be correct.

Improvements have been seen in the IAPT recovery rates with the number of DNA rates reducing.

A Task and Finish Group has been set up to address the predicted waits. This will include a review on staffing and their banding, as staff are moving to different positions once they have been trained. IAPT waits are being scrutinised with a focus on Ribble Valley and BwD trajectories.

Pennine Lancashire Quality Committee 25 September2019 Page 4 of 9 Minutes Approved by the Chair: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

The Memory Assessment Service performance is improving and is on trajectory to recover. Sickness absence and staffing vacancies have impacted on the Pennine Service and bank staff have been utilised to address this.

It was noted that the staff sickness record was not work related and the Commissioning Lead has been working with the Pennine team to support a recovered position.

The Chair queried the recording of workforce staffing rates for BMI Beardwood reported on pages 12 and 40 as they appeared to conflict.

Action: Simon Bradley to confirm staffing rates. SB

Action: Caroline Marshall to bring the Mixed Sex Accommodation deep dive to the next meeting. CM

Flu Update

Vanessa Morris provided an update on the infection control workstream; the report has been updated and the designation determinations are placed on it. There was nothing further to add to the flu update presented in August 2019 around seasonal flu in Australia. Some areas have commenced this year’s vaccinations. CCG staff are able to request a voucher to have their flu injections at Boots chemists. There is some capacity for staff to have the vaccination at East Lancashire Hospital Trust (ELHT) site as in previous years. Staff are supported to have their injection undertaken in work hours.

Sepsis Update

Caroline Marshall gave an update on the Sepsis workstream across Primary Care and ELHT. Miss Julie Iddon (Interim Deputy Medical Director at ELHT) will be presenting at the BwD and EL CCG Protected Learning Time event later in the week regarding early identification of Sepsis. In addition, a volunteer from the Sepsis Trust has been secured at the event also. Caroline reported that ELHT are undertaking a significant amount of work in regard to Sepsis with the Sepsis bundle updated. The outlying mortality position of the Trust for Septicaemia is now not alerting; this can partly be attributed to the coding amendments. The CCG sits on the Trusts Mortality Steering Group where Sepsis is widely discussed.

19.200 CONFIDENTIAL: Provider Update Paper

This paper was tabled for reference. The content of this item is for Committee members and attendees only and is not for wider distribution. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received and acknowledged this report.

19.201 CONFIDENTIAL: ICS Mental Health Systems Improvement Board

This paper was tabled for reference. These were distributed prior to the meeting for information. No comments were raised. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received these minutes.

Pennine Lancashire Quality Committee 25 September2019 Page 5 of 9 Minutes Approved by the Chair: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

19.202 Pennine Lancashire Research Update

Dr Lisa Rogan gave an overview of the quarterly report. Presentations are given to the Governing Bodies and these have been received positively.

Healthy Weight pathways need to be embedded. Lisa has spoken to Claire Richardson regarding how this can be embedded in the commissioning portfolio; no feedback had been received at the time of the meeting.

Good clinical practice needs to be embedded following the Evaluating Primary Care Heart Failure Review.

One team is working with a LCFT pharmacy around STOMP, this work is extensive for each patient around psychotropic drugs, and each plan is individual to each patient. Part of the STOMP work is co-designed at national and PCN level along with connections with organisations around Autism.

Geraint requested the outcomes of the reports. Further discussions then took place on the outcomes and which will be reported accordingly.

Action: Citations to be included in future reports. LR

Members received, acknowledged and supported this report.

Travis Peters joined the meeting.

19.203 Pennine Lancashire Equality and Inclusion Team Quarterly Report – Quarter 2

Travis Peters highlighted the key areas of the report.

Equality Delivery System: Staff will be asked to grade the CCGs in Quarter 3 as to how supported they feel overall as a workforce.

Race Equality Standard: Data has been uploaded to NHS England ready for analysis.

Equality Impact and Risk Assessments: Work is ongoing and updates will be given accordingly.

Dr Geraint Jones enquired if Friends and Family are included. Travis confirmed that communication and engagement included diversity monitoring statistics.

Members acknowledged receipt of this report.

Travis Peters left the meeting.

19.204 Pennine Lancashire CQUIN 2019/20 Q4 Update

Simon Bradley provided the update on CQUIN and the Lancashire Care Foundation Trust (LCFT) position for CQUIN 3a.

A lengthy discussion took place on the CQUIN 2017/19 year two payments for LCFT, specifically indicator 3a. Committee members acknowledged that some improvements have taken place in terms of patient care, but further improvements are required. Evidence is required that the CQUIN work is being embedded; this should be in the Trusts quality report requirements. It was agreed that a caveat should be placed around the CQUIN payment

Pennine Lancashire Quality Committee 25 September2019 Page 6 of 9 Minutes Approved by the Chair: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

that is to be released for indication 3a. The caveat agreed was that continued improvements should be in place and evidenced to the CCG by Q4 by the Trust.

It was cited that all CQUIN reports are approved at this meeting.

Members were happy to approve the payment on the basis of the above stated caveat. 19.205 Pennine Lancashire Risk Management Strategy 2019/20

Debra Atkinson presented the paper and highlighted the main amendments to the revised strategy document.

Corporate Risk Register: Any risks that have had the score reduced to less than 9 will be monitored through the programme management risk approach. All risks rated 15 and above will transfer onto the Governing Body Assurance Framework.

Risk Management Group – The East Lancashire Risk Management and Compliance Group Terms of Reference and membership have been reviewed; this is now the Pennine Lancashire Risk Management Group. The Terms of Reference for the BwD Information Governance Steering (IG) Group have been reviewed and this will now be the Pennine Lancashire Information Governance and Compliance Group which will focus on Information Governance, Freedom of Information compliance, Fire, Health and Safety and Security and staff compliance with mandatory training

Chief Finance Officer, Governance, Assurance and Delivery Manager and CSU Senior Risk Officer – Changes have been made to roles and responsibilities.

Members were happy to receive and support this strategy.

19.206 Risk Management Group Terms of Reference

Debra Atkinson presented the paper advising that the core membership of the meeting has been reduced, although risk owners will be invited to attend the monthly meetings and provide updates. The Committee raised concerns that the membership of the group is at the level to provide assurance on the individual risks. A recommendation was made that Primary Care should be represented at the group due to issues around risk recording raised at East DA Lancs Primary Care Committee.

Action: Deborah Atkinson to request that Primary Care is represented at the Risk Management Group..

Members acknowledged receipt and supported the Terms of Reference.

19.207 Information Governance and Compliance Group Terms of Reference

Members acknowledged receipt and supported the Terms of Reference.

19.208 Pennine Lancashire CCGs Risk Management Report

Deborah Atkinson presented the bi-monthly risk management report and the key areas were highlighted as follows:

There are 2 x SEND risks that are currently being held as separate risks; additionally BwD CCG holds a stroke risk on its risk register; which is being reviewed to see if it should be reflected as a Pennine Lancashire risk.

Pennine Lancashire Quality Committee 25 September2019 Page 7 of 9 Minutes Approved by the Chair: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

The A&E “target risk” rating has been increased to “8” to reflect the expectation of the risk rating being achieved by March 2020. A number of discussions have taken place regarding the target risk ratings being realistic and achievable.

A Scheduled Care Delivery Board has been established across Pennine Lancashire which will focus on the 18 week performance and have a system level oversight and scrutiny. This will be updated on a regular basis.

The Lancashire SEND re-inspection is imminent.

The BwD CCG 2018/19 Corporate Objective risks will be migrated onto the risk register and then reviewed.

A significant amount of work has been undertaken around the updating of risks and it was felt that the colour coding was a useful tool.

A Mersey Internal Audit exercise had previously highlighted that when the Risk Report is presented it should be explicitly referenced that it also includes the Governing Body Assurance Framework.

The recommendations in the Risk Management Report were supported by the members.

19.209 LD Transforming Care, STOMP and LeDer Update

Dr Lisa Rogan gave an overview of the report which sets the strategy for the next five years, and work plan for the next 12 months. This was an update on the original paper presented but is still in draft form.

The Chair requested that efforts to understand the patient experience be considered LR as part of the strategy in line with the first principle of the Royal Pharmaceutical Society good practice guidance on medicine optimisation.

Discussions took place on the lack of services for psychological COPD dependent patients. These people are supported by rehabilitation services and social prescribing may help. It was noted that not all GPs are aware of the services.

Dr Lisa Rogan was thanked for the thorough report.

Members acknowledged the report.

19.210 Pennine Lancashire Prescribing and Medicines Optimisation Strategy 2019-25 and Work Programme 2019-20

Members acknowledged the report.

19.211 Quality Meetings Draft Minutes

9.1a ELHT Quality Review Meeting Minutes – August 2019 9.1b MCFT Quality Minutes – August 2019 9.1c BMI Quality Minutes – August 2019

These minutes were tabled for reference. They were distributed prior to the meeting for information. No comments were raised.

Members received these minutes

Pennine Lancashire Quality Committee 25 September2019 Page 8 of 9 Minutes Approved by the Chair: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

19.212 Risk Management and Compliance Group Minutes

The minutes were tabled for reference. These were distributed prior to the meeting for information. No comments were raised.

Members received these minutes.

19.213 Pennine Lancashire Research, Innovation and Clinical Effectiveness Committee Minutes – July 2019

The minutes were tabled for reference. These were distributed prior to the meeting for information. No comments were raised.

Members received these minutes.

19.214 Pennine Lancashire Research, Innovation and Clinical Effectiveness Committee Minutes July 2019

The minutes were tabled for reference. These were distributed prior to the meeting for information. No comments were raised.

Members received these minutes.

19.215 Items for Inclusion on the Corporate Risk Register

There were no new risks identified.

19.216 Date & Time of Next Meeting

The next meeting has been scheduled on Wednesday 30th October 2019 at 1.00 pm Meeting Room 1, Walshaw House, Nelson

Deadline for papers is 5.00 pm on 23rd October 2019.

Pennine Lancashire Quality Committee 25 September2019 Page 9 of 9 Minutes Approved by the Chair: Appendix 5

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

Pennine Lancashire Committees in Common Minutes of the Blackburn with Darwen CCG Commissioning Business Group and East Lancashire CCG Sustainability Committee held on 21st August, 2019 at Walshaw House

PRESENT: Blackburn with Darwen CCG Dr John Randall General Practitioner (GP) Executive Member Dr Adam Black GP Executive Member Paul Hinnigan Lay Member (Governance) Dr Penny Morris Clinical Director Roger Parr Deputy Chief Executive/Chief Finance Officer Dr Zaki Patel GP Executive Member Dr Preeti Shukla GP Executive Member East Lancashire CCG: David Swift Lay Member (Governance ) - CHAIR Dr Santhosh Davis GP, Clinical Lead Burnley Dr Mark Dziobon Medical Director Kirsty Hollis Chief Finance Officer Dr Tom McKenzie GP. Clinical Lead Rossendale Alex Walker Director of Performance & Delivery

In Attendance: Jason Newman Head of Performance & Delivery Dr Lisa Rogan Associate Director of Medicines, Research and Clinical Effectiveness Dr David White Clinical Lead – Urgent Care Stuart Hayton Urgent Care Transformation Manager Elaine Craven Executive Assistant - Minutes

Min Ref: ACTION 19:101 Welcome & Chairs Update

The Chair welcomed members to the meeting.

19:102 Apologies

Apologies were received from Dr Julie Higgins, Dr Fiona Ford, Dr Ridwaan Ahmed, Naz Zaman, Kathryn Lord, David Rogers, Julie Kenyon and Debra Atkinson.

It was advised that Dr Lisa Rogan would be arriving late.

19:103 Governance

The Chair reminded members of their obligation to declare any interest they may have on any issues arising during the meeting, which might conflict with the business of the Clinical Commissioning Groups. The Chair referred members to the outline definitions in relation to types of interest, attached to the meeting agenda.

Declarations of Interest: There were no declarations of interest made at this meeting.

Quoracy: Both Committees were quorate.

- 1 - Minutes Approved by Committees 16.10.19 19:104 Minutes of the meeting held on 17th July, 2019:

The minutes of the meeting held on 17th July, 2019 were approved as an accurate record by both Committees.

The Chair confirmed that following the 17th July Committees in Common meeting, as the East Lancashire Clinical Commissioning Group Sustainability Committee was not quorate, the minutes were circulated to those members not present at the meeting. Sufficient support was received to ensure that the decisions made at the meeting were quorate and a record has been placed on file for audit purposes.

19:105 Action Matrix:

18:31: Pennine STEP (Succeed Thrive Empower Pennine) Service. Alex Walker provided a brief update. A new service specification is in place, a key change is that the service is no longer based in the Accident and Emergency Department. Alex advised that greater numbers of patients are now being referred into the service. A more detailed briefing to be brought to the September Committees in Common meeting.

19:39: Stroke Association – Stroke Recovery Service Included on the agenda.

19:54: Contracts due to Expire Included on the agenda.

19:83: Governance This was discussed at a Joint Governing Body meeting on 7th August and it was agreed that the move towards a joint structure will address the issues regarding quoracy. Agreed that a meeting will be arranged to include both Committee Chairs and Paul Hinnigan to review the Terms of Reference for a joint committee.

19:88: Mental Health Improvement Plan The first meeting of the Pennine Lancashire Mental Health Delivery Board is to be set for September 2019, the terms of reference are to be re-designed in light of the NTW (Northumberland, Tyne and Wear) report. NTW will be a support partner to Lancashire Care Foundation Trust (LCFT). The Board will be co-chaired by Russell Patton (LCFT) and Alex Walker. A report will be brought to the October Committees in Common meeting outlining the revised plan. The Terms of Reference will provide clarity regarding the Board’s remit and will cover community and crisis pathways.

Additional action:

Gifford Kerr asked for the following additional action to be added in reference to the Tuberculosis Service Review item which was discussed at the Committees in Common meeting on 5th May, 2019:

19:72: Tuberculosis Service Review  Identify a Pennine Lancashire Clinical Commissioning Group representative to lead on developing a next steps plan for the service.  Agenda item for the October Committees in Common meeting.

19:106 Matters Arising:

There were no matters arising.

- 2 - Minutes Approved by Committees 16.10.19 19:107 Same Day Primary Care

Dr David White and Stuart Hayton attended for this agenda item. Dr White delivered a presentation entitled - Developing a Pennine Lancashire model and phased delivery plan for ‘Same Day Primary Care’ (Same Day Primary Care refers to access for individuals (all ages) who feel they need clinical input/advice ‘today’.). The purpose of the presentation was to assess support for the model concept and gather feedback.

A copy of the presentation was circulated prior to the meeting. Dr White made the following key points during his presentation:  The aim is to develop sustainable services wrapped around the individual.  Maximise recruitment and retention.  Accurate signposting/navigation for patients.  Consultation has taken or is taking place including a Steering Group to outline aims and develop a model.  The Model has already been to Accident and Emergency Delivery Board, Clinical Reference Group and Local Community Partnership for discussion.  Relative Urgent Care activity: 111 dealing with 350 calls per day and online 80 calls per day.  Blackburn site 200 cases per day, Burnley 150, and Minor Injuries Units 40. Primary Care 4000 cases per day.  Clitheroe example - 40 walk in same day cases per day.  The 111 contract is due for renewal in October 2020.  Urgent Treatment Centres needs to be in place by Autumn 2020 – may be able to seek permission to extend this due date.  Need consistent triage and navigation.  Groups of patients will benefit from a local service (from start to finish).  Discussions at Integrated Care System level looking at a modular system with local level services.  Virtual clinical assessment service in place to support 111.  Lower category 999 patients could be better served by a clinical assessment service.  Urgent Treatment Centres are seeing a greater number of patients than the national specification.  Blackburn Urgent Treatment Centre, all out of hours are off site. Burnley Urgent Treatment Centre, out of hours are on the same site, but not connected. Work is to be done around this.  Urgent Treatment Centres can be counted in Performance Indicators, however if sites are not actually called an Urgent Treatment Centre they can’t be counted.  Variability in local Primary Care offer.  Estates constraints issue, the Emergency Department is too small for the population size.  Model concept – could we do things differently?

During discussion, the following comments and observations were made:  Observations in respect of the 111 service are that it is a service with ineffective triage. The opinion is that this needs to be looked at in depth before progressing with the rest of model. Could clinical triage be done locally, is there sufficient resource?  The evidence suggests that Urgent Treatment Centres should be GP led, but in practice this is not the case, they are hospital led.  A finance programme is required to address funding issues across services.  Need to look at change and will current resources support.  A question was asked as to how the proposed model simplified the service

- 3 - Minutes Approved by Committees 16.10.19 provision. Need to clarify components, break up into chunks where decisions are required, identify areas where key decisions are needed, work up recommendations/options and put forward for decision. Go back to zero base and then assess what do we ideally want and how do we get it.  The question in the North West, is do we want to take control locally. Minimise some of the burdens/constraints.  Key enabler is IT/information sharing, a full electronic record is essential.  Single point of access – what is the desired direction for this? GPs want to be dealing with complex cases and not minor illnesses e.g. coughs, colds etc.  Need to get prevention right to address demand and then work on the rest of system.  Should patients be deflected if they turn up to the wrong part of the system, providing that it is safe to do so.  Improve Primary Care performance as well, demand from patients is different in different practices/areas, there is a variation in quality and performance.  Slim down the model.

Dr White thanked the committee for their useful feedback and advised that a next step project plan will follow.

Dr White and Stuart Hayton left the meeting at this point.

19:108 Contract tracker – Assurance

Jason Newman updated the committees in relation to their request for assurance in respect of contract decisions. He advised that a contracts update is now a standing item on the agenda for the fortnightly Senior Management Team meetings, this then feeds into a meeting tracker, which is then used to inform committee agendas. At the last Senior Management Team meeting, 41 contracts were on record as due to expire in March 2020, these are being followed up with Senior Managers to ensure that they are being tracked. Mechanisms are in place to take these forward.

Discussion followed:  The committees wanted assurance where these contracts are being dealt with and what Committees in Common should expect to come to their meetings. If the contracts are not to come to Committees in Common, where will they go for scrutiny and decision. Jason advised that contracts of a higher value will come to Committees in common, lower value items will be scrutinised at Senior Management Team (SMT) or at the Senior Managers Meeting (SMM), also held fortnightly which is attended by all Senior Directors.  There needs to be an incremental process to ensure that 41 business cases don’t come through to Committees in Common, all at the same time.  Primary Care Committee are seeing some decisions that don’t go through Senior Management Team. Jason agreed to liaise with Collette to ensure that these are documented.  Committees in Common were seeing last minute requests for decisions. Jason gave assurance that this will be mitigated, Senior Management Team will ensure that the business ask is manageable, and the meeting tracker will calendar details of expected items.

Jason added that the register is only as good as the information provided by colleagues, but assurance was given that there is a process in place.

- 4 - Minutes Approved by Committees 16.10.19 Dr Mark Dziobon left the meeting at this point, his departure did not affect quoracy.

19:109 Prescribing & Medicines Optimisation Annual Report Dr Lisa Rogan joined the meeting at this point and guided the committees through the content of the report. The report provides a comprehensive review of the performance and outcomes delivered through the East Lancashire Prescribing and Medicines Optimisation Work Programme 2018-19. The report demonstrated delivery of £2,426,236 of savings which exceeded the original target of £1.4 million and set against a national cost pressure of £2,156,190 due to NCSO price concessions. Although an East Lancashire report, Lisa also related the content to Blackburn with Darwen.

Discussion then took place:  A question was asked, if there was any new research to show the results between Doacs and warfarin in relation to a reduction in the number of stroke cases. Lisa responded that there is no evidence that Doacs have reduced the number of strokes.  Need to look at Communication strategy around services as well as self-care promotion.  Really good report, the work of the Medicines Management Team is really appreciated.  A question was asked, as we move to a more integrated team will the relationship with hospital colleagues improve prescribing issues experienced. Lisa responded that collaborative work is already taking place in pathways.  In relation to Eclipse, Lisa advised that the team have made this work. Most practices are trying to meet targets, not necessarily just in relation to costs but because they want it to work.  A question was asked, if there are any other areas doing things better and is there learning to be gained. Lisa advised that comparisons tend not to be made on a like for like basis, therefore data doesn’t necessarily demonstrate better outcomes. Lisa added that there are some examples of good practice and improved outcomes, where these are identified better practices are rolled out.

The Committees accepted the report.

19:110 Pennine Lancashire Diabetes Health Improvement Board Minutes and Action Matrix April 2019

The minutes and action matrix of the Pennine Lancashire Diabetes Health Improvement Board meeting held on 3rd April were received for information.

19:111 East Lancashire Medicines Management Board Minutes – 20th March & 15th May, 2019

The minutes of the East Lancashire Medicines Management Board meetings held on 20th March and 15th May were received for information.

19:112 Any other business:

There were no other items of business in this section of the meeting.

19:113 Date & Time of Next Meeting:

The next meeting was confirmed as Wednesday, 18th September, 2019 commencing at 1.00 p.m. at the Innovation Centre, Haslingden Road, Blackburn.

- 5 - Minutes Approved by Committees 16.10.19 Appendix 6

BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP (CCG) Minutes of the Information Governance Group Meeting held on 11th June 2019 at 10:30 – 11.30 – Walshaw House

PRESENT: Neil Holt – Head of Commissioning Performance (Chair) Paul Hinnigan – Governance Lay Member Claire Moir - Governance, Assurance and Delivery Manager Kirsty Hollis – Chief Finance Officer Debra Atkinson – Head of Corporate Business Bronwyn Casey – Information Governance Business Partner – Lancashire Olivia Binsley – Information Governance Support Officer - Lancashire

Agenda Actions Item: 1 Apologies None noted.

2 Minutes and Actions of the Previous Meeting – 11th February 2019 Minutes of the meeting held on 10th of February 2019 require a few Olivia amendments. Olivia Binsley to amend minutes of meeting that took place Binsley on the 11th of February 2019 and re-send to members of the group. 3 Declarations of Interest None noted.

4 Any Matters Arising

Lancashire Care Foundation trust (LCFT) – Reoccurring breach An LCFT incident occurred last year which involved the sending of personal data in an email trail, this was resolved. However, a further incident involving a 12- hour breach report was sent to the CCG where a column containing NHS numbers had been left in the report but hidden. Another breach then occurred as the result of the second breach, as the report was forwarded on to a distribution list for a meeting. Claire Moir had been chasing the incident for some time however no resolution was reached until recently it was confirmed via a report that the incident has now closed after the Information Commissioners Office (ICO) conducted and completed a review. The outcome is that policies and procedures are tightened up and staff receive training around Information Governance.

Shred It – location of contract In the minutes dated 11/02/2019, there was an action regarding the location of the Shred It contract. As the CCG do not directly contract Shred It, as this is procured via their landlord, St Modwen’s. It was agreed by Roger Parr previously that assurances from St Modwen’s would be sufficient to meet the requirements for the Data Security and Protection Toolkit (DSPT). It was agreed this action was closed. However, the group disagreed that this action should have been closed and for assurance purposes and protection of the CCG, as a result reopened the action. The CCG would prefer to continue to chase the contract or Bronwyn

Page 1 of 4 instruct the landlord to re-precure the service and seek confidential waste with a Casey different provider. The group agreed that, Bronwyn Casey will check with Claire other CCGs covered by MLCSU that may have a contract in place with Moir, Shred It which can be used and Blackburn with Darwen and East Debra Lancashire CCG’s to contact their landlords regarding a contract. Atkinson

Information Asset Assistants and Information Asset Owners (IAAs & IAOs) The group discussed the need for more IAA’s and IAO’s within teams. Previously Roger Parr had agreed that more support can be provided if needed however the group is happy with the amount of IAA’s and IAO’s as it stands for now as there is currently no timetable for when teams will be coming together with the CCG’s merging. Once this stage has been completed it was agreed that the IAAs & IAOs will be reviewed then. It was highlighted that there is a missing IAO in the commissioning team as a member of staff left the organisation. Bronwyn Bronwyn Casey will temporarily pick up the IAO role for the commissioning team Casey until notified otherwise.

GDPR Accountability principle - CCG Contracts A list of possible third-party providers who may process personal data was sent to Claire Moir as a previous action, which needs reviewing to check if personal Bronwyn data is processed. Claire Moir had advised she is still in the process of doing Casey, this. Bronwyn Casey and Claire Moir to meet and discuss the providers and Claire contracts for GDPR accountability principle. Moir

Information Governance Annual Refresher Training The group discussed the annual refresher training, previously there was an action for the CCG to achieve a 95% compliance completion rate which was a requirement for the Data Security and Protection Toolkit (DSPT). This action was closed as the compliance rate was achieved prior to submission for 2018-19.

Data Protection Officer (DPO) service The group discussed the DPO service and the new requirement for CCGs to be responsible for providing a DPO service to practices covered by the CCG. It was confirmed that Andrew Harrison, is currently in discussions with the Head of Information Governance, Hayley Gidman on behalf of all CCG’s in Lancashire.

In relation to the previous action where Claire Moir had been liaising with Hayley Gidman regarding a 6-month review of the DPO service. The service level agreement for the DPO service details that the CCG would receive a quarterly Bronwyn report. To date, one report has been received, running from June - December Casey, 2018. The action is ongoing with Claire Moir to see how the DPO service Claire progresses and Bronwyn Casey will liaise with Hayley Gidman regarding Moir the reporting aspect of the DPO Service.

5 January bi-monthly report

Bronwyn Casey discussed the report with the group advising that the 2018-19 Data Security and Projection Toolkit (DSPT) was submitted on time in March and the new DSPT for 2019-20 was released on the 10th June 2019. Details of the workplan will be outlined in the next bi-monthly report, which will be sent out in July. Bronwyn Casey advised that the new toolkit has a higher focus on data quality and cyber security. All IG Policies are now complete and are not due to be revisited until 2021 unless there are assertions in the new toolkit which require amendments to be made.

It was mentioned that the Code of Conduct as agreed by the CCG would be monitored and completed annually via individuals Electronic Staff Record (ESR) however the group agreed that the assurance of completion wasn’t satisfactory as individuals would only need to scroll from the top to the bottom of the Page 2 of 4 document to complete, meaning that staff may not read the document properly. The group would prefer a tick box alongside a statement confirming that an individual has read and understood the document for assurance purposes. The group also agreed that in the meantime, it would be useful for a communication to be sent out to staff advising them pause completion on the Code of Conduct until a resolution was established regarding ESR. Bronwyn Casey to enquire Bronwyn about the tick box option and Neil Holt to compose and circulate a Casey, communication to all staff within the CCG regarding the Code of Conduct. Neil Holt In addition, the IG training is also available on ESR however face-to-face training will be made available to both CCG locations later in the year.

In regard to Data Protection Impact Assessments (DPIA’s), Bronwyn Casey advised that there are no outstanding DPIA’s awaiting sign off from the Senior Information Risk Owner (SIRO). Concerns were raised around the time scales in which actions were taking to be completed regarding a project in which Fylde & Wyre CCG had taken the lead on. Bronwyn Casey confirmed this had been delayed however is now progressing. The group also discussed the layout of the DPIA’s on the report specifically in keeping 2018-19 and 2019-20 DPIA’s separated rather than having a 12-month rolling period on the report.

The group also discussed Information Risk and The Caldicott Guardian log, Bronwyn Casey mentioned that for Information Risk, a new way of providing information into the report is being investigated by the IG team, with an idea to use a team by team structure to show information assets within each team and the stages. In relation to the Caldicott Guardian log, Bronwyn Casey mentioned the log was up to date as far as she is aware but will link in with Janet Thomas to Bronwyn check for any discrepancies. Bronwyn Casey to link in with Janet Thomas to Casey compare Caldicott Guardian logs.

Bronwyn Casey briefly advised the group that the Contracts and Agreements along with the Data Sharing Agreement sections of the report are new and will be separated logs in future report and continue to be displayed in this manner.

6 Terms of Reference (TOR)

The group discussed the Terms of Reference, Kirsty Hollis as SIRO across both organisations would like to see the Information Governance Steering Group streamlined to cover both CCG’s and to have one Pennine Lancashire bi- monthly report.

The group agreed that with Blackburn with Darwen CCG and East Lancashire CCG’s coming together and discussions on going with the structure it would make sense if the format of the Bi-monthly report moving forward, would like to have both CCG’s together on one report and the annual report remain separated.

In relation to FOI, for Blackburn with Darwen CCG the report feeds into the IG Steering Group however for East Lancashire CCG, the report goes to Quality Committee. The group would prefer both reports to come into the IG Steering Group.

The group also discussed the minutes of the group and where they are ratified however as discussions around the structure of the CCG’s merging are still in progress, it was undecided of how this will work moving forward. Further discussions are required when the new structure is in place.

The membership of the group will meet four times a year and ideally the meetings will follow the Risk Management Group and the quarters finalised FOI report. Page 3 of 4 7 Freedom of Information (FOI) The FOI Freedom of Information Quarterly Report 01/04/2019 – 30/06/2019 was not available for the meeting as Q1 was not yet a full quarter.

The group had a brief discussion around FOI. It was agreed there are issues with FOI requests being sent to the correct team member to deal with. Debra Atkinson and Claire Moir have a teleconference meeting with Louise Booker to discuss the reports and service moving forward with the two CCG’s joining.

8 Any other business The group agreed that the governance structure needs to be in place before the next meeting can be planned in.

Neil Holt mentioned the new Data Protection Impact Assessment (DPIA) template, advising that it would be helpful for the CCG staff members to have guidance to aid when a DPIA would be used. Bronwyn Casey advised that the IG team run DPIA Webex training on a monthly basis, have training included within the annual refresher training and have drop in sessions specifically for individuals to seek guidance around IG issues including DPIA’s. It was agreed for Bronwyn Casey to liaise with David Rogers by the 20th of June 2019 for him to send out some information to the CCG’s regarding DPIA’s as drafted by the IG team.

9 Next Meeting TBC

Page 4 of 4

BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

Blackburn with Darwen CCG Governing Body & East Lancashire CCG Governing Body Meeting in Common

Agenda Report Title: Sub Committee & Stakeholder Minutes 5.2b No: Meeting Date: 13 November 2019 Summary of Report: The report provides Members with minutes of the Sub Committees of the Governing Body for receipt. Stakeholder Committee minutes are also included for information. Report Recommendations: Members are requested to receive the report. Financial Implications: None Procurement Implications: None Report Category: Tick Support and recommend/forward the report. Approve the recommendations outlined in the report. √ Debate the content of the report. Receive the report for information. Author: Anne Holden, Corporate Administration Manager

Report supported & approved by your Senior Lead? Y/N Presented By: Debra Atkinson, Head of Corporate Business Other Committees Consulted: Has a PIA been completed in respect of this report? Privacy Impact Assessment N (PIA) If Yes, please attach If No, provide reason below. Has an EIA been completed in respect of this report? Equality Impact Analysis N (EIA) If Yes, please attach If No, provide reason below. Data Protection Impact Is a Data Protection Impact Assessment Required? N Assessment Risks: Have any risks been identified / assessed? N Conflict of Interest: Is there a conflict of interest associated with this report? N Has any clinical engagement/involvement taken place as part N Clinical Engagement: of the proposal being presented. Patient Engagement: Have patients been involved in the drafting of this report? N Privacy Status: Can the document be shared Y

CCG Corporate Objectives :

To commission the best quality and effective services to deliver optimal healthcare CO1 outcomes for our local population. Ensure the balance of our health investment reflects our population’s needs and keeps CO2 the population well. CO3 Deliver the 10 year strategy by engagement with the population we serve and ensure we commission services that meet local needs, with a clear focus on population health management strategies. CO4 We will focus on population health outcomes through helping to deliver successful Integrated Care Partnerships and ensure decisions, provision and access to local services is based on the needs of our population. CO5 As local health leaders, we will focus on increasing life expectancy across Pennine Lancashire to be at, or about, the national average in the next 10 years.

1

BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

Agenda Item No: 5.2b

Blackburn with Darwen CCG Governing Body & East Lancashire CCG Governing Body Meeting in Common

13 November 2019 SUB COMMITTEE & STAKEHOLDER GROUP MINUTES

1. INTRODUCTION

1.1 The report provides Members with minutes of the Sub Committees of the Governing Body for receipt. Stakeholder Committee minutes are also included for information.

2. SUB COMMITTEES AND STAKEHOLDER GROUPS

2.1 Audit Committee : Chair – David Swift The minutes of the Audit Committee held on 23 July 2019 are attached at Appendix A. The minutes of the meeting held on 15 October 2019 have been approved by the Chair but not yet ratified by the Committee.

2.2 Primary Care Committee : Chair – Naz Zaman The ratified minutes of the meeting held on 20 August and 17 September are attached at Appendix B.

2.3 Pennine Lancashire Quality Committee : Chair – Michelle Pilling The ratified minutes of the meetings held on 24 July, 28 August and 25 September 2019 are attached at Appendix C.

2.4 EL CCG & BwD CCG Committees in Common The minutes of the meetings held on 21 August are attached at Appendix D, noting that the September meeting was stood down. The minutes of the meeting held on 16 October are not yet ratified, however key commissioning decisions agreed at that meeting are outlined in the Joint Chief Officers report at para 3.3.

2.5 Locality Steering Group Summaries : Chair – GP Clinical Leads Locality Summaries are attached at Appendix E.

3. STAKEHOLDER COMMITTEES COMMON TO BOTH CCGs

3.1 Stakeholder Committees: . Lancashire Health & Wellbeing Board The minutes of the meeting held on 10 September 2019 are attached at Appendix F. The next meeting is taking place on 19 November 2019.

. Joint Committee of CCGs The minutes of the meeting held in public on 2 May are attached at Appendix G. The JCCCGs last met on Thursday, 5 September 2019 and the minutes will be shared when received.

4. Recommendations

4.1 Members are requested to receive the report.

DEBRA ATKINSON Head of Corporate Business 2 Appendix A

AUDIT COMMITTEE

Minutes of the meeting held on Tuesday 23 July 2019 Meeting Room 1, Walshaw House

PRESENT David Swift Chair, Lay Member Governance & Audit Michelle Pilling Lay Advisor Quality and Patient Involvement - Deputy Chair

IN ATTENDANCE Kirsty Hollis Chief Finance Officer Deidre Lewis Deputy Chief Finance Officer Debra Atkinson Head of Corporate Business Andrew Smith Engagement Lead, Grant Thornton Lisa Warner Senior Internal Audit Manager, MIAA Zainab Patel Principal Auditor, MIAA David Alford MIAA, Local Anti-Fraud Specialist Fiona Cluskey Executive Assistant

APOLOGIES Dr Santhosh Davis GP, Clinical Lead, Burnley Dr Paul Taylor Secondary Care Doctor Sophia Iqbal Audit Manager, Grant Thornton

Minute ACTION Ref: 19.38 WELCOME, INTRODUCTIONS & CHAIRS UPDATE

The Chair welcomed all to the meeting.

19.39 APOLOGIES

Apologies for today’s meeting are recorded as above. The meeting was quorate; two committee members are required for quoracy.

19.40 GOVERNANCE

The Chair reminded members of their obligation to declare any interest they may have on any issues arising during the meeting, which might conflict with the business of the Clinical Commissioning Group. The Chair referred members to the outline definitions in relation to types of interest, now attached to the meeting agenda.

. Declarations of Interest – None were received over and above those already declared to the CCG. . Quoracy – the meeting was quorate, 2 members of the committee are required.

19.41 MINUTES OF MEETING 21 MAY 2019

The minutes for the meeting held on 21 May 2019 were approved as an accurate reflection of the meeting.

19.42 ACTION MATRIX

Page 1 of 6 Approved by the Chair 03.10.2019 19.36 Internal Audit Reports – Head of Internal Audit Opinion Lisa Warner updated that the Head of Internal Audit Opinion has been updated and the reference of STP on page 11 has been changed to ICS. The updated document was circulated to the committee prior to the meeting. Action closed.

19.43 CFO REPORT ON CCG FINANCES

Kirsty Hollis provided the committee with Month 2 reporting information, for the two month period to 31 May 2019. Kirsty highlighted the following;  There is currently no prescribing data, therefore the finance team taking caution on reporting of figures  The CCG is anticipated to meet all statutory duties and is on plan to deliver a 1% surplus  The CCG is on target with the Better Payment Practice code (BPPC)  The CCG is in a stable position with its debtors and creditors  Activity within the trust is Trust is slightly over plan, this is however being managed  QIPP is a potential risk for this financial year. The CCG is required to deliver savings of circa £12.7m, non-recurrent schemes have been identified but new schemes are required  A share of the £2.5m system risk has been built into the CCGs financial position  NHSE have announced that CCGs have a responsibility to accept and review Previously Unassessed Periods of Care (PUPoC) cases now from 1st April 2012, the impact of this is currently 33 cases awaiting review and future cases predicted of 4 per annum. CSU are to provide regular updates to the CCG and the latest information estimates the CCG will have to fund £1.7m for these packages  The CHC audit has started  Delivery of the shared control total is challenging, conversations with Blackburn with Darwen CCG and ELHT are ongoing  Workforce is currently a challenge  A&E costs continue to be high.

The Chair asked the committee for any questions on the CCGs financial position.

Michelle Pilling asked if the CSU CHC team is now embedded into the CCG and if this is showing any benefits or changes to the systems of work. Kirsty responded that yes they are now embedded, it is early days, there have been some staffing challenges and therefore is unable to report the benefits at this time.

Michelle Pilling also commented on the workforce challenge and expressed that Chorley patients could overspill into East Lancashire.

The Chair queried why Airedale activity has tripled; Kirsty confirmed that it is due to activity. It was asked if funding for LD was likely to reduce and by how much. Kirsty responded that it is likely to be £400k across Lancashire; transformation will be withheld until a plan is in place to meet the trajectory.

There were no further questions and the Chair thanked Kirsty for the update provided.

19.44 PENNINE LANCASHIRE QUALITY COMMITTEE MINUTES

Michelle Pilling provided a summary of the Quality Committee meetings which

Page 2 of 6 Approved by the Chair 03.10.2019 were held in April and May 2019. She highlighted the following information to the committee;

April meeting:  The terms of reference have now been amended to address quoracy challenges, however the meetings were still not quorate unfortunately for April or May  CQC results were reported as good for all practices  An independent report from Healthwatch was presented on feedback from service users relating to the quality of commissioned care home services. Overall findings identified good practice and a number of areas of improvement were highlighted  A deep dive has been undertaken into referral to treatment for neurology waiting lists as there is pressure in the system in this area. Chorley and South Ribble who commission the service are working on a recovery plan  Dr L Rogan presented a Pennine Lancashire research update  There was an audit submission to NHSE on STOMP concerns, Kirsty Hollis is now leading in this area.

May meeting:  There is lots on work ongoing into the neurology pathway. Kirsty Hollis has been tasked to oversee this work and to keep it on track  There is continued focus on referral to treatment and cancer waiting times as targets are not being met  The annual Serious Incident Review report was presented  The risk management update gave the committee cause for concern over scoring, a reduction of scores was seen but they saw little evidence to grant this and this is being addressed  An update was provided on the current position for Lancashire in regard to healthcare associated infections.

The Chair asked the committee for any questions on the update provided. There were no questions and The Chair thanked Michelle for the update provided.

19.45 EXTERNAL AUDIT REPORTS

Andrew Smith attended the meeting and provided the committee with the annual audit letter.

The letter summarises the key findings from the work Grant Thornton have carried out in accordance with the National Audit Office guidance. It is requested for the CCG to approve and publish this on the website.

Andrew updated that the Mental Health Investment Standards guidance has not been finalised as yet and that some pilots are not yet complete and that some objections were received. Due to this Grant Thornton are unable to send an engagement letter to the CCG and it has been fed back that the September deadline may not be realistic. He will provide another update when further information has been received.

The Chair commented that the NTW review will help to shape Mental Health Investment Standards and it will be interesting to see the outcome. Michelle Pilling is also interested to see the outcome due to the report showing an underspend in this area from the CCG.

Andrew advised that a debrief with finance the team has been arranged for

Page 3 of 6 Approved by the Chair 03.10.2019 the audit process, to help make it even smoother for next year.

The Chair asked the committee for their agreement on the annual audit letter. The committee agreed.

The Chair thanked Andrew for attending and for the update provided.

19.46 INTERNAL AUDIT REPORTS

Zainab Patel attended the meeting and presented the committee with the progress report, audit charter and insights update. She highlighted the following to the committee;

Progress Report  The risk management audit gave substantial assurance with 3 recommendations  There are a number of outstanding actions from previous audits; o Key Financial Systems – one outstanding action which is work in progress o QIPP – 2 recommendations which it was updated that this was completed at the last Committees in Common meeting o Provider Contract Management – evidence is being sought to complete this action o GDPR – 2 recommendations which are currently in progress.  The Continuing Healthcare review has started and a meeting with Judith Johnston has been held.

Audit Charter This was provided for approval from the committee, there are no substantial changes, however a couple of minor amendments have been made.

The committee approved the Audit Charter.

Insights Update This was provided for information.

The Chair asked about the 2 spare days on the audit plan. Deidre Lewis and Julie Hardman are aware of this and they will be moved as required and an update will be brought back to the next meeting of Committee.

There were no further questions and The Chair thanked Lisa for attending and for the update provided.

19.47 ANTI FRAUD REPORTS

David Alford attended the meeting to provide the committee with the anti fraud progress report as at July 2019. He highlighted the following;  Preparation is underway and all relevant notices have been actioned in accordance with the Cabinet Office’s timetable for the National Fraud Initiative  There is a pilot ongoing for a new approach to the inclusion of identified fraud risks within the CCGs existing risk management policy and strategy  There have been 2 queries received from members of staff in relation to fraud where advice has been given. Neither have resulted in needing an investigation.

The Chair asked for any questions on the report, there were no further

Page 4 of 6 Approved by the Chair 03.10.2019 questions.

The Chair thanked David for attending and for the update provided.

19.48 CONSIDERATION OF EMERGING ISSUES

Debra Atkinson attended the meeting to provide the committee with the assurances on the emerging issues highlighted by the external auditors from their update reports. The report outlines the appropriate actions that have been out into place by the CCG.

The 20 areas highlighted in the report were all accepted by members.

The Chair asked for any questions on the report, there were no further questions and he thanked Debra for the update.

19.49 RISK MANAGEMENT AND BOARD ASSURANCE FRAMEWORK

Debra Atkinson updated the committee on the CCGs risk management process to enable to the committee to evaluate the assurance of risk management within the CCG. Debra highlighted the following;

 The revised risk management strategy was presented to the Pennine Lancashire Quality Committee in November 2018  East Lancashire and Blackburn with Darwen CCGs are working together to align corporate functions including risk management strategies, systems and proceses following the appointment of the Joint Chief Officer  The findings from the risk appetite exercise were presented to the governing body in January 2019  Discussions have been held about any financial risks, moving forward it is proposed there is one risk for the financial element and another for quality premium.

The Chair asked both internal and external audit colleagues if they have seen some good quality risk registers that perhaps the CCG could adopt. Lisa replied that she would make some enquiries and report back.

There were no further questions on the report; the Chair thanked Debra for the update provided.

19.50 MANAGING CONFLICTS OF INTEREST: QUARTERLY SELF CERTIFICATION

Debra Atkinson updated the committee following the CCGs quarter 1 conflicts of interest return which was submitted at the beginning of July 2019, she asked the committee for any questions on the return.

There were no questions and the Chair thanked Debra for the update provided.

19.51 ANY OTHER BUSINESS

There was no further business at todays meeting. The Chair thanked all for attending.

The meeting closed at 13.30.

Page 5 of 6 Approved by the Chair 03.10.2019 19.52 Date of Next Meeting

Tuesday 15 October 2019, 12.30, Walshaw House

Apologies were given by Michelle Pilling and Debra Atkinson for this meeting.

Page 6 of 6 Approved by the Chair 03.10.2019 Appendix B (a)

NHS EAST LANCASHIRE CCG PRIMARY CARE COMMITTEE Minutes of the Meeting held on Tuesday, 20 August 2019, 2pm

.6.19 Members Title .8.19 .9.19 .5.18 2. 8 10.4.19 23.7 .19 1 20. 17. 15 .10.19 19 .11.19 17 .12.19

Dr Aliya B hat GP, Hyndburn  A A  A Melanie Crabtree Practice Manager Representative A    A Dr Julie Higgins Chief Officer A A A A A Kirsty Hollis Chief Finance Officer    A  Kathryn Lord Director of Quality and Chief Nurse    A A (Interim) Dr Tom Mackenzie GP Locality Lead    A  Michelle Pilling Lay Member, Quality & Patient  A    Engagement & CCG Deputy Chair David Swift Lay Member, Governance   A   Alex Walker Director of Commissioning (Int)  A A   Naz Zaman Lay Member, Equality Inclusion      Chair Debra Atkinson Head of Corporate Business  A    Lisa Cunliffe Primary Care Development Mgr      Dr Richard Daly Primary Care Clinical Lead A A A A Sarah Danson NHSE    A  Jackie Forshaw NHSE A A A A A Lynsey Beniston Healthwatch Lancashire - A A   Peter Higgins Local Medical Committee A A A   David Massey Local Medical Committee    A A Cllr Lian Pate Health and Wellbeing P’ship - - - - - Richard Robinson CCG Clinical Chair A A A A A Collette Walsh Head of Integrated Care & Deputy      Director of Performance IN ATTENDANCE Caroline Marshall Attended for Kathryn Lord   Debbie McCann Executive Assistant – Notes     

Min ACTION Ref: 19:171 Welcome & Chairs Update The Chair welcomed all members to the meeting and advised that item 6.1 would be taken under Part 2 of the meeting.

19:172 Apologies Apologies were received as listed above.

19:173 Governance

. Declarations of Interest: David Swift declared an indirect interest in item 6.3, Oswald Relocation Update as a patient of Oswald Medical Practice. He remained in the meeting but did not participate in the discussion.

. Quoracy: The meeting was quorate [6 members required] In the absence of Kathryn Lord (Interim Director of Quality & Chief Nurse), Caroline Marshall (Head of Quality) formally deputised.

19:174 Minutes of the meeting held on 23 July 2019 At minute reference 19:153 line 5 it was noted that Lancashire & South Cumbria PCN should read Lancashire & South Cumbria ICS. With this amendment, the minutes of the meeting held on 23 July 2019 were approved as an accurate record.

Page 1 of 2 Minutes Approved by the Chair : 3.9.17 19:175 Action Matrix The Action Matrix was reviewed and updated.

19:176 Matters Arising There were no matters arising to note.

19:177 Primary Care Network Update Collette Walsh updated the Committee in relation to Primary Care Networks and confirmed 13 new Clinical Directors are in post. She advised that a Consortium had been formed with monthly meetings to share learning and is currently in the process of looking at how developments can be accelerated with the Primary Care Network and the Neighbourhood.

Peter Higgins requested advice regarding training and development and the proposal for protected learning time. Collette advised that the logistics were being worked through in this regard and that Peter will be CW updated at the completion of discussions.

19:178 P81160 Oswald Relocation Update Lisa Cunliffe confirmed the approval of the relocation of two sites for Oswald Medical Centre:

- 296 Union Road, Oswaldtwistle, BB5 3JD to 274 Union Road, Oswaldtwistle, BB5 3JB - 421 Blackburn Road, Accrington, BB5 1RT and 154 Blackburn Road, BB5 0AE to Aston House, 389-391 Blackburn Road, Accrington, BB5 1RP

Oswald Medical Centre are working with the Comms team and plan to open the new premises on 23 September 2019. The Patient Participation Group members have been invited to attend to look around the new premises.

19:179 Any Other Business

19:179.1 Items for Inclusion on the Corporate Risk Register There were no new items for inclusion on the Risk Register

There was no further business.

19:180 Date & Time of Next Meeting The next meeting was confirmed as Tuesday 17 September 2019, 2pm Meeting Room 3, Walshaw House.

RESOLUTION: “That representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.” (Section 1[2] Public Bodies (Admission to Meetings) Act 1960.

Page 2 of 2 Minutes Approved by the Chair : 3.9.17 Appendix B (b)

NHS EAST LANCASHIRE CCG PRIMARY CARE COMMITTEE Minutes of the Meeting held on Tuesday, 17 September 2019, 2pm

.6.19 Members Title .8.19 .9.19 .5.18 2. 8 10.4.19 23.7 .19 1 20. 17. 15 .10.19 19 .11.19 17 .12.19

Dr Aliya Bhat GP, Hyndburn  A A  A  Melanie Crabtree Practice Manager Representative A    A  Dr Julie Higgins Chief Officer A A A A A A Kirsty Hollis Chief Finance Officer    A  A Kathryn Lord Director of Quality and Chief Nurse    A A A (Interim) Dr Tom Mackenzie GP Locality Lead    A  A Michelle Pilling Lay Member, Quality & Patient  A    A Engagement & CCG Deputy Chair David Swift Lay Member, Governance   A    Alex Walker Director of Commissioning (Int)  A A    Naz Zaman Lay Member, Equality Inclusion       Chair Attendees Title

Debra Atkinson Head of Corporate Business  A    A Lynsey Beniston Healthwatch Lancashire - A A   A Lisa Cunliffe Primary Care Development Mgr       Sarah Danson NHSE    A   3pm Jackie Forshaw NHSE A A A A A A Peter Higgins Local Medical Committee A A A    David Massey Local Medical Committee    A A A Cllr Lian Pate Health and Wellbeing P’ship ------Richard Robinson CCG Clinical Chair A A A A A A Collette Walsh Head of Integrated Care & Deputy       Director of Performance In Attendance Deidre Lewis Attended for Kirsty Hollis  Caroline Marshall Attended for Kathryn Lord    Debbie McCann Executive Assistant – Notes       Min ACTION Ref: 19:196 Welcome & Chairs Update The Chair welcomed all members to the meeting.

19:197 Apologies Apologies were received as listed above.

19:198 Governance

. Declarations of Interest: None declared for Part 1 of the meeting

. Quoracy: The meeting was quorate [6 members required]

- In the absence of Kathryn Lord (Interim Director of Quality & Chief Nurse), Caroline Marshall (Head of Quality) formally deputised.

- In the absence of Kirsty Hollis (Chief Finance Officer), Deidre Lewis (Deputy Chief Finance Officer) formally deputised.

19:199 Minutes of the meeting held on 20 August 2019 At minute reference 19:178 last line, it was noted that PPG members were invited to look around the new premises and not patients as recorded.

Page 1 of 2 Minutes Approved by the Chair : 2.10.19 With this amendment, the minutes of the meeting held on 20 August 2019 were approved as an accurate record.

19:200 Action Matrix The Action Matrix was reviewed and updated.

19:201 Matters Arising There were no matters arising to note.

19:202 Primary Care Network Update Collette Walsh updated members in relation to Primary Care Networks and advised that the focus is currently on exploring what resources are needed by PCNs to ensure that they have a stable infrastructure. This includes looking at their staffing and training needs and how they can be supported to develop across organisational boundaries. This work is being undertaken at an ICP and an ICS level.

Collette confirmed the need to ensure that the newly developing, self- directed neighbourhood teams support clinicians in the core GP practice teams to provide a more comprehensive, holistic offer of care.

All PCNs have the opportunity now to employ a Social Prescribing Link Worker and we are currently exploring how best to achieve this. Any developments will build on the excellent social prescribing infrastructure in place across Pennine Lancashire.

A plan is currently being produced in conjunction with PCN Clinical Directors to accelerate neighbourhood integration using a series of commissioning levers including an Alliance Agreement. If successful, this initiative will see Population Health Management embedded across Pennine Lancashire within 18 months and a focus on improving health outcomes and standards of care for some of the most vulnerable people, with complex needs, in Pennine Lancashire.

Action: A progress update will be presented to the October meeting. CW 15.10.19

19:203 Corporate Plan Action: This agenda item was deferred to the next meeting. CW 15.10.19

19:204 Any Other Business There was no further business.

19:205 Date & Time of Next Meeting The next meeting was confirmed as Tuesday 15 October 2019, 2pm Meeting Room 1, Walshaw House.

RESOLUTION: “That representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.” (Section 1[2] Public Bodies (Admission to Meetings) Act 1960.

Page 2 of 2 Minutes Approved by the Chair : 2.10.19 Appendix C (a)

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

PENNINE LANCASHIRE QUALITY COMMITTEE Minutes of the meeting held on 25th July 2019 PRESENT:

Name and Title Org. 2018 2018 2018 2018 2018 2018 2018 2019 2019 2019 2019 2019 2019 2019 27/06 27/06 25/07 22/08 02/10 24/10 28/11 19/12 23/01 27/02 27/03 24/04 22/05 26/06/ 25/07/ Clinical Representatives (two needed): Lay Advisor: Quality and Patient Engagement – Chair ELCCG   A     A  A     Michelle Pilling Secondary Care Doctor (retired) BwDCCG  A  A   A      L  Geraint Jones: Chair Chair Chair Chair Associate Director of Quality and Commissioning BwDCCG  A  A - A  A A  -  A A Janet Thomas Associate Director of Quality and Nursing / Head of Quality ELCCG E A   A          Kathryn Lord until August 2018; Caroline Marshall from August 2018 Chief Finance Officer ELCCG  A A AR AR AR E AR A A AR A  A Kirsty Hollis Director of Performance and Delivery / Director of Commissioning ELCCG  A    AR E AR A A AR AR AR  Sharon Martin until August 2018; Alex Walker from August 2018 Director of Quality & Chief Nurse (Clinical Post) ELCCG   A   A    A AR   A Jackie Hanson until August 2018; Kathryn Lord from August 2018 Director of Quality and Performance (Clinical Post) BwDCCG       A      A  Dr M Ridgway until October 2018; Dr Ridwaan Ahmed from November 2018 Governance, Assurance and Delivery Manager BwDCCG A  A  A A   A    A  Claire Moir GP Quality Lead (Clinical Post) ELCCG E  A  A  A A     A  Dr Umesh Chauhan GP Representative (Clinical Post) BwDCCG A A A A A A   A    A  Dr Stephen Gunn GP Representative (Clinical Post) ELCCG   A  A  A    A  A A Dr Zeenat Sykes Lay Member BwDCCG               Dr Nigel Horsfield Secondary Care Consultant ELCCG  A      A  A  A  A Dr Paul Taylor Medicines Management Representative (one needed): Senior Operating Officer, Primary, Community & Medicines Commissioning BwDCCG ------A - A - - - - A Julie Kenyon Associate Director of Research, Medicines & Clinical Effectiveness ELCCG   A    A   A     Lisa Rogan Safeguarding Representative (one needed): Head of Safeguarding (Adults) and MCA Leads PLCCG -   A -   -      A Peter Chapman Head of Safeguarding (Children) PLCCG  - - -  ------A Susan Clarke Head of Safeguarding (Children) PLCCG - - - -  - -  - A - - -  Debbie Ross Clinical Representatives: : present A: apols L: arrived late E: left early R: representative in attendance

In Attendance:

Ruth Administration, BwD CCG Simon Bradley Quality & Performance Manager (Pennine) MLSCU Vanessa Morris Infection and Prevention Control Nurse (Pennine) Lewis Wilkinson Quality and Performance Office MLSCU Deirdre Lewis Deputy CFO, ELCCG Jillian Wild DGM Medicines and Emergency, ELHT Travis Peters Equality and Inclusion Business Partner MLSCU Kirsty Hamer Commissioning Lead Childrens, Family and Maternity (Pennine) Adele Thornburn Nursing and Quality Manager (Pennine)

Quoracy shall consist of 50% of the Committee and must include 1 Non-Executive Governing Body Member / Executive Governing Body Member from each CCG, and one clinical representative from each CCG, one of whom must be a GP.

Pennine Lancashire Quality Committee 26/06/2019 Page 1 of 15 Minutes Approved by the Chair: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

REF: ACTION 19.145 Welcome & Chair’s Update

The Chair opened the Pennine Lancashire Quality Committee and welcomed all attendees. 19.146 Apologies

Apologies were received as above. 19.147 Declarations of Interest

No declarations of interest noted. Any that transpire during the meeting are to be declared.

The meeting was quorate. 19.148 Minutes of the Meeting held on 26th June 2019

Two amendments were requested for the minutes of the meeting held on 26th June 2019.

19.125 Neurology Update: “S Flynn to share the NHS England Peer Review Report on Neurosurgery” should read “Neurology”.

19.133 Medicines Management Update

The paragraph needs to be amended to read: “Dr L Rogan provided a brief summary of the patient safety work undertaken on DOAC prescribing with a focus on checking renal function and Hb levels and highlighted some of the findings discussed at the Eclipse Conference. A template has been developed by the Medicines Management Team that has been embedded in EMIS to improve the safety of anticoagulation prescribing in Primary Care.”

The comment was made that Katherine had just flagged up that the wording should be changed to read “… to try and contact patient representatives who have substance misuse” rather than “… to try to contact patient representatives that have struggled with opioid use.”

With the above amendments, the minutes were recommended for approval as an accurate record of the meeting.

19.149 Action Matrix

19.083.2 Pennine Lancashire Referral to Treatment Neurology Performance Report SB commented that the specialty pressures are now included in the report and cover the actions being taken to address the wider position. J Wild has covered some of the urgent care issues in her presentation. The Chair thanked the team for this information as it is helpful to have the additional narrative within the report.

19.084.1 Pennine Lancashire Primary Care Update The Chair spoke of the issue concerning the Friends and Family test, She informed the members that she had received a letter that went out to all Chief Executives of all Trusts, Accountable Officers of CCGs and Primary Care Professional Bodies on 10th July 2019 announcing the forthcoming changes to the Friends and Family test following extensive consultation and research. It concerned the feedback regarding the mandatory question which they felt could be clearer and more accessible, which lead to the formulation of a new universal mandatory question. She read the letter to the members and commented that she believed the conversations previously held in this committee meant members were already sighted on the issues, which was positive. More information will be available in September 2019 about how this will change before it comes into force in April 2020. The intention is that the same principles across the Lancashire area. The Chair confirmed she was happy to

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close this action; she has spoken to Katherine and will get the third report from the Workshops.

19.086.3 Pennine Lancashire Quality and Performance Report Month 11 LCFT: IAPT JJ The Chair advised that J Johnston would be able to provide an update in her scheduled Aug report for August 2019. 2019

19.103: Minutes of the Meeting held on 27 March 2019 The Chair confirmed this action was complete.

19.062 Pennine Lancashire Quality and Performance Report Month 10 ELHT: A&E Breaches J Wild has agreed to present her report to committee in July 2019. This action to remain open until her presentation.

19.108.1: Pennine Lancashire Quality and Performance Report Month 12 52-week Waits It was advised that this action is with Specialised Commissioning and not Blackpool CCG. C Marshall has been in contact with Spec Comm and is awaiting a response. It was confirmed that the patient awaiting cardiology surgery had not experienced any harm or adverse consequences as a result of awaiting surgery. The patient is now 8-weeks post-surgery and had recovered well. This action can be closed once Spec Comm have been in contact with C Marshall

19.108.2: Pennine Lancashire Quality and Performance Report Month 12 CQC The staffing pressures will be discussed at the Scheduled Care Board, once it is established. A Demand Management review is being undertaken to ascertain what services could be moved to a community setting. The outcome of this will be reported in the Quality Report when available. This is being supported with NHS Improvement. This action can be closed.

19.108.5: Pennine Lancashire Quality and Performance Report Month 12 CQC The Chair confirmed this action could be closed

19.112: Pennine Lancashire Complaints Report 2018/19 Quarter 4 Sarah Harrison, Head of Patient Feedback Team at LCFT, was to have attended the meeting today, but needed to send her apologies. She has been rescheduled for September 2019. This action to be kept open until complete. The Chair asked that S Harrison be informed about the issues with 12-hour patients, as discussed with J Wild today, so that this could be covered within the report.

19.124 The Terms of Reference This action has been completed. The ToR are on the agenda today for final comments. N Horsfield advised that his title was incorrect. These are to be amended.

19.125.1 The NHS England Peer Review Report on Neurosurgery SF Steve Flynn to be reminded to share this report.

19.125.2 Presentation: Neurology Pathway K Hollis had provided an update, advising that the ICS has included Neurology as a workstream, and it is being considered as a priority area, although no specific timescales have been provided. It was stated that the ICS has set its work programme for this year and this was not included, so members asked that this be expressed to the ICS as an area of

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high concern. It was confirmed that this action can be closed.

19.132 CCG Safeguarding Strategy This will be included as part of the quarterly safeguarding update, and does not need a separate agenda item.

19.133.1 Prescribing and Medicines Optimisation Annual Report 2018/19 The Chair advised she has liaised with Dr L Rogan regarding review of the pathway around opioid prescribing. The Chair has also in contact with the Drug and Alcohol Services who have advised there is a user group that could be contacted.

19.134 Pennine Lancashire Primary Care Update C Wright and M Pilling are taking the FFT Test to the PPG meetings. The action can be closed.

19.150 4 Hour Flow

J Wild, ELHT, attended to present the latest update around the 4-hour trajectory at A&E. The challenging position concerning the A&E Department performance trajectory highlighting how we are performing in terms of 4 hour performance. The admitted breaches up to 8th July 2019 demonstrated that 56.8% of patients got to a bed within 4 hours. In terms of admitted and non-admitted performance, the position is below the 82% target trajectory. . Currently, we have dipped slightly and today we are at 81.33% - we are trying to improve this.

The highlighting of the problem on Monday 8th July 2019 at the Royal Blackburn site was discussed, when there were 738 attendances with 41% of cases presenting at A&E arriving between 4.00 p.m. and midnight.

There were also issues concerning medical staffing with 3 gaps in the evening/overnight due to sickness and the failure to attend by an agency doctor. There are no consequences to the failure of the agency doctor to attend other than a request not to use that agency doctor again, but it was felt there should be some accountability.

Another, more recent date, was shown as a counter example with 393 attendances and performance at 92.11% for most of the day This report showed that the majority of patients, 138, attended between 7.30 pm and midnight; performance dropped to 82%. Many breaches occur overnight and some of this is linked to medical staffing, but also how demand has moved to later in the day. The Trust has tried to mitigate this with changes to the rotas so that from 5th August there will be 7 doctors on overnight which should help increase the flow through. However, the main issue is flow through the system which impact on the ability to meet the 4 hour standard.

On 08 July the Primary Care IT issue also occurred. Whilst it is say whether this also had any impact, it is notable. There will be a question asked in Parliament by one of the local MPs regarding that day and what the waiting time was and the Trust have been asked to provide some information across the system, as they are asking about plans to manage the waiting time.

Action: The Chair has asked to see that escalated onto the Risk Management Group.

It was stated that 08 July 2019 was further compounded by a reported respiratory issue on the same day. There has been a spike in respiratory conditions because of the present weather conditions and work is being done around hot spots and days when there is extra

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pressure to support forward planning. This would link through to community services, as well as flow through the hospital. Urgent care also performs better than ED because of the urgent care path of non-admitted patients, which are simpler cases, rather than the more complex cases at ED, including those with comorbidities and frail elderly.

In order to try and manage the 12-hour breaches, and improve flow through the system, patients are being moved in the early hours of the morning from one ward to another; however this has had consequences with vulnerable patients.

There was discussion regarding the level of vacancies and the plans to fill these. It was noted that ELHT has largest A&Es in the North West, and there was comparison about the staff vacancies compared to other local A&E departments. J Wild confirmed that new staff rotas will be published in August and September 2019, and that there is a lot of work ongoing to improve the staffing complement.

In June there were 8 mental health breaches of 12 hours of patients waiting for a bed to admit; to-date there have been 13 cases in July so there is a deterioration which has an impact within the department. It is not the right environment for patients, and it means cubicles become blocked; there are 28 cubicle spaces available so a reduction in availability will impact on ED performance.

The Chair raised the question of whether it is understood what endeavours are being used to capture patients’ experiences in the 12 hour breach pathway. It was noted that the friends and family feedback has not shown feedback from patients with mental health concerns in that department; this is raising concerns that there must be some issues. The Chair reiterated if there are any proactive endeavours to capture the experiences of people from that 12 hour breach pathway. J Wild confirmed that feedback is usually received from family because the patients are acutely unwell which make it very difficult to get feedback directly from them. The Chair observed that a report was received that stated there were no complaints which, given the environment, was a concern.

Action: J Wild will review the process of capturing feedback from patients on the 12- hour breach pathway and ascertain how this can be clearly identified and reported.

These are a plethora of actions being taken to improve performance. These discharges before 1.00 p.m, although there are a number of challenges being faced with this. The Chair queried the involvement of pharmacy, as late discharges are often as a result of waiting for medications. J Wild assured members that this is another area of focus, and that this also forms part of trying to improve discharges over the weekend rather than waiting. The Trust is currently monitoring the weekly discharge rate, and it was agreed that this review would be shared with the CCG.

Action: J Wild agreed to circulate the weekly discharge rate review

A new building will be opening in December 2020, but is recognised that this will not help to improve performance on its own. Therefore there is also a piece of work underway to change the medical model and try to improve the identified inefficiencies in the system. There are a series of workshops that are going to happen over the next 12 months to develop that model of care, test it out and do some bed modelling so that when the Unit opens it will start working very differently.

A discussion followed concerning the same day primary care work-stream, working together with primary care colleagues to deflect patients from the front door and ensure the patients get to the right places. Patients are not turned away, as often there is nowhere to turn the patients away to. It was emphasised that co-operation with primary care was needed to

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deliver a different model to serve the patients.

A Walker pointed out that there were two issues to be looked at. Firstly, there has been a change from the walk-in centre in terms of activity and access, particularly people accessing RBH and UCC, so there is some work needed around re-designing the family care pathways to make it more obvious and intuitive for them to use. Secondly, the avoidance of some of those more complex needs and the issue about shared care rather than it being about building ever bigger assessment areas and ED capacity.

Dr U Chauhan commented that it was not clear why there is a demand around 4.00 until 12.00 and what the causes can be attributed to.

Action: J Wild could pick this point up and whether it would be possible, particularly where the weekend was concerned, to ascertain any known external causes that could explain the change in demand

It was stated that the high conveyance was also an issue that needs addressing. This may be connected to population change in terms of whether people are not coming out of work for example and therefore accessing the health system at different times. There may well be some softer issues that are going on there. A Walker assured the meeting that he felt this was being addressed to understand the patterns. It was emphasised that it was helpful that the Trust and the CCGs have a really good working. However, it was pointed out that where the change in patient behaviour is concerned, it is very difficult to put it down to one thing, especially as lifestyle has completely changed.

A Thornburn commented on the slide around nursing vacancies and asked whether there was an opportunity to look at the skill mix differently. It was confirmed that training opportunities are available, and a bid for funding has been put forward to support ED with a different staff mix.

V Morris provided a personal case study of her experience of going through the system recently with her sick father and having to call 111. The process took hours with her first call to 111 taking place at 7.30am and finally getting a call back at 3.00pm instructing her to go to ED. It was queried whether this is contributing to patients presenting at hospital after 4.00pm.

Action: MP asked if we could do a brief update at the next meeting. It was agreed that there would be a brief feedback on this issue.

J Wild was thanked for her presentation.

Dr G Jones emphasised that there was no single answer but there were concerns around the demand. The number of cubicles available do not support the number of ambulance conveyances happening.

Dr L Rogan discussed a joint approach with primary care across Blackburn for the self-care approach with a view to directing people away from GPs and directing them to pharmacies. She highlighted a situation which had occurred recently where a GP had directed the patient to the pharmacy, but they had chosen instead to present at ED where they were treated for something which the patient could have easily obtained over the counter at the pharmacy, and which the GP had asked them to go and get. The patient was told at ED that they should have gone to the GP for this. This illustrates the need for consistent messages across the system to prevent a breakdown of trust.

Action: Consistent messages need to be extended to the wider system

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MP thanked the team for their hard work and acknowledged the severe amount of pressure they were all working under.

19.151 NHS Patient Safety Strategy

L Wilkinson attended to provide the committee with a summary of the changes to the NHS Patient Safety Strategy.

The intention of the new strategy is to emphasise learning to prevent incidents, share safety insight and improve patient safety. There are a number of changes to the Patient Safety Incident Response Framework as a result of the refreshed strategy, with a broader scope for incident management and less of a focus on the current threshold for ‘Serious Incidents’. The intention is to develop a risk-based approach, with transparency and support for patients, relatives and staff. This will include a change in the governance and oversight provided by commissioners. The 60 working day deadline will be removed, with the adoption of timelines based on an investigation management plan, agreed with those affected. Investigations will be led by those with safety investigation training, and with the dedicated time and resource to complete the work. There will be greater involvement of patients, families, carers and other lay people.

For primary care, there will be a replacement of the NRLS system with a more responsive and interactive reporting system. This will improve the dissemination and implementation of Patient Safety Alerts through PCNs.

A full timeline is in place for implementation of the strategy by Summer 2021.

The Chair thanked L Wilkinson for this update, noting that the involvement of patients and relatives in the investigation process was positive. There are a number of challenges with the new strategy, but these will be reported through as they arise.

Members noted the update

19.152 Pennine Lancashire Quality and Performance Report Month 02

S Bradley presented key points from the Pennine Lancashire Quality and Performance Report for Month 01. Full details are available within the report.

ELHT: A&E Breaches In May 2019 both CCGs did not achieve the 95% target. Work is focussed on reducing length of stay in the Trust to improve flow through the system and an action plan has been agreed to support this.

Ambulance Calls At the time of writing performance for May 2019 was not available

Referral to Treatment (RTT) Incomplete The referral to treatment (RTT) incomplete pathway target was not met by either CCG in May 2019. For BwD CCG of the patients with a wait over 18 weeks, 734 were at ELHT, 293 were at Lancashire Teaching Hospitals Trust (LTHTr) and the remainder were lower numbers across multiple providers.

For EL CCG of the patients with a wait over 18 weeks, 1,678 were at ELHT, 427 were

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at LTHTr, 171 were at Manchester University Foundation Trust (MUFT) and the remainder were lower numbers across multiple providers.

For ELHT there were 10 underperforming specialties in month.

52-week Waits In May 2019, there were 1 patients reported with a wait of over 52 weeks for EL CCG and 1 patients for BwD CCG. These have both been seen.

Cancer Patients seen within 2-weeks of an Urgent Referral for Breast Symptoms where Cancer is Not Suspected In May 2019 the target was not met by either CCG, with 7 breaches for BwD or 19 breaches for EL.

There has been an increase in the number of referrals into the service from an average of 175 referrals per month in 2017/18 for Pennine Lancashire Patients into ELHT to 202 per month in 2018/19.

A new revised breast referral template has been distributed to GP Practices and uploaded to EMIS to support the discussion on the importance of attending appointments.

Cancer - % of patients receiving definitive treatment within 31 days of a cancer diagnosis In May 2019 the target was not met by EL with 9 breaches. Surgical capacity continues to be a pressure in a number of tumour sites, relevant Directorates are working day to day to ensure sufficient capacity is available and where not, exploring all options to increase the number of surgical lists provided.

Cancer Patients Receiving First Definitive Treatment for Cancer within 2-months In May 2019 the target was not met by either CCG, with 6 breaches for BwD and 21 breaches for EL. The CCG continues to work closely with the Trust on Cancer pathway efficiencies to progress the 28 Day Project, to allow compliance with the Day 28 target by April 2020.

A one stop clinic model was trialled in June 2019 from Prostate. Findings are currently being evaluated.

A review of 62 Day patient escalation processes has been carried out on behalf of Lancashire and South Cumbria Cancer Alliance Board. The report is currently going through factual accuracy checks and will be shared more widely in its final version.

Diagnostics with 6-Weeks The target for <1% of patients to have a wait within 6 weeks for diagnostic tests was not met in May 2019 with performance at 1.8%.

Methicillin Resistant Staphylococcus Aureus (MRSA) In May 2019 there were zero cases of MRSA bacteraemia identified within the population of EL CCG and zero cases in BwD CCG; the total number of cases of MRSA BSI for 2019/20 remains at zero. The numbers are not changing. The EColi work group, with ELHT, LCC and the community is going well, with positive feedback.

C-Diff

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Each CDI case continues to be assessed through the PIR process to determine whether it was linked to a lapse in the quality of care provided to patients. For each community apportioned case the registered General Practitioner (GP) completes a case review prior to being reviewed by the CCG infection prevention team. For each acute apportioned case the relevant acute trust initiates the PIR process. Some cases require input from a variety of providers. The findings are shared and discussed at the Pennine Lancashire HCAI meeting with representation from the acute trust, EL CCG, BWD CCG and Lancashire County Council (LCC). Any lessons learnt are shared with the provider.

LCFT: Early Intervention Psychosis (EIP) The target for 56% of service users to receive treatment within 2 weeks was not achieved at Trust level in May 2019, with performance at 46.34%. The target was not achieved for EL CCG with performance at 44.44%, but the target was achieved for BwD CCG with performance at 100.00%

Duty of Candour There have been 5x breaches of Duty of Candour in May 2019.

Memory Assessment Service The 70% 6-week target was achieved at Trust level in May 2019 with performance at 71.04%. However, BwD CCG and EL CCG failed to meet the target with performance at 12.50% and 20.73% respectively.

IAPT In May 2019, the applicable notional monthly prevalence target was not achieved at Trust level with performance at 1.38%. The target was also not met for BwD CCG with performance at 1.36%, however was achieved for EL CCG with performance at 1.41%. Regarding Recovery, the overall Trust target of 50% was achieved with performance being reported at 52.50%. The target was achieved for both BwD CCG and EL CCG with performance at 53.80% and 52.90% respectively.

CPA The target for 95% of service users on CPA to be followed up within 7 days of discharge from psychiatric inpatient care was achieved at Trust level in May 2019, with performance at 97.91%. The target was achieved for BwD CCG (100%) and EL CCG (97.50%).

Referral to treatment Incomplete (LCFT) For BwD CCG the overall RTT target was not met with performance at 72.7%.

There were 2 underperforming specialties: Children's Occupational Therapy Service (52.8%) and Children’s Speech and Language Therapy (59.1%)

Lewis is working with the LCFT Community team and will keep us updated.

The Committee formerly received the report for information 19.153 CONFIDENTIAL: Provider Update

This paper was tabled for reference. The content of this item is for Committee members and attendees only and is not for wider distribution. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received and acknowledged this report.

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19.154 CONFIDENTIAL: GP Quality Group Minutes for BwD and EL CCGs: June 2019

This paper was tabled for reference. These were distributed prior to the meeting for information. No comments were raised. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received these minutes.

19.155 CONFIDENTIAL: ICS – LCFT Mental Health Oversight Group Minutes: June 2019

This paper was tabled for reference. These were distributed prior to the meeting for information. No comments were raised. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received these minutes.

19.156 Serious Incident Review Group Recommendations

This report is provided to the Pennine Lancashire Quality Committee to provide an analysis of incidents. It aims to provide assurance of a robust process of scrutiny, challenge and shared learning undertaken by the Quality Team along with outlining the developments of these processes over the financial year.

CCG Performance In Q1 of 2019/20 48 x RCA reports have been submitted by providers hosted by EL CCG and BwD CCG. These reports have been reviewed by the CCG Serious Incident Review Groups (SIRG) in line with the Serious Incident Framework (2015). Information from these reports has also been used to produce themes and trends of incidents reported by providers.

East Lancashire Hospital Trust The chart exhibited on page 2 of the report show a similar number of incidents reported in April and June in 2018 and 2019; however a higher number were reported in May 2019 compared to the previous year.

In May 2018 there were 0x pressure ulcers reported by ELHT however in May 2019 4x have been reported. This may be reflective on the new pressure ulcer reporting guidance that was implemented in April 2019.

Pressure ulcers remain in the top 5 incident types reported in Q1 2018/19 and 2019/20, however an increased number were reported in Q1 2019/20.

The number of slips trips and falls reported has reduced in Q1 2019/20 compared to Q1 2018/19, which reflects the falls prevention programme of work.

Treatment delay was the 2nd highest reported incident type in Q1 2019/20There seems to be a common factor that patients are not following the advice given and ELHT are to undertake a thematic review of these incidents.

There has been 1 x Never Event reported by ELHT in Q1 2019/20, relating to a retained foreign object post procedure.

Lancashire Care Foundation Trust

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Apparent/actual/suspected self-inflicted harm remains the highest incident type in Q1 2019/20 as expected from a Mental Health Trust. However, there has been an increase of 9x of these incidents in Q1 2019/20 from Q1 2018/1. Date has been published by the National Confidential Inquiry into suicide and homicides which shows that LCFT are below the nation median suicide rate.

Harm to LCFT staff has gone down in this quarter and we are currently piloting a body camera scheme.

The position for reports that have been reviewed by the CCG and returned to LCFT for further work has now improved significantly and LCFT should be commended for the work done to improve this position within the agreed timeframe.

The serious incident positions for providers hosted by East Lancashire and Blackburn with Darwen CCGs continue to be positive in Q1 2019/20, and providers are continuing to implement several improvements as highlighted in this report. The Quality Team continues to work closely with providers to aid in these improvements.

Members received and acknowledged this report

19.157 Pennine Lancashire E & I Quarterly Report

Travis Peters presented the paper, and assumed that it had been read. The paper is a joint report reflecting on the Equality and Inclusion work undertaken across Blackburn with Darwen CCG and East Lancashire CCG, providing updates between the months of April and June 2019.

He discussed the work programme for the year ahead, and the EDS goals. The workforce race equality standards introduced by NHS England, aims to tackle race discrimination across the NHS, in 2019 as in 2018, the date will be reported separately for each CCG however this year a joint report will also be compiled. HR has been asked to provide the data required by 31st August 2019 for national analysis and publication.

Since April 2019, the Equality and Inclusion Business has met with commissioners to support the following Equality Impact and Risk Assessments. The annual report was approved at the PLQC in April 2019, and has subsequently been published on the Equality and Inclusion pages on each of the CCG websites.

There has been some changes to the structure of the MLSCU Equality and Inclusion Team, and Gemma Aspinall will support Travis in ensure quality of work delivered on behalf of Blackburn with Darwen CCG and East Lancashire CCG is maintained.

Members received and acknowledged this report

19.158 Pennine Lancashire Risk Management Update

C Moir presented the Pennie Lancashire Risk Management Update. The Committee receives the Corporate Risk Register (CRR) and Governing Body Assurance Framework (GBAF) from both CCGs in order to enable members to evaluate the assurance on the management of corporate risks.

It was reported at the last PLQC meeting that a composite risk register would be developed in support of the aligned systems. This will replace the need to maintain 2 separate risk

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registers, therefore reducing duplication and supporting a more streamlined approach to managing and reporting on risks

As previously reported, within NHS Blackburn with Darwen CCG (BwD CCG) there were 11 operational risks and 6 strategic risks held on the register.

Within NHS East Lancashire CCG (EL CCG) there were 16 risks on the CCG Risk Register with 7 of these with a risk rating >15 escalated to the GBAF.

Across Pennine Lancashire there were 10 risks which were included on the risk registers of both CCGs.

1. (259/2015.05) Accident and Emergency 4 Hour Standard 2019/20 2. (157) Failure to adhere to standards outlined in the Ambulance Response

Programme (ARP)

3. (239 18-19) 62 Day Cancer Waiting Times Target 4. (262) Failing to deliver the 18 Week Incomplete Pathway (Referral to Treatment) NHS Constitutional Standard 5. (264) Mental Health system pressures 6. (227) Initial Health Assessments for Looked After Children 7. (263) Failure to meet the reforms for children with Special Educational Needs and

Disabilities (SEND)

8. (265) UK’s exit from the EU (with a ‘deal’ or ‘no deal’) presents unknown risks that may adversely affect healthcare delivery across Pennine Lancs. 9. (256/2018.05) Loss of Residential and Nursing Home Beds from Care Home Sector and impact upon system resilience (under review) 10. (243) Re-procurement of 0-19 services

All the 7 extreme risks on the register, rating 15 have all been reviewed and action plans

updated.

Following review at the RMCG meeting on 9th July 2019, Risk 227 has reduced in rating (“12”) and therefore is no longer held on the GBAF.

All the 10 significant/moderate risks have been reviewed and updated and action plans have been updated for existing risks.

There are no new risks for addition to the CRRs, however Risk ID 131 will be re-assessed and a new entry added at the next presentation of the CRR to the PLQC

Claire Moir recommended that the following four risk be closed:

1. (243) Re-procurement of 0-19 services (This is one of the 10 joint risks noted above) 2. (131) Lack of Access to Inpatient Beds for Children and Young people with Mental Health issues (Tier 4 beds) 3. (EL 143) Current IPA commissioning packages of care fails to adhere to the Mental Capacity Act 2005 in relation to Deprivation of Liberties and CCG Responsibilities 4. (EL 245) Increased risk of legal challenge and consequent financial impact relating to legal Deprivation of Liberty Challenges by CHC funded patients and their legal

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representatives.

The Chair asked for assurance that there was no issue with the Tier 4 risks, which was given from Kirsty Hamer in the Children and Young Peoples Team.

The chair agreed the recommendation.

19.159 Pennine Lancashire Safeguarding Dashboard

Debbie Ross presented the Safeguarding Quarterly Dashboard, to ensure that the Pennine Lancashire quality Committee was sighted on the key safeguarding priorities and aware of the safeguarding activity which has taken place within the last 3 months.

1. Development of the Pan Lancashire Safeguarding Arrangements and ICS A paper has been taken through Blackburn with Darwen and East Lancashire’s joint Governing body in relation to the new Multi-agency Safeguarding arrangements (MASA) for children and the proposed modelling for safeguarding Designated function in the ICS and ICP. The plans had to be submitted by 29th June and a paper was formulated and signed off by the CCGs. The plans are expected to be in place by September 2019.

2. CCG Safeguarding Resource

The CCG Safeguarding team is currently holding a number of vacancies : 1x WTE B7 1X WTE B5 Proposals for reconfiguring hours with other staff members. B7 – has been out to advert with no successful applicants. This has been re-advertised closing date 9th July 2019 B5 – recruitment will commence w/c 29th July 2019

3. Looked after children (LAC) BwD and East Lancashire The LCC and Health Looked After Children Health assessment project has now moved into the redesign phase and a joint action plan has developed to address the project findings. An improvement action plan is in place for Initial Health Assessments in PL which is led on by the Pennine CCG Safeguarding Team and Children’s Commissioner.

East Lancs performance has improved.

4. GP Development

An event was held at the Dunkehalgh on the 12th June, which was attended by 160 participants. The event was very well received by all Penning GPs.

5. BwD CQC Safeguarding and LAC Review April 2019

The CQC Safeguarding and LAC review was carried out 29th April 2019 – 3rd May 2019. The final report was published on the CQC website on the 2/7/19.

The key learning points were discussed and questions and answers followed. Debbie Ross agreed to update as required.

Members received and acknowledged this report 19.160 Pennine Lancashire SEND Update

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Kirsty Hamer presented a paper updating the committee on the progress to implement reforms for children and young people with special education needs and/or disabilities following the previous update in April 2019.

Both CCGs had be identified that progress had been made, however further work is required to implement consistent outcomes. An outcomes framework for children and young people is being developed across the ICS and due for completion in March 2020.

Discussed followed on the areas of progress and the areas for improvement, and Kirsty confirmed to the committee what the RAG ratings meant, i.e. Green – Compliant etc.

It was confirmed that everything was on track for commissioning for September.

Members received and acknowledged this report 19.161 BwD CQC Safeguarding and Looked after Children Review – Final Report published June 2019

A review was carried out between 29th April 2019 and 3rd May 2019, and the final publication had been distributed to the committee.

The review findings and key areas were discussed. This had been shared with the designated nurses for safeguarding who completed a factual inaccuracy check, which was returned to CQC on 3rd June 2019, allowing for the final report to be published.

An action plan now needs to be completed and submitted by 31st July 2019 and the key issues needing to be included were confirmed.

It was agreed that the complete action plan will be received by the committee once Sept completed. 2019

Members received and acknowledged this report 19.162 Quality Contract Meeting Draft Minutes: June 2019 East Lancashire Hospitals NHS Trust BMI Lancashire Quality Review

These were distributed prior to the meeting for information. No comments were raised.

Members acknowledged the minutes.

19.163 ELCCG Risk Management & Information Governance Group Draft Minutes – June 2019

These were distributed prior to the meeting for information. No comments were raised.

Members acknowledged the minutes.

19.164 Cancer Tactical Meeting – June 2019

These were distributed prior to the meeting for information. No comments were raised.

Members acknowledged the minutes.

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19.165 Items for Inclusion of the Corporate Risk Register

Flu in Australia (Discussed during the Quality and Performance Report)

The current flu reports from Australia are the worst recorded incidents for a decade. This is peaking 2 months earlier than usual and we need to prepare for the consequences.

Vanessa Morris commented that this will follow to the UK and there is already a Flu Locality Group in place which NHS England Chairs. She does attend this group and will regularly feedback.

The current vaccines and their effectiveness were discussed and Vanessa is to put together VM a comprehensive paper for the August Meeting. Aug 19

It was agreed that this needed to be added to the Risk Register. CM Aug 19 16.166 Date & Time of Next Meeting

The next meeting has been scheduled on Wednesday 28th August 2019 at 1pm Meeting Room 1, Walshaw house, Nelson

Deadline for papers is 5pm on 19th August 2019.

Pennine Lancashire Quality Committee 26/06/2019 Page 15 of 15 Minutes Approved by the Chair: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group Appendix C (b) PENNINE LANCASHIRE QUALITY COMMITTEE Minutes of the meeting held on 28 August 2019 PRESENT:

Name and Title Org. 2018 2018 2018 2018 2018 2019 2019 2019 2019 2019 2019 2019 2019 2019 22/08 22/08 02/10 24/10 28/11 19/12 23/01 27/02 27/03 24/04 22/05 26/06/ 25/07/ 28/08/ 25/09/ Clinical Representatives (two needed): Lay Advisor: Quality and Patient Engagement – Chair ELCCG A     A  A      Michelle Pilling Secondary Care Doctor (retired) BwDCCG  A   A      L   Geraint Jones: Chair Associate Director of Quality and Commissioning BwDCCG  A - A  A A  -  A A A Janet Thomas Associate Director of Quality and Nursing / Head of Quality ELCCG   A           Caroline Marshall Chief Finance Officer ELCCG A AR AR AR E AR A A AR A  R  Kirsty Hollis Director of Performance and Delivery / Director of Commissioning ELCCG    AR E AR A A AR AR AR  A Alex Walker Director of Quality & Chief Nurse (Clinical Post) ELCCG A   A    A AR   A A Kathryn Lord Director of Quality and Performance (Clinical Post) BwDCCG     A      A  A Dr M Ridgway until October 2018; Dr Ridwaan Ahmed from November 2018 Governance, Assurance and Delivery Manager BwDCCG A  A A   A    A   Claire Moir GP Quality Lead (Clinical Post) ELCCG A  A  A A     A   Dr Umesh Chauhan GP Representative (Clinical Post) BwDCCG A A A A   A    A   Dr Stephen Gunn GP Representative (Clinical Post) ELCCG A  A  A    A  A A  Dr Zeenat Sykes Lay Member BwDCCG              Dr Nigel Horsfield Chair Secondary Care Consultant ELCCG      A  A  A  A A Dr Paul Taylor Medicines Management Representative (one needed): Senior Operating Officer, Primary, Community & Medicines Commissioning BwDCCG - - - - A - A - - - - A A Julie Kenyon Associate Director of Research, Medicines & Clinical Effectiveness ELCCG A    A   A     A Lisa Rogan Safeguarding Representative (one needed): Head of Safeguarding (Adults) and MCA Leads PLCCG  A -   -      - - Peter Chapman Head of Safeguarding (Children) PLCCG - -  ------ Susan Clarke Head of Safeguarding (Children) PLCCG - -  - -  - A - - -  - Debbie Ross Clinical Representatives: : present A: apols L: arrived late E: left early R: representative in attendance

Jacquie Allan Executive Assistant, BwDCCG (Minutes) Gemma Aspinall Equality and Inclusion Officer, MLCSU (1 item) Kim Ciraolo Quality & Performance Manager (Pennine), M&LCSU Kirsty Hamer Commissioning Lead – Children, Family and Maternity Services (1 item) Judith Johnston Head of Clinical Commissioning, ELCCG Vanessa Morris Infection and Prevention Control Nurse (Pennine), PLCCGs Angela Thornton Head of Mental Health and Cancer Commissioning Teams (1 item) Anita Watson Infection, Prevention and Control Lead, LCC (1 item) Catherine Wright Primary Care Quality Lead (Pennine), PLCCGs (1 item)

Pennine Lancashire Quality Committee 28 August 2019 Page 1 of 12 Minutes Approved by the Chair: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

REF: ACTION 19.167 Welcome & Chair’s Update

The Chair opened the Pennine Lancashire Quality Committee and welcomed all attendees.

19.168 Apologies

Apologies were received as above.

19.169 Declarations of Interest

No declarations of interest noted. Any that transpire during the meeting are to be declared.

The meeting was quorate.

19.170 Minutes of the Meeting held on 28th August 2019

Any minor amendments to be sent to J Allan

With the minor amendments to be sent to J Allan, the minutes were recommended for approval as an accurate record of the meeting.

19.171 Action Matrix

19.108.1 Pennine Lancashire Quality and Performance Report Month 12 52-week Waits It was confirmed that no harm had been caused to the patient and long waits in Blackpool Hospital are being monitored. This action is now closed.

19.108.5 Pennine Lancashire Quality and Performance Report Month 12 CQC This action is complete as of last month.

19.112 Pennine Lancashire Complaints Report 2018/19 Quarter 4 This has been deferred by S Harrison to the September 2019 meeting. To be included on the September 2019 agenda.

19.124 PLQC Terms of Reference These were formally ratified; this item is now complete.

19.125.1 Presentation: Neurology Pathway This has not been received from S. Flynn, therefore will be chased for inclusion in the September 2019 meeting.

19.150.1 4 Hour Flow The risks, actions and mitigations around recent IT disruptions in Primary Care were reviewed by the Risk Management Group and do not meet the threshold to be added to the risk register – concerns have been captured with communication going out to practices and other concerned stakeholders. This action is now complete.

19.150.2 4 Hour Flow These are being looked at by J. Wild who is linking with S. Bradley and the Friends and Families survey regarding 12hour waits. S. Bradley will bring an update to a future meeting.

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19.150.3 4 Hour Flow Weekly Discharge Rate Review C. Marshall to check that E. Fleming has received this report.

19.150.4 4 Hour Flow 111 Redesign Considerable work has been done around this and an update to be given at the October 2019 meeting.

19.155 Flu in Australia An update was included on the July 2019 agenda; this is now complete.

19.161 Safeguarding Looked After Children The action plan has been through the management committees and comments have been received from the inspectors. This will be reviewed and an updated action plan will be discussed at the September 2019 meeting.

19.172 Northumberland, Tyne and Wear Peer Review

A. Thornton gave an overview of the presentation and advised that the Northumberland, Tyne and Wyre (NTW) Trust review was initiated in April 2018 with a substantial outcome report which is available should Committee members require a copy/link. The report was due to be published in January 2019 but was not available until May 2019. Service user and primary care feedback were essential to this report. The review was around the urgent care pathway in acute and Emergency Departments. Section 136 is used by the police for a place of safety and Lancashire is seen as an outlier nationally. A ‘frequent flyer’ pilot is being undertaken in East Lancashire by a SPN and a policer officer which is enabling some people to be appropriately managed at home. Relationship management is an area to be strengthened across Lancashire stakeholders.

Over the next three weeks assessments will be undertaken by Price Waterhouse Cooper regarding Commissioner capabilities and capacity with a number of workshops taking place. There is a focus on bed management and local bed base across Pennine Lancashire with a lot of work being undertaken on in the background with Lancashire Care Foundation Trust (LCFT). A local Mental Health Improvement Board has been set up which will drive forward local actions. A Thornton updated Committee members on the recent CQC inspection and the decision taken by LCFT/wider system in relation to the closure of Mental Health Decision Units by 8th October 2019; it is reported that staff will be redeployed into mental health liaison teams.

East Lancashire Hospitals Trust (ELHT) Mental Health CQC registration remains an outstanding area and the ICS are discussing this with ELHT and LCFT.

The CCG and the Pennine Mental Health teams are meeting regularly where good relationships are being fostered leading to proactive notification of areas of concern. A Thornton proceeded to outline work underway across Pennine Lancashire in respect of the urgent care pathway. There is an intention to undertake a full review including older adults and to link closer with Primary Care Networks (PCNs) and a more stable approach is required for an integrated neighbourhood service.

The NTW-Integrated Care System (ICS) work is being led by Dr J Higgins and will commence next week focussing on Pennine Lancs as a key transformation piece of work. Over the next 6 - 12 months focus will be on community health provision and learning will then be replicated across the ICS. Dr J Higgins has been linking with A Bennet and A Doyle to enable a system wide approach and there have already been improvements seen in the

Pennine Lancashire Quality Committee 28 August 2019 Page 3 of 12 Minutes Approved by the Chair:

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

crisis team and mental health liaison team, with extra investment put in locally and into the Richmond Fellowship who are supporting the crisis teams. Local teams have good ideas around efficiency and case load management which should be embraced.

It was noted that M Nelligan, Director of Nursing is due to commence in post in September 2019 with a cross/hand over period intended with the current interim Director of Nursing, P Lumsdon.

Dr S Gunn questioned the work that was to commence in September 2019 by the Transformation Team. A Thornton advised that they are to commence with recommendations and actively assist the local teams to facilitate change.

Dr S Gunn also questioned the current state of the local service. A Thornton advised that a conversation has taken place at a recent Mental Health Commissioners meeting around national scrutiny of the commissioning of the mental health service. It was felt that the Lancashire and South Cumbria CCGs needed a more global system in place as it was chaotic in the provision at the present time. Emerging issues have been identified and it is not always clear who is responsible for what; this needs to be addressed through the PWC work described earlier. It was felt that governance and accountability had been lacking as identified by this committee; these deficits are being addressed.

Dr G Jones enquired how are we going to change what we are doing around mental health as a Committee. LCFT have requested a significant amount of money across the system and locally yet it is felt that there is investment that is not understood as there are no service lines and it would be interesting to see what PWC would come up with.

Dr Jones queried the timescales for the delivery of this work?. A Thornton advised that the Pennine Lancashire Mental Health Delivery Board will provide assurance, direction and leadership and hold organisations to account. This Board is a Pennine Lancashire Integrated Care Partnership (ICP) group; minutes will be presented to Governing Body meetings to ensure appropriate oversight.

Action: Quarterly updates to be brought to the meeting by Cathy Gardener. C Gardener

Dr Gunn questioned how this will work better than before as the Committee do not seem to have influence to resolve the initial problem. A Thornton advised that all stakeholders need to fully embrace the NTW report and work collaboratively to implement the changes needed, at pace, to deliver the right services, in the right place at the right time. Committee members all agreed that there needs to be regular oversight on this to be re-assured positive changes are having a positive impact.

The Chair thanked A Thornton for her presentation and detailed information.

A Thornton left the meeting.

19.173 Pennine Lancashire Quality and Performance Report – Month 03

K. Ciraolo advised that the key exceptions within the report would be presented on slides in an attempt to facilitate debate and discussion. The key highlights were presented, discussed, debated and challenge provided in line with the slides:

Ambulance service performance For BwD CCG the Category 1 target was met, however there was underachieved against all other categories in June 2019. For EL CCG there was underperformance against all ambulance response programme targets in June 2019, response times for Category 2-4

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have improved in month. In order to improve performance, NWAS has increased provision of See and Treat, with the aim of reducing conveyance to A&E. In June 2019 27.4% of calls resulted in See and Treat. The entire qualified paramedic workforce is now trained in the application of the Manchester Triage System and training is scheduled for the Newly Qualified Paramedics cohorts due to qualify in August 2019.

Referral to Treatment and 52 week wait patients For BwD CCG of the patients with a wait over 18 weeks, 822 were at ELHT, 311 were at Lancashire Teaching Hospitals Trust (LTHTr) and the remainder were lower numbers across multiple providers. For EL CCG of the patients with a wait over 18 weeks, 1,907 were at ELHT, 470 were at LTHTr, 166 were at Manchester University Foundation Trust (MUFT) and the remainder were lower numbers across multiple providers. The main pressure at LTHTr remains in Neurology, where there are 129 BwD CCG and 298 EL CCG patients with a wait over 18 weeks. As previously reported Greater Preston CCG will be taking service redesign of neurosciences forward as a programme of work in 2019/20.

Cancer performance There continue to be a high number of breaches relating to patient-initiated delays, which makes up 54% of all the Pennine Lancashire Breaches in month. The Pennine Lancashire public campaign ‘Let’s Talk Cancer’ is highlighting the importance of attending appointments and there are plans to roll out the campaign across the Cancer Alliance footprint and to support GP participation in the National Cancer Diagnosis Audit process. There were a large number of breaches relating to outpatient capacity, with a majority (76%) under suspected skin. Recruitment is currently underway to replace a Consultant Dermatologist and the service are looking to appoint a locum consultant in the interim. Capacity and demand is being modelled for skin referrals into Maxillofacial to ensure appropriate capacity for outpatient and biopsy demand to manage 2 week wait patients. Trial one stop clinics for dermatology patients took place in June 2019, this is being evaluated. Surgical capacity continues to be a pressure in a number of tumour sites, relevant Directorates are working day to day to ensure sufficient capacity is available and where not, exploring all options to increase the number of surgical lists provided. The CCG continues to work closely with the Trust on Cancer pathway efficiencies to progress the 28 Day Project, to allow compliance with the Day 28 target by April 2020. The Trust has increased workforce to support the 28 day faster diagnosis standard and will evaluate if this will translate into achievement of the target or if other factors are impacting on performance. A workshop is planned for October 2019. ELHT have undertaken a process mapping exercise which the CCG Cancer Team attended. Pathway analysis is currently underway. A review of 62 Day patient escalation processes has been carried out on behalf of Lancashire and South Cumbria Cancer Alliance Board. The final report has been circulated and ELHT are carrying out a gap analysis against the recommendations in the report.

Clostridium Difficile Infection Each CDI case continues to be assessed through the PIR process to determine whether it was linked to a lapse in the quality of care provided to patients. For each community apportioned case the registered General Practitioner (GP) completes a case review prior to being reviewed by the CCG infection prevention team. For each acute apportioned case the relevant acute trust initiates the PIR process. Some cases require input from a variety of providers. The findings are shared and discussed at the Pennine Lancashire HCAI meeting with representation from the acute trust, EL CCG, BWD CCG and Lancashire County Council (LCC). Any lessons learnt are shared with the provider.

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Memory Assessment Service The 70% 6-week target was achieved at Trust level in June 2019 with performance at 70%. However, BwD CCG and EL CCG failed to meet the target with performance at 34.28% and 29.24% respectively. In June 2019 there has been a continued increase in the number of referrals received and accepted by the Pennine MAS teams. There continues to be sickness and vacancies in the team and bank staff are being utilised where possible. The additional support from other teams had to be stepped down as they were experiencing their own resource issues.

To assist in the continuous improvement of the position the current measures are in place:  Additional assessment slots for current clinicians to fill days that were previously protected for other MAS work, such as duty work, diagnostic and consultation days.  A vacancy has been recruited to and is now seeing a full capacity of assessment slots per week.  Daily courtesy calls are made to help reduce the number of DNAs.  Additional support from bank staff is being secured to provide extra assessment slots and weekend home visits if required.  A trajectory remains in place for September and it has been noted that there has been a further increase in performance in July 2019, and that the trajectory should be met.

IAPT LCFT are currently working towards a prevalence target of 16.8% for EL CCG and 19% for BwD CCG for 2019/20. Actions are in place to increase performance against the prevalence target:  A redesign of the assessment stage to improve efficiency and patient experience  The screening and telephone assessment PDSA are now in progress in the East locality to test out new assessment models, with an aim to roll this out across all teams in quarter 3.  Several referrals are not translating into first appointments as the appointment is not attended. LCFT are currently looking at a communications strategy to achieve more appropriate referrals. With an aim that more appropriate referrals will reduce the number of DNAs and patients dropping out of treatment.

It was highlighted in PEG on 1st August 2019 that the nationally only one area is achieving the prevalence target and that LCFT are doing well when compared to other areas including exemplar Trusts. However, work is still required to achieve the target in Lancashire and South Cumbria.

Committee members all agreed that the slide presentation was helpful and facilitated constructive challenge and discussion.

The Chair thanked K Ciraolo for the update.

19.174 CONFIDENTIAL: Provider Update Paper

The content of this item is for Committee members and attendees only and is not for wider distribution. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received and acknowledged this report.

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19.175 CONFIDENTIAL: Pennine Lancashire General Practice Quality Group Minutes – 28 August 2019

The content of this item is for Committee members and attendees only and is not for wider distribution. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received and acknowledged this report.

19.176 CONFIDENTIAL: ICS Mental Health Oversight Group Minutes – 28 August 2019

This paper was distributed prior to the meeting for information. No comments were raised. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received these minutes.

19.177 CONFIDENTIAL: NHS England – LCFT Quality Oversight Group Minutes – 18 July 2019

This paper was distributed prior to the meeting for information. No comments were raised. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received these minutes.

19.178 Pennine Lancashire Primary Care Update

C. Wright provided an overview of the report as below:

An overview of the most recent complaints information as provided whilst acknowledging that as complaints are reported to NHS England, trying to gather information is difficult due to their capacity.

The Primary Care web tool is being accessed, with 9 practices that have a review identified. These have been mapped onto the dashboard to determine if a quality visit is required.

Human factors training is being undertaken and will be evaluated.

Friends and Family Test (FFT) results are being submitted via a bulletin and information is being shared with practice staff. FFT will change in April 2020. Different data sets are being categorised and a review will be analysed by the two clinical leads.

Annual GP patient survey has been published, this can be circulated with the minutes and a link provided. Analysis has been undertaken on East Lancashire and Blackburn with Darwen comparing response rates, which are similar. This has been compared to national averages – 6 are better for EL and 11 for BwD, this is a snapshot of information. There is a need to understand how practices are achieving, this learning can then be shared.

ACTION: Learning to be brought to the next meeting. C Wright

ACTION: Apex/IPlato/Digital position update to be presented at the next meeting C Wright including virtual GP appointments.

The Chair thanked C Wright for her update.

Members received and acknowledged this report

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19.179 Pennine Lancashire CQUIN 2019/20 Q1 Payments

K Ciraolo provided an overview of the CQUIN report for Quarter (Q) 4 2018/19 and Q1 2019/20 with recommendations for Committee provided in the report along evidence of achievement.

Attention was brought to the Q4 2018/19 submission from Mersey Care where further evidence has been provided.

For LCFT CQUIN 3a there are discrepancies between the LCFT data and national clinical data that has recently been published. This hinders the reconciliation of the indicator therefore the Trust have been requested to submit a narrative to explain the discrepancies to allow Committee to debate and discuss. Members questioned the value of CQUIN 3a for the Trust and K Ciraolo advised she would ascertain this and advise.

ACTION: To ascertain the value of CQUIN 3a for LCFT

The Chair thanks K Ciraolo for the update.

Committee members supported the recommendations as outlined in the paper.

19.180 Pennine Lancashire IPA and CHC Update

J Johnston presented the paper highlighting the 2 positive points across Lancashire and South Cumbria which are the future states and future models.

J Johnston highlighted the Continuing Healthcare (CHC) local staffing issues and explained the difficulties within Midlands and Lancashire Commissioning Support Unit (MLCSU) in recruiting suitable candidates and retaining them within the team. It was outlined that the matter has been escalated to CCG Directors and a meeting is scheduled to take place this Friday to discuss and address these issues with MLCSU. The recovery action plan is to be looked at by Executive Team given the level of investment into the service. A number of complaints are being received from family members andMPs around delays on Retrospective Reviews. K. Hollis has been asked to draft a letter on behalf of Dr Higgins to request a meeting with Mr Derek Kitchen, Managing Director of MLCSU.

ACTION: Update required next month around CHC complaints.

The Chair thanked J Johnston for the update on activity.

Members received and acknowledged this report.

19.181 Pennine Lancashire Complaints Report 2019/20 Q1 Report

C Marshall provided an overview of the report drawing members attention to key areas.

Focus has been given on the analysis of activity as there has been an increase in the EL CCG complaints for medicine management (associated with the implementation of the self- care policy); work is being undertaken to address this by the Medicine Management Pharmacists. There has also been an increase in complaints for both CCGS regarding CHC as highlighted in the previous agenda item.

There have been 11 letters from MPs during Q1 2019/20.

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C Marshall outlined that nationally the CCGs are held to account to acknowledge, investigate and respond to complaints within 60 days.

Locally the CCGs have set their own target at 40 days, to ensure they are all closed within the 60 days. Response times in Q1 2019/20 for some complaints are disappointing; in particular in May 2019 for BwD CCG. The reasons for the delays was provided along with an assurance that improvement work is being targeted in this area.

The Chair thanked C Marshall for the report.

Members received and acknowledged this report.

19.182 Infection Prevention Team Report Healthcare Associated Infections Update Q1 2019/20

The Chair welcomed A Watson to the meeting and invited her to provide an overview of the circulated report.

It was reported that 4 MRSA incidents had been reported across Lancashire with no themes identified following detailed analysis. A Watson advised that Hospital onset of clostridium difficile targets are now two days rather than three days.

Committee members were advised that the ICS has the lowest performance around E.coli in the North West and lot of work is to be undertaken to compare the differences between the ICSs nationally.

As part of the national priority for early identification and treatment of sepsis a lot of work is being undertaken with care homes and hand hygiene in schools. This work will complement the work underway with primary care and providers.

Dr G Jones questioned the origins of the sepsis and E.coli. V. Morris agreed to forward the data, but sometimes the cause is not identified. V Morris advised that it can be difficult to collect the data as it may not always be logged in the GP data. Data is being collected for Q2 and Q3 2019/20 and the acute trust are undertaking work around gall bladders. NHSI have organised an event to discuss this.

Action: V Morris to forward the data around the origins of sepsis and E.Coli to V Morris Dr G Jones

The chair thanks A Watson and V Morris for the update.

Members received and acknowledged this report

A Watson left the meeting

19.183 Pennine Lancashire Seasonal Influenza Planning Report 2019

V. Morris presented the previously circulated paper and highlighted the flu planning report which has an action plan that will be updated every month. The Pennine Lancashire Flu Locality Group is well attended and there is very positive input. Terms of Reference for the group are at the back of the report.

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V Morris advised that if there is an outbreak of flu there is a Standard Operating Procedure in place to follow regarding prescribing antivirals. If antivirals are to be used, access to the correct dosage is required and there are now 5 pharmacies in the area that will hold the stock with out of hours distributing to specific care homes.

Messages that are sent by out the Communications team are to be kept clear and evidence based with the message that flu vaccines should not be given too early. Dr N Horsfield raised concerns that the risks around flu vaccination are not explained to patients. V. Morris explained that patients should be given the opportunity for informed consent around the risks prior to the administration of the vaccine. Dr U Chauhan asked how much informed consent is given when the vaccine is administered to residents in Care Homes. V Morris advised that residents are encouraged to receive the vaccination in care homes and the workforce are also required to have the vaccination.

V Morris was thanked for the report.

Members received and acknowledged this report

19.184 Workforce Race Equality standard Report for ELCCG and BwD CCG

The Chair welcomed G Aspinall to the meeting.

G Aspinall provided an overview of the report which summarises the WRES report. Both EL and BwD CCGs have increased the number of BME staff and have seen an increase in the number of staff self-reporting. All gaps in reporting are being addressed as outlined in the action plan.

NHSE have asked for raw data to be submitted to NHS Digital, this has been undertaken and once it has been approved can be reported to NHSE.

The issue of Executive and Board representation will be flagged to the Governing Body and is on the action plan.

Members received and acknowledged and approved this report.

G Aspinall left the meeting

19.185 SEND Inspection

K Hamer provided an overview of the report and advised that since the last meeting the outcome letter has been received which was positive and highlighted some areas for improvement around health. There is a contrast between the BwD and Lancs position and K Hamer advised Committee members that the 12 areas of concern are being monitored and addressed.

The Chair requested that a RAG rating be presented at subsequent meetings. K Hamer advised the Committee that there is an audit tool in place for SEND reforms and the12 areas are RAG rated.

Members acknowledged the report

K Hamer left the meeting

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19.186 LD Transforming Care, STOMP and LeDer Update

J. Johnston provided an overview of the report.

She explained that there is continued good process to reduce the number of admissions, with a number of patients are being stepped down from secure units. There has been a recent visit from the lead psychiatrist at NHSE (Transforming Care Programme) to review patients and consider how their future needs can be met on the former Calderstones site. This was to support the original plan to transfer patients to social landlords and provision of care by the existing staff. This will enable the site to be de-regulated. There is a planned programme of work around community services to look at this.

J Johnston advised that the STOMP plan has been implemented and officers are continuing to look at options for annual health checks.

There is a pilot with Pendle PCN which is looking at stopping over medicating and is funded by the NHS. It was pointed out that some of the reds on the action plan have now turned to green.

ACTION: An updated report around STOMP to be presented at the October 2019 J Johnston meeting.

LeDer reviews will be undertaken as outlined in Section 5; from a governance perspective it has been agreed that the completed review will be presented to the Serious Incident Review Group panels to ensure sufficient scrutiny and learning/theming/trending. There is a backlog of cases, therefore extra panels will be required to facilitate timely presentation of the cases.

The Chair thanked J Johnston for her update.

Members acknowledged the report.

19.187 Quality Meetings Draft Minutes

9.1a ELHT Quality Review Meeting 9.1b LCFT Joint MH & Community Performance & Quality Meeting 9.1c LCFT Quality and Performance Group

These minutes were presented for reference purposes only. They were distributed prior to the meeting for information. No comments were raised.

Members received these minutes

19.188 Risk Management and Compliance Group Minutes

The minutes were presented for reference purposes only. These were distributed prior to the meeting for information. No comments were raised.

Members received these minutes.

19.189 Pennine Lancashire Cancer Tactical Group Minutes – July 2019

The minutes were presented for reference purposes only. These were distributed prior to the meeting for information. No comments were raised. Members received these minutes.

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19.190 Pennine Lancashire Research, Innovation and Clinical Effectiveness Committee Minutes July 2019

The minutes were presented for reference purposes only. These were distributed prior to the meeting for information. No comments were raised.

Members received these minutes.

19.191 Items for Inclusion on the Corporate Risk Register

There were no new risks identified.

19.192 Date & Time of Next Meeting

The next meeting has been scheduled on Wednesday 25th September 2019 at 1pm Meeting Room 1, Walshaw House, Nelson.

Deadline for papers is 5pm on 16th September 2019.

Pennine Lancashire Quality Committee 28 August 2019 Page 12 of 12 Minutes Approved by the Chair: Appendix C (c)

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancs Clinical Commission Group

PENNINE LANCASHIRE QUALITY COMMITTEE Minutes of the Meeting Held on 25th September 2019 PRESENT: 2019 2020

Name and Title Org 22/05 26/06 25/07 28/08 25/09 30/10 27/11 22/01 26/02 25/03 00/04 00/05 00/06 00/07 00/08 00/09 00/10 00/11 00/12 *25/12* Clinical Representatives (two needed): Lay Advisor: Quality and Patient Engagement - Chair - ELCCG      Michelle Pilling Secondary CareDoctor (Retired) - Chair - Geraint BwDCCG  L    Jones Associate Director of Quality and Commissioning - Janet BwDCCG  A A A A Thomas Associate Director of Quality and Nursing/Head of Quality - ELCCG      Kathryn Lord, Caroline Marshall Chief Finance Officer - Kirsty Hollis ELCCG A  A  A Director of Performance and Delivery/Director of ELCCG AR AR  A AR Commissioning - Sharon Martin, Alex Walker Director of Quality and Chief Nurse (Clinical Post) - Jackie ELCCG   A A  Hanson, Kathryn Lord Director of Quality and Performance (Clinical Post) - Dr BwDCCG  A  A  M Ridgway, Dr Ridwaan Ahmed Governance, Assurance and Delivery Manager - BwDCCG  A   A Clair Moir GP Quality Lead (Clinical Post) - Dr Umesh Chauhan ELCCG  A   

GP Representative (Clinical Post) - Dr Stephen Gunn BwDCCG  A   

GP Representative (Clinical Post) - Dr Zeenat Sykes ELCCG  A A  L

Lay Member - Dr Nigel Horsfield BwDCCG     

Secondary Care Consultant - Dr Paul Taylor ELCCG A  A A A

Medicines Management Representatives (one needed): Senior Operating Officer, Primary, Community and BwDCCG - - A A A Medicines Commissioning - Julie Kenyon Associate Director of Research, Medicines and Clinical ELCCG    A  Effectiveness - Lisa Rogan Safeguarding Representative (one needed): Head of Safeguarding (Adults) and MCA Leads - Peter PLCCG   A -  Chapman Head of Safeguarding (Children) - Susan PLCGG - - A  - Clarke Head of Safeguarding (Children) - Debbie PLCGG - -  - - Ross

: Present A: Apologies L: Arrived Late E: Left Early R: Representative in Attendance

In Attendance:

Debra Atkinson - Head of Corporate Business Judith Johnston - Head of Clinical Commissioning deputising for Alex Walker Simon Bradley - quality and Performance Manager Sarah Harrison Vanessa Morris - IPC Lead Nurse Travis Peters

Quoracy shall consist of 50% of the Committee and must include 1 Non-Executive Governing Body Member/Executive Governing Body Member from each CCG and one clinical representative from each CCG, one of whom must be a GP. NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

REF: ACTION 19.193 Welcome & Chair’s Update

The Chair opened the Pennine Lancashire Quality Committee and welcomed all attendees.

19.194 Apologies

Apologies were received and noted as above.

19.195 Declarations of Interest

No declarations of interest were noted. Any conflicts that transpire during the meeting are to be declared and managed appropriately.

The meeting was quorate.

19.196 LCFT Complaints Team

Sarah Harrison from LCFT was welcomed to the meeting. Sarah advised Committee members that she is responsible for the patient experience element of the quality agenda at Lancashire Care, especially around listening and engaging with patients. This information is then shared with the quality improvement team. Patients are encouraged to talk about their individual experiences with work also being carried out with hard to reach groups. To support, this, a two day training package has been put in place for all staff.

Level 1 complaints and rapid resolution are dealt with within five to ten days. There are a low number of level 2 complaints, which are around safeguarding and suicide concerns. The complaints graph circulated, addressed issues in the Pennine area. Face to face meetings will take place unless it will be detrimental to a patient’s health. All complaints are assigned to a case officer and this enables any themes to be picked up in a specific location.

It is hoped the patient meetings will be volunteer led and that the meetings will trigger changes on the wards at the point of care. Patient meetings will feed into team meetings to share and learn from experiences. The first star for “Triangle of Care” was awarded to the Trust in July 2019 and was for a self-assessment of inpatient settings and crisis teams across Lancashire. Actions plans are in place on how to improve engagement with carers. Every area has a carer’s information board; Champions are being identified for each area to share up-to-date information with colleagues. The “Triangle of Care” process will constantly evolve due to the involvement of family members and information gathered through listening. It will take two years to complete the Triangle of Care exercise for the whole area.

Sarah also outlined how a film of people’s experiences of seclusion is available to share with staff. Seclusion leaflets are now accessible for families and patients. Work has been undertaken around nicotine management, and this is an ongoing piece of work.

The Meridian System is an additional to the Friends and Family Tests to improve on feedback from engagement to improve care. The new Executive team has brought new ideas to instigate change.

Kathryn Lord thanked Sarah for the presentation and believed that there have been a lot of positive improvements regarding transparency with staff, patients and carers and that this positive improvement should be widely shared.

Pennine Lancashire Quality Committee 25 September2019 Page 1 of 9 Minutes Approved by the Chair: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

Dr Geraint Jones thanked Sarah for the presentation and for listening to people. He asked if there was any evidence of changes that have taken place following a complaint theme. Sarah outlined a national award had been received for the “Always There Event” that had been developed at The Guild Lodge.

Following this a meeting had taken place with staff and service users. This resulted in the installation of ligature safe patient feedback post boxes, which are emptied by admin staff. A complaint had been received regarding the way information around diversity was being received from patients. This has now been improved and the issue has been addressed.

Dr Umesh Chauhan queried the complaints from MPs, as the majority are patient focused.

Peter Chapman asked what the link was between complaints and safeguarding; Sarah confirmed that any mention of safeguarding or complaints which referenced harm or abuse triggers a phone conversation with the safeguarding duty team and the case officer, who will request a check is made on the person if required.

Caroline Marshall thanked Sarah for the positive work that has been undertaken around complaints. Caroline advised Committee members that there is a positive closer working relationship between the Trust and the CCGs .

The Chair asked how proactive the Trust are in gaining feedback from people in significant mental health distress. Sarah confirmed that they do not approach these patients regarding their experiences until they are out of distress. The complaints received in relation to Section 136 suites specifically highlight the delays in waiting for beds across the county.

Work is being undertaken on the experiences of people in Mental Health Decision Units specifically focusing on care needed to enable the individual to remain at home. The Synergy Project on the Fylde Coast enables a police officer, ambulance crew and mental health professional to attend a person in mental health distress and try and support them at home; the initial feedback has been positive and the work is being formally evaluated externally.

The Chair thanked Sarah for her presentation and welcomed the approach to involving patients and carers.

Sarah Harrison then left the meeting.

19.197 Minutes of the Meeting held on 28th August 2019

The date of the meeting was highlighted as incorrect therefore is to be amended. If there are any further amendments to the attendees stated, the meeting administrator is to be informed.

With the date of the meeting to be amended the minutes were recommended for approval as an accurate record of the meeting.

Dr Zeenat Sykes joined the meeting.

Pennine Lancashire Quality Committee 25 September2019 Page 2 of 9 Minutes Approved by the Chair: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

19.198 Action Matrix

19.086.3 Pennine Lancashire Quality and Performance Month 11 LCFT: IAPT Any crisis services will be reported by Judith Johnston at future meetings; this action is now closed.

19.112 Pennine Complaints Report 2018/19 Quarter 4 A presentation has been delivered; this action is now closed. In addition, the action is to be amended to remove incorrect information.

10.125.1 Presentation: Neurology Pathway The Neurology peer review report and action plan has been received from Steve Flynn and to be circulated. A summary report is to be completed by Simon Bradley and then shared with the Governing Bodies.

19.150.4 4 Hour Flow Verbal update to be given at the October meeting

19.161 BwD CQC Safeguarding and Looked After Children Review – Final Report published June 2019 This report and actions undertaken by Kirsty Hamer was circulated at the meeting. Item now closed.

19.172 Northumberland Tyne and Wear Peer Group Item now closed as quarterly updates will be given in the regular reports to Committee.

19.178.1 Pennine Lancashire Primary Care Update Update to be given at the October 2019 meeting.

19.178.2 Pennine Lancashire Primary Care Update Update to be given at the October 2019 meeting.

19.179 Pennine Lancashire CQUIN 2019/20 Q1 Payments CQUIN update on the agenda. Item is now closed.

Vanessa Morris joined the meeting.

19.180 Pennine IPA and CHC Update Update to be given at the October 2019 meeting through the scheduled Committee paper.

19.182 Infection Prevention Team Report Healthcare Associated Infections Update Q1 2019/20 Action: Vanessa Morris to forward the report to Dr Geraint Jones.

19.186 LD Transforming Care, STOMP and LeDer Update To be presented at the October 2019 meeting through the scheduled Committee paper.

VM 19.199 Pennine Lancashire Quality and Performance Report – Month 04

A PowerPoint presentation of the performance report was given by Simon Bradley. The key highlights presented were:

A&E four hour performance remains static. There has been an increase in Type 1

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attendances, adding further pressure to the position however there are times when the performance is at 95% or above. It has been recognised that the 4 am SITREP often shows a reduction in performance, which is a key area of focus. When compared nationally, the Trust’s position has improved.

Conversations around staffing caps need to take place to ensure consistency across the system. Discussions took place on increased demand; this may be due to inappropriate attendances and there are many factors which may impact on this. Simon Bradley will review data from 111 to ascertain if there is a link to demand increases.

Action: Simon Bradley to review the data from 111 to ascertain if there is a link to demand. SB

Ambulance performance is seeing an increase in the number of calls being received. The service is focussing on See and Treat. Paramedics are trained in the Manchester Triage technique and there is a rolling programme for new starters. It should be noted that there has been an improvement in ambulance handover times which impacts on crews being able to return onto ‘the road’. SB Action: Simon Bradley to amend the performance trajectory arrows to an extra context box to indicate trends graphs (pages 3, 7 and 8).

The new RTT performance pilot measure commenced 1 August 2019 with an average waiting time set at 8.5 weeks. The current performance is 11 weeks. Different ways of working and recruitment are being addressed to improve performance. There are concerns regarding the downward trajectory; for example due to Consultant staff reluctance to undertake overtime due to additional pension liabilities. Focus is on reducing the waiting times by maximising the skill mix available and where activity can be undertaken in the community. This is a test phase and the Trust have been given some the different ways of working to try and reduce the waiting lists.

A patient waiting more than 52 weeks for surgery has now received treatment; this was a complex procedure requiring two Consultants as previously reported. As of month 5 2019/20 there are no breaches for either CCG.

The pressure on the two week cancer breaches are predominately around patient choice. Work continues with GPs around emphasising the need for patients to attend the two-week appointments. The “Let’s Talk Cancer” campaign will focus on the screening programmes. The Trust has produced an information leaflet on diagnosis tests. 31 day breach numbers are struggling due to surgical capacity. 62 days is seeing improvements on performance and there is support to help with pathways. Diagnostics will hopefully be undertaken on the day to reduce appointments.

Early Intervention and Psychosis (IAPT) has seen improvements for July. The National Team have visited and looked at the processing policies. The changes have potentially helped with the improvements and referrals processes need to be correct.

Improvements have been seen in the IAPT recovery rates with the number of DNA rates reducing.

A Task and Finish Group has been set up to address the predicted waits. This will include a review on staffing and their banding, as staff are moving to different positions once they have been trained. IAPT waits are being scrutinised with a focus on Ribble Valley and BwD trajectories.

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The Memory Assessment Service performance is improving and is on trajectory to recover. Sickness absence and staffing vacancies have impacted on the Pennine Service and bank staff have been utilised to address this.

It was noted that the staff sickness record was not work related and the Commissioning Lead has been working with the Pennine team to support a recovered position.

The Chair queried the recording of workforce staffing rates for BMI Beardwood reported on pages 12 and 40 as they appeared to conflict.

Action: Simon Bradley to confirm staffing rates. SB

Action: Caroline Marshall to bring the Mixed Sex Accommodation deep dive to the next meeting. CM

Flu Update

Vanessa Morris provided an update on the infection control workstream; the report has been updated and the designation determinations are placed on it. There was nothing further to add to the flu update presented in August 2019 around seasonal flu in Australia. Some areas have commenced this year’s vaccinations. CCG staff are able to request a voucher to have their flu injections at Boots chemists. There is some capacity for staff to have the vaccination at East Lancashire Hospital Trust (ELHT) site as in previous years. Staff are supported to have their injection undertaken in work hours.

Sepsis Update

Caroline Marshall gave an update on the Sepsis workstream across Primary Care and ELHT. Miss Julie Iddon (Interim Deputy Medical Director at ELHT) will be presenting at the BwD and EL CCG Protected Learning Time event later in the week regarding early identification of Sepsis. In addition, a volunteer from the Sepsis Trust has been secured at the event also. Caroline reported that ELHT are undertaking a significant amount of work in regard to Sepsis with the Sepsis bundle updated. The outlying mortality position of the Trust for Septicaemia is now not alerting; this can partly be attributed to the coding amendments. The CCG sits on the Trusts Mortality Steering Group where Sepsis is widely discussed.

19.200 CONFIDENTIAL: Provider Update Paper

This paper was tabled for reference. The content of this item is for Committee members and attendees only and is not for wider distribution. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received and acknowledged this report.

19.201 CONFIDENTIAL: ICS Mental Health Systems Improvement Board

This paper was tabled for reference. These were distributed prior to the meeting for information. No comments were raised. The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received these minutes.

Pennine Lancashire Quality Committee 25 September2019 Page 5 of 9 Minutes Approved by the Chair: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

19.202 Pennine Lancashire Research Update

Dr Lisa Rogan gave an overview of the quarterly report. Presentations are given to the Governing Bodies and these have been received positively.

Healthy Weight pathways need to be embedded. Lisa has spoken to Claire Richardson regarding how this can be embedded in the commissioning portfolio; no feedback had been received at the time of the meeting.

Good clinical practice needs to be embedded following the Evaluating Primary Care Heart Failure Review.

One team is working with a LCFT pharmacy around STOMP, this work is extensive for each patient around psychotropic drugs, and each plan is individual to each patient. Part of the STOMP work is co-designed at national and PCN level along with connections with organisations around Autism.

Geraint requested the outcomes of the reports. Further discussions then took place on the outcomes and which will be reported accordingly.

Action: Citations to be included in future reports. LR

Members received, acknowledged and supported this report.

Travis Peters joined the meeting.

19.203 Pennine Lancashire Equality and Inclusion Team Quarterly Report – Quarter 2

Travis Peters highlighted the key areas of the report.

Equality Delivery System: Staff will be asked to grade the CCGs in Quarter 3 as to how supported they feel overall as a workforce.

Race Equality Standard: Data has been uploaded to NHS England ready for analysis.

Equality Impact and Risk Assessments: Work is ongoing and updates will be given accordingly.

Dr Geraint Jones enquired if Friends and Family are included. Travis confirmed that communication and engagement included diversity monitoring statistics.

Members acknowledged receipt of this report.

Travis Peters left the meeting.

19.204 Pennine Lancashire CQUIN 2019/20 Q4 Update

Simon Bradley provided the update on CQUIN and the Lancashire Care Foundation Trust (LCFT) position for CQUIN 3a.

A lengthy discussion took place on the CQUIN 2017/19 year two payments for LCFT, specifically indicator 3a. Committee members acknowledged that some improvements have taken place in terms of patient care, but further improvements are required. Evidence is required that the CQUIN work is being embedded; this should be in the Trusts quality report requirements. It was agreed that a caveat should be placed around the CQUIN payment

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that is to be released for indication 3a. The caveat agreed was that continued improvements should be in place and evidenced to the CCG by Q4 by the Trust.

It was cited that all CQUIN reports are approved at this meeting.

Members were happy to approve the payment on the basis of the above stated caveat. 19.205 Pennine Lancashire Risk Management Strategy 2019/20

Debra Atkinson presented the paper and highlighted the main amendments to the revised strategy document.

Corporate Risk Register: Any risks that have had the score reduced to less than 9 will be monitored through the programme management risk approach. All risks rated 15 and above will transfer onto the Governing Body Assurance Framework.

Risk Management Group – The East Lancashire Risk Management and Compliance Group Terms of Reference and membership have been reviewed; this is now the Pennine Lancashire Risk Management Group. The Terms of Reference for the BwD Information Governance Steering (IG) Group have been reviewed and this will now be the Pennine Lancashire Information Governance and Compliance Group which will focus on Information Governance, Freedom of Information compliance, Fire, Health and Safety and Security and staff compliance with mandatory training

Chief Finance Officer, Governance, Assurance and Delivery Manager and CSU Senior Risk Officer – Changes have been made to roles and responsibilities.

Members were happy to receive and support this strategy.

19.206 Risk Management Group Terms of Reference

Debra Atkinson presented the paper advising that the core membership of the meeting has been reduced, although risk owners will be invited to attend the monthly meetings and provide updates. The Committee raised concerns that the membership of the group is at the level to provide assurance on the individual risks. A recommendation was made that Primary Care should be represented at the group due to issues around risk recording raised at East DA Lancs Primary Care Committee.

Action: Deborah Atkinson to request that Primary Care is represented at the Risk Management Group..

Members acknowledged receipt and supported the Terms of Reference.

19.207 Information Governance and Compliance Group Terms of Reference

Members acknowledged receipt and supported the Terms of Reference.

19.208 Pennine Lancashire CCGs Risk Management Report

Deborah Atkinson presented the bi-monthly risk management report and the key areas were highlighted as follows:

There are 2 x SEND risks that are currently being held as separate risks; additionally BwD CCG holds a stroke risk on its risk register; which is being reviewed to see if it should be reflected as a Pennine Lancashire risk.

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The A&E “target risk” rating has been increased to “8” to reflect the expectation of the risk rating being achieved by March 2020. A number of discussions have taken place regarding the target risk ratings being realistic and achievable.

A Scheduled Care Delivery Board has been established across Pennine Lancashire which will focus on the 18 week performance and have a system level oversight and scrutiny. This will be updated on a regular basis.

The Lancashire SEND re-inspection is imminent.

The BwD CCG 2018/19 Corporate Objective risks will be migrated onto the risk register and then reviewed.

A significant amount of work has been undertaken around the updating of risks and it was felt that the colour coding was a useful tool.

A Mersey Internal Audit exercise had previously highlighted that when the Risk Report is presented it should be explicitly referenced that it also includes the Governing Body Assurance Framework.

The recommendations in the Risk Management Report were supported by the members.

19.209 LD Transforming Care, STOMP and LeDer Update

Dr Lisa Rogan gave an overview of the report which sets the strategy for the next five years, and work plan for the next 12 months. This was an update on the original paper presented but is still in draft form.

The Chair requested that efforts to understand the patient experience be considered LR as part of the strategy in line with the first principle of the Royal Pharmaceutical Society good practice guidance on medicine optimisation.

Discussions took place on the lack of services for psychological COPD dependent patients. These people are supported by rehabilitation services and social prescribing may help. It was noted that not all GPs are aware of the services.

Dr Lisa Rogan was thanked for the thorough report.

Members acknowledged the report.

19.210 Pennine Lancashire Prescribing and Medicines Optimisation Strategy 2019-25 and Work Programme 2019-20

Members acknowledged the report.

19.211 Quality Meetings Draft Minutes

9.1a ELHT Quality Review Meeting Minutes – August 2019 9.1b MCFT Quality Minutes – August 2019 9.1c BMI Quality Minutes – August 2019

These minutes were tabled for reference. They were distributed prior to the meeting for information. No comments were raised.

Members received these minutes

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19.212 Risk Management and Compliance Group Minutes

The minutes were tabled for reference. These were distributed prior to the meeting for information. No comments were raised.

Members received these minutes.

19.213 Pennine Lancashire Research, Innovation and Clinical Effectiveness Committee Minutes – July 2019

The minutes were tabled for reference. These were distributed prior to the meeting for information. No comments were raised.

Members received these minutes.

19.214 Pennine Lancashire Research, Innovation and Clinical Effectiveness Committee Minutes July 2019

The minutes were tabled for reference. These were distributed prior to the meeting for information. No comments were raised.

Members received these minutes.

19.215 Items for Inclusion on the Corporate Risk Register

There were no new risks identified.

19.216 Date & Time of Next Meeting

The next meeting has been scheduled on Wednesday 30th October 2019 at 1.00 pm Meeting Room 1, Walshaw House, Nelson

Deadline for papers is 5.00 pm on 23rd October 2019.

Pennine Lancashire Quality Committee 25 September2019 Page 9 of 9 Minutes Approved by the Chair: NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group Appendix D Pennine Lancashire Committees in Common Minutes of the Blackburn with Darwen CCG Commissioning Business Group and East Lancashire CCG Sustainability Committee held on 21st August, 2019 at Walshaw House

PRESENT: Blackburn with Darwen CCG Dr John Randall General Practitioner (GP) Executive Member Dr Adam Black GP Executive Member Paul Hinnigan Lay Member (Governance) Dr Penny Morris Clinical Director Roger Parr Deputy Chief Executive/Chief Finance Officer Dr Zaki Patel GP Executive Member Dr Preeti Shukla GP Executive Member East Lancashire CCG: David Swift Lay Member (Governance ) - CHAIR Dr Santhosh Davis GP, Clinical Lead Burnley Dr Mark Dziobon Medical Director Kirsty Hollis Chief Finance Officer Dr Tom McKenzie GP. Clinical Lead Rossendale Alex Walker Director of Performance & Delivery

In Attendance: Jason Newman Head of Performance & Delivery Dr Lisa Rogan Associate Director of Medicines, Research and Clinical Effectiveness Dr David White Clinical Lead – Urgent Care Stuart Hayton Urgent Care Transformation Manager Elaine Craven Executive Assistant - Minutes

Min Ref: ACTION 19:101 Welcome & Chairs Update

The Chair welcomed members to the meeting.

19:102 Apologies

Apologies were received from Dr Julie Higgins, Dr Fiona Ford, Dr Ridwaan Ahmed, Naz Zaman, Kathryn Lord, David Rogers, Julie Kenyon and Debra Atkinson.

It was advised that Dr Lisa Rogan would be arriving late.

19:103 Governance

The Chair reminded members of their obligation to declare any interest they may have on any issues arising during the meeting, which might conflict with the business of the Clinical Commissioning Groups. The Chair referred members to the outline definitions in relation to types of interest, attached to the meeting agenda.

Declarations of Interest: There were no declarations of interest made at this meeting.

Quoracy: Both Committees were quorate.

- 1 - Minutes Approved by Committees 16.10.19 19:104 Minutes of the meeting held on 17th July, 2019:

The minutes of the meeting held on 17th July, 2019 were approved as an accurate record by both Committees.

The Chair confirmed that following the 17th July Committees in Common meeting, as the East Lancashire Clinical Commissioning Group Sustainability Committee was not quorate, the minutes were circulated to those members not present at the meeting. Sufficient support was received to ensure that the decisions made at the meeting were quorate and a record has been placed on file for audit purposes.

19:105 Action Matrix:

18:31: Pennine STEP (Succeed Thrive Empower Pennine) Service. Alex Walker provided a brief update. A new service specification is in place, a key change is that the service is no longer based in the Accident and Emergency Department. Alex advised that greater numbers of patients are now being referred into the service. A more detailed briefing to be brought to the September Committees in Common meeting.

19:39: Stroke Association – Stroke Recovery Service Included on the agenda.

19:54: Contracts due to Expire Included on the agenda.

19:83: Governance This was discussed at a Joint Governing Body meeting on 7th August and it was agreed that the move towards a joint structure will address the issues regarding quoracy. Agreed that a meeting will be arranged to include both Committee Chairs and Paul Hinnigan to review the Terms of Reference for a joint committee.

19:88: Mental Health Improvement Plan The first meeting of the Pennine Lancashire Mental Health Delivery Board is to be set for September 2019, the terms of reference are to be re-designed in light of the NTW (Northumberland, Tyne and Wear) report. NTW will be a support partner to Lancashire Care Foundation Trust (LCFT). The Board will be co-chaired by Russell Patton (LCFT) and Alex Walker. A report will be brought to the October Committees in Common meeting outlining the revised plan. The Terms of Reference will provide clarity regarding the Board’s remit and will cover community and crisis pathways.

Additional action:

Gifford Kerr asked for the following additional action to be added in reference to the Tuberculosis Service Review item which was discussed at the Committees in Common meeting on 5th May, 2019:

19:72: Tuberculosis Service Review  Identify a Pennine Lancashire Clinical Commissioning Group representative to lead on developing a next steps plan for the service.  Agenda item for the October Committees in Common meeting.

19:106 Matters Arising:

There were no matters arising.

- 2 - Minutes Approved by Committees 16.10.19 19:107 Same Day Primary Care

Dr David White and Stuart Hayton attended for this agenda item. Dr White delivered a presentation entitled - Developing a Pennine Lancashire model and phased delivery plan for ‘Same Day Primary Care’ (Same Day Primary Care refers to access for individuals (all ages) who feel they need clinical input/advice ‘today’.). The purpose of the presentation was to assess support for the model concept and gather feedback.

A copy of the presentation was circulated prior to the meeting. Dr White made the following key points during his presentation:  The aim is to develop sustainable services wrapped around the individual.  Maximise recruitment and retention.  Accurate signposting/navigation for patients.  Consultation has taken or is taking place including a Steering Group to outline aims and develop a model.  The Model has already been to Accident and Emergency Delivery Board, Clinical Reference Group and Local Community Partnership for discussion.  Relative Urgent Care activity: 111 dealing with 350 calls per day and online 80 calls per day.  Blackburn site 200 cases per day, Burnley 150, and Minor Injuries Units 40. Primary Care 4000 cases per day.  Clitheroe example - 40 walk in same day cases per day.  The 111 contract is due for renewal in October 2020.  Urgent Treatment Centres needs to be in place by Autumn 2020 – may be able to seek permission to extend this due date.  Need consistent triage and navigation.  Groups of patients will benefit from a local service (from start to finish).  Discussions at Integrated Care System level looking at a modular system with local level services.  Virtual clinical assessment service in place to support 111.  Lower category 999 patients could be better served by a clinical assessment service.  Urgent Treatment Centres are seeing a greater number of patients than the national specification.  Blackburn Urgent Treatment Centre, all out of hours are off site. Burnley Urgent Treatment Centre, out of hours are on the same site, but not connected. Work is to be done around this.  Urgent Treatment Centres can be counted in Performance Indicators, however if sites are not actually called an Urgent Treatment Centre they can’t be counted.  Variability in local Primary Care offer.  Estates constraints issue, the Emergency Department is too small for the population size.  Model concept – could we do things differently?

During discussion, the following comments and observations were made:  Observations in respect of the 111 service are that it is a service with ineffective triage. The opinion is that this needs to be looked at in depth before progressing with the rest of model. Could clinical triage be done locally, is there sufficient resource?  The evidence suggests that Urgent Treatment Centres should be GP led, but in practice this is not the case, they are hospital led.  A finance programme is required to address funding issues across services.  Need to look at change and will current resources support.  A question was asked as to how the proposed model simplified the service

- 3 - Minutes Approved by Committees 16.10.19 provision. Need to clarify components, break up into chunks where decisions are required, identify areas where key decisions are needed, work up recommendations/options and put forward for decision. Go back to zero base and then assess what do we ideally want and how do we get it.  The question in the North West, is do we want to take control locally. Minimise some of the burdens/constraints.  Key enabler is IT/information sharing, a full electronic record is essential.  Single point of access – what is the desired direction for this? GPs want to be dealing with complex cases and not minor illnesses e.g. coughs, colds etc.  Need to get prevention right to address demand and then work on the rest of system.  Should patients be deflected if they turn up to the wrong part of the system, providing that it is safe to do so.  Improve Primary Care performance as well, demand from patients is different in different practices/areas, there is a variation in quality and performance.  Slim down the model.

Dr White thanked the committee for their useful feedback and advised that a next step project plan will follow.

Dr White and Stuart Hayton left the meeting at this point.

19:108 Contract tracker – Assurance

Jason Newman updated the committees in relation to their request for assurance in respect of contract decisions. He advised that a contracts update is now a standing item on the agenda for the fortnightly Senior Management Team meetings, this then feeds into a meeting tracker, which is then used to inform committee agendas. At the last Senior Management Team meeting, 41 contracts were on record as due to expire in March 2020, these are being followed up with Senior Managers to ensure that they are being tracked. Mechanisms are in place to take these forward.

Discussion followed:  The committees wanted assurance where these contracts are being dealt with and what Committees in Common should expect to come to their meetings. If the contracts are not to come to Committees in Common, where will they go for scrutiny and decision. Jason advised that contracts of a higher value will come to Committees in common, lower value items will be scrutinised at Senior Management Team (SMT) or at the Senior Managers Meeting (SMM), also held fortnightly which is attended by all Senior Directors.  There needs to be an incremental process to ensure that 41 business cases don’t come through to Committees in Common, all at the same time.  Primary Care Committee are seeing some decisions that don’t go through Senior Management Team. Jason agreed to liaise with Collette to ensure that these are documented.  Committees in Common were seeing last minute requests for decisions. Jason gave assurance that this will be mitigated, Senior Management Team will ensure that the business ask is manageable, and the meeting tracker will calendar details of expected items.

Jason added that the register is only as good as the information provided by colleagues, but assurance was given that there is a process in place.

- 4 - Minutes Approved by Committees 16.10.19 Dr Mark Dziobon left the meeting at this point, his departure did not affect quoracy.

19:109 Prescribing & Medicines Optimisation Annual Report Dr Lisa Rogan joined the meeting at this point and guided the committees through the content of the report. The report provides a comprehensive review of the performance and outcomes delivered through the East Lancashire Prescribing and Medicines Optimisation Work Programme 2018-19. The report demonstrated delivery of £2,426,236 of savings which exceeded the original target of £1.4 million and set against a national cost pressure of £2,156,190 due to NCSO price concessions. Although an East Lancashire report, Lisa also related the content to Blackburn with Darwen.

Discussion then took place:  A question was asked, if there was any new research to show the results between Doacs and warfarin in relation to a reduction in the number of stroke cases. Lisa responded that there is no evidence that Doacs have reduced the number of strokes.  Need to look at Communication strategy around services as well as self-care promotion.  Really good report, the work of the Medicines Management Team is really appreciated.  A question was asked, as we move to a more integrated team will the relationship with hospital colleagues improve prescribing issues experienced. Lisa responded that collaborative work is already taking place in pathways.  In relation to Eclipse, Lisa advised that the team have made this work. Most practices are trying to meet targets, not necessarily just in relation to costs but because they want it to work.  A question was asked, if there are any other areas doing things better and is there learning to be gained. Lisa advised that comparisons tend not to be made on a like for like basis, therefore data doesn’t necessarily demonstrate better outcomes. Lisa added that there are some examples of good practice and improved outcomes, where these are identified better practices are rolled out.

The Committees accepted the report.

19:110 Pennine Lancashire Diabetes Health Improvement Board Minutes and Action Matrix April 2019

The minutes and action matrix of the Pennine Lancashire Diabetes Health Improvement Board meeting held on 3rd April were received for information.

19:111 East Lancashire Medicines Management Board Minutes – 20th March & 15th May, 2019

The minutes of the East Lancashire Medicines Management Board meetings held on 20th March and 15th May were received for information.

19:112 Any other business:

There were no other items of business in this section of the meeting.

19:113 Date & Time of Next Meeting:

The next meeting was confirmed as Wednesday, 18th September, 2019 commencing at 1.00 p.m. at the Innovation Centre, Haslingden Road, Blackburn.

- 5 - Minutes Approved by Committees 16.10.19 Appendix E

Sub Committees & Stakeholder Minutes

13 November 2019

Locality Summary Report:

The priorities for the team since the last briefing have been:

1. Supporting the development of Primary Care Networks (PCNs) in terms of the identification of individual Clinical Directors and preparation of the PCN registration paperwork 2. Continuation of both locality wide and PCN specific work streams

Burnley Key Priority: Primary Care Networks – The two Burnley PCNs have agreed to employ a Social Prescribing Link Workers through Burnley, Pendle and Rossendale Council for Voluntary Service (BPR CVS) and they are set to work closely with the already established Community Connectors, offering both support and guidance to appropriately referred patients, whilst at the same time reducing the impact on some mainstream GP Practice services. These roles will involve reducing health inequalities by addressing the wider determinants of health, such as debt, poor housing and physical inactivity.

This has required the PCNs to secure investment for the management and supervision costs to support the infrastructure around their employment.

Additional Area of Interest/Innovation: From 01 October 2019 patients of the former Daneshouse Surgery, who were being cared for by the Burnley Group Practice, have been welcomed into surrounding local practices.

Hyndburn Key Priority: Primary Care Networks – Co-location and co-working has begun in earnest in Hyndburn Central with 3 of the 5 practices now in the prescribing hub, a Clinical Pharmacist employed and the INT staff now all in Acorn. Significant plans are on-going to further develop this and create a community hub.

Hyndburn Rural have appointed a clinical pharmacist. Hyndburn Rural are looking at general practice resilience and working together to create a more robust primary care offer. Initial discussions around co-working are developing, with a significant challenges being estate and capacity.

Both PCNs have had Social Prescribing Link Workers in post since the middle of September. Undertaking the same remit as those described for Burnley. Additional Area of Interest/Innovation: The 2 PCNs in Hyndburn in conjunction with the Health and Wellbeing partnership are looking at a place based care strategy for Hyndburn.

Hyndburn has seen a significant increase in suicides and drug related deaths and teenage pregnancies and STIs in the last 18 months which will be topics of discussion in the near future. Initial conversations have started between the PCNs, the borough council and LCC.

Page 1 of 3 Pendle Key Priority: Primary Care Networks - Both Pendle East and West PCNs continue to meet on a monthly basis to strengthen relationships between practices and highlight both the responsibilities and expectations of PCNs.

Both PCNs agreed to employ their social prescribing worker through BPR CVS working in conjunction with the Community Connectors. This has required the PCNs to secure investment for the management and supervision costs to support the infrastructure around their employment.

Area of Interest/Innovation: As part of the Pendle Health and Well Being Partnership Group, a Pendle Cultural Strategy is being written of which, health is a key priority. The strategy is looking at what arts can do for health and identified loneliness, dementia, mental health and social isolation as key areas. The Group have agreed to support the strategy with the possibility of utilising the social prescribing funds.

The Dementia Positive Pendle Steering Group are working with GP surgeries to pull together a dementia information pack. It is envisaged that the pack will form part of the dementia annual reviews and will provide uniformed information/advise to the patient, and their families/carers.

Ribblesdale Key Priority: Primary Care Network - The network have had Social Prescribing Link Workers in post since 23 September and they have just finished all their required training. They are set to work closely with the already established Community Connectors and will be hot desking across the four GP practices.

Area of Interest/Innovation: The Ribblesdale Heart Failure Project started in July 2017 with the overall aim of developing an evidence-based pathway for the management of patients with heart failure. A project group was formed with a GP and / or nurse from each of the four practices, in collaboration with East Lancashire Hospitals NHS Trust (ELHT) Cardiology Department and Heart Failure Specialist Nursing Service. The project has been supported by the British Heart Foundation (BHF) who provided evidence and examples of best practice from a national perspective.

The project has made steady progress in achieving the original objectives with ongoing and valued support from Ribblesdale PCN and ELHT Cardiology and Heart Failure Nursing Services. Much has been learnt about the importance of coding, both for diagnosis, and for evaluating the quality of primary care heart failure reviews. The project is at a stage of wanting to share what has been learnt so far, and exploring options for upscaling the activities, and working with new stakeholders to take forward new ideas. The group are working on a bid for Heart Failure funding from the British Heart Foundation to test and evaluate innovation in the care and treatment of HF patients.

Rossendale Key Priority: Primary Care Networks (PCNs) – Both Rossendale PCNs have jointly agreed to employ their Social Prescribing Link Workers through Burnley, Pendle and Rossendale Council for Voluntary Service (BPR CVS) and they are set to work closely with the already established Community Connectors, offering both support and guidance to appropriately referred patients, whilst at the same time reducing the impact on some mainstream GP Practice services. These roles will involve reducing health inequalities by addressing the wider determinants of health, such as debt, poor housing and physical inactivity. Page 2 of 3 This has required the PCNs to secure investment for the management and supervision costs to support the infrastructure around their employment.

Area of Interest/Innovation: After a series of discussions at Rossendale PCN meetings, both PCNs have jointly agreed to support an ‘Active Rossendale’ bid in connection with the Together an Active Future initiative. When approved this will allow for the delivery of a variety of schemes, broadly aimed at encouraging physical activity for those who are currently considered to be inactive, whilst at the same time understanding what barriers currently exist for people identified as being inactive. The Active Rossendale schemes will collectively cost £338,161 and are being funded by Sport England with similar schemes running in other parts of Pennine Lancashire.

Locality Managers

East Lancashire CCG

Page 3 of 3 Appendix F

Lancashire Health and Wellbeing Board

Minutes of the Meeting held on Tuesday, 10th September, 2019 at 2.00 pm in Committee Room 'C' - The Duke of Lancaster Room, County Hall, Preston

Present:

Chair

County Councillor Shaun Turner, Lancashire County Council

Committee Members

County Councillor Graham Gooch, Lancashire County Council County Councillor Phillippa Williamson, Lancashire County Council Dr Sakthi Karunanithi, Public Health, Lancashire County Council Louise Taylor, Adult Services and Health and Wellbeing, Lancashire County Council Edwina Grant OBE, Education and Children's Services, Lancashire County Council Stephen Young, Growth, Environment, Transport and Community Services, Lancashire County Council Dr John Caine, West Lancashire CCG Kirsty Hollis, East Lancashire Clinical Commissioning Group Jonathan Wood, Lancashire Teaching Hospitals Foundation Trust Gary Hall, Lancashire Chief Executive Group Victoria Gibson, Lancashire Safeguarding Adults Board Councillor Bridget Hilton, Central District Council Tammy Bradley, Housing Providers David Russel, Lancashire Fire and Rescue Service Peter Tinson, Fylde and Wyre CCG Samantha Gorton, Democratic Services, Lancashire County Council

Apologies

Dr Geoff Jolliffe Morecambe Bay CCG Suzanne Lodge North Lancashire Health & Wellbeing Partnership Graham Urwin NHS England, Lancashire and Greater Manchester Councillor Steve Hughes Rossendale Borough Council Cllr Viv Willder Fylde Coast District Council Councillor Margaret France Central Health and Wellbeing Partnership Greg Mitten West Lancashire Health and Wellbeing Partnership Denis Gizzi Chorley and South Ribble CCG and Greater Preston CCG Joanne Moore Lancashire Care Foundation Trust David Blacklock Healthwatch

1. Appointment of Chair for the Meeting

As the Chair was now present at the meeting, this item was no longer required.

1 2. Welcome, introductions and apologies

The Chair welcomed all to the meeting.

Apologies were noted as above.

New members of the Board were as follows:

Joanne Moore has replaced Caroline Donovan, Lancashire Care Foundation Trust.

Replacements for the meeting were as follows:

Victoria Gibson for Jane Booth, Lancashire Safeguarding Adults Board and Stephen Ashley, Lancashire Safeguarding Children's Board. Jonathan Wood for Karen Partington, Lancashire Teaching Hospitals Foundation Trust. Kirsty Hollis for Dr Julie Higgins, East Lancashire Clinical Commissioning Group

Apologies were also received from Arif Raipura, Director of Public Health, Blackpool Council.

3. Disclosure of Pecuniary and Non-Pecuniary Interests

There were no disclosures of interest in relation to items appearing on the agenda.

4. Minutes of the Last Meeting and Matters Arising

Resolved: That the Board agreed the minutes of the last meeting.

The Chair informed the meeting that it was Suicide Prevention Awareness Day and that the Board would observe a 40 second silence at 2.40pm.

A workshop would be held on 9 October 2019 to progress the collaboration and joint working between Blackburn with Darwen, Blackpool and Lancashire Health and Wellbeing Boards. Invites for the day had been sent out and further details would be circulated shortly.

The draft Integrated Care Service Partnership Agreement response was currently being drafted and would be circulated to the Board as soon as it was available.

5. Action Sheet and Forward Plan

Resolved: That the Board noted the actions from the last meeting, along with items for the Board's consideration at future meetings as detailed on the forward plan.

2 6. Lancashire Special Educational Needs and Disabilities (SEND) Partnership

Sian Rees, Special Educational Needs and Disabilities Consultant, Lancashire County Council, reported on the progress following the inspection by Ofsted and Care Quality Commission in November 2017 to judge how effectively the special educational needs and disability reforms had been implemented, as set out in the Children and Families Act 2014. The inspection identified two fundamental failings and twelve areas of significant concern.

Formal review visits by the Department for Education (DfE) and NHS England had taken place since 2018 to consider the progress being made in line with the Written Statement of Action; the most recent being on 19 August 2019.

Preparation for the forthcoming re-visit by Ofsted and Care Quality Commission (CQC) to the Lancashire local area had been taking place; the visit would assess the progress made in addressing the twelve areas of concern detailed in the original report.

The re-visit was expected to take place before the end of October 2019 and in preparation for this the Special Educational Needs and Disabilities Partnership Board would consider the self-assessment at its next meeting on 16 September 2019. The re-visit would include all partners and engagement with parents, children and young people.

Headlines from the 36 page self-assessment were presented to the Board and the full self- assessment would be circulated to members following the meeting of the Partnership Board on 16 September 2019.

Five areas were also identified where the pace of progress needed to be accelerated and again, these would be considered and the plans agreed at the Partnership Board also in September. The five areas were:

Quality of Education, Health and Care Plans Education Outcomes Transition Arrangements Information about the Local Offer Implementing Neuro-development Pathway

The self-assessment was felt to be a fair and reasonable assessment, evidenced by some fundamental changes.

Resolved: That the Health and Wellbeing Board:

i) Received a presentation to outline the process of the forthcoming re- visit by Ofsted and the Care Quality Commission (CQC); ii) Summarised the assessment of progress to date; iii) Shared the process in place to accelerate progress where this was required.

3 7. Population Health Management

Declan Hadley, Digital Lead, Healthier Lancashire and South Cumbria Integrated Care System and Lindsey Roome, Digital Programme Manager, Sustainability and Transformation Partnerships, NHS England North (Lancashire and South Cumbria) presented the PowerPoint presentation that was circulated with the agenda.

The presentation provided an update on the 20 weeks population health management accelerator programme and a short video clip was shown.

The programme would give opportunities for partners to collaborate more than was currently happening and needed to link with national initiatives. Data sharing was still a key challenge and a solution was still being sought regarding this and the Board was asked to support this across the sector. Everybody needed to work better with the resources they had and use it in a better way. The success of this programme will be how the rest of the public sector, including transport, housing etc work with each other.

Resolved: That the Health and Wellbeing Board:

i) Discussed and endorsed next steps to embed population health management as an approach to implement Integrated Care Services priorities, in particular the development of neighbourhoods. ii) Receive a further update report in January 2020 which a progress report on information sharing agreements.

8. Urgent Business

There were no items of urgent business received.

9. Date of Next Meeting

The next scheduled meeting will be held at 2pm on 19 November 2019 in the Duke of Lancaster Room – Committee Room 'C' at County Hall, Preston.

L Sales Director of Corporate Services

County Hall Preston

4 Appendix G Agenda item no. 3

Notes of the Joint Committee of Clinical Commissioning Groups (JCCCGs) Thursday 02 May 2019 13:00-15:00 NHS Morecambe Bay CCG (Main Lecture Theatre), Moor Lane Mils, Moore Lane, Lancaster, LA1 1AD

Present Phil Watson Independent Chair JCCCGs Dr Richard Robinson Clinical Chair East Lancashire CCG Geoffrey O’Donoghue Lay Member Chorley and South Ribble CCG Dr Geoff Jolliffe GP and Clinical Chair Morecambe Bay CCG Doug Soper Lay Member West Lancashire CCG Dr Gora Bangi Chair Chorley South Ribble CCG David Bonson Chief Operating Officer Blackpool CCG Roy Fisher Chair Blackpool CCG Dr Sumantra Mukerji Chair Greater Preston CCG Paul Kingan Chief Finance Officer West Lancashire CCG Graham Burgess Chair Blackburn with Darwen CCG Louise Taylor Executive Director for Adult Lancashire County Council Services and Health and Wellbeing Dr Adam Janjua GP and Acting Chair Fylde and Wyre CCG In Attendance Andrew Bennett Executive Lead Commissioning Healthier Lancashire and South Cumbria ICS Margaret Williams Chief Nurse Morecambe Bay CCG (attended for item 7) Elaine Johnstone Chair, Commissioning Policy Midlands and Lancashire Development and Implementation Commissioning Support Unit Group (CPDIG) (attended for Items 5 and 8) Rebecca Higgs Individual Funding Request (IFR) Midlands and Lancashire Policy Development Manager Commissioning Support Unit Roger Parr Chief Finance Officer East Lancashire and Blackburn with Darwen CCGs Denis Gizzi Chief Officer Chorley & South Ribble CCG and Greater Preston CCG Gary Raphael Finance Lead Healthier Lancashire and South Cumbria ICS Amanda Doyle Chief Officer Healthier Lancashire and South Cumbria ICS Andy Curran Medical Director Healthier Lancashire and South Cumbria ICS Jane Cass Locality Director Healthier Lancashire and South Cumbria ICS Neil Greaves Head of Communications and Healthier Lancashire and Engagement South Cumbria ICS Linda Riley Director of Operations Midlands and Lancashire Commissioning Support Unit Rachel Snow-Miller Director of Commissioning for All Healthier Lancashire and Age Mental Health and Learning South Cumbria ICS Disability Services (attended for Item 6) Heather Bryan Programme Manager/Service Midlands and Lancashire Redesign Team Commissioning Support Unit (attended for Item 6) 1 Agenda item no. 3

Apologies Debbie Corcoran Lay member Greater Preston CCG Harry Catherall Chief Executive Blackburn with Darwen Borough Council ICS Jerry Hawker Chief Officer Morecambe Bay CCG Steve Thompson Director of Resources Blackpool Borough Council Julie Higgins Chief Officer East Lancashire and Blackburn with Darwen CCGs Andrew Bibby Assistant Regional Director of NHS England/NHS Specialised Commissioning (North) Improvement Gary Hall Chief Executive Chorley Borough Council Neil Jack Chief Executive Blackpool Borough Council Sakthi Karunanithi Director of Public Health Lancashire County Council Angie Ridgwell Chief Executive Lancashire County Council Carl Ashworth Service Director Midlands and Lancashire Commissioning Support Unit Hilary Fordham Chief Operating Officer Morecambe Bay CCG Talib Yaseen Director of Transformation Healthier Lancashire and South Cumbria ICS Kevin Toole Lay Member Fylde and Wyre CCG

A. Standing items

1. Welcome and Introductions The Chair welcomed members to the regular business meeting of the Joint Committee of Clinical Commissioning Groups (JCCCGs) held in public. Members were reminded that the business today was being live-streamed and recorded so that decisions are accessible and available to members of the public following the meeting, on the Healthier Lancashire and South Cumbria (HL&SC) YouTube channel. It was reported that in line with recent meetings, members of the public had been invited to raise any questions relating to items on the agenda prior to the start of the meeting and again at the end of the meeting. Questions were also welcomed in writing.

The Chair reminded members that local elections are taking place and due to purdah, and the meeting being live-streamed, asked members to be mindful of specific restrictions on communications activity.

2. Declaration of Interests G O’Donoghue, Lay Member, Chorley and South Ribble CCG, declared an interest in Item 5 (Glucose Monitoring and Flash Glucose Monitoring to patients with Diabetes Mellitus). The Chair determined that this was a non-financial personal interest and it was agreed that Mr O’Donoghue could stay in the room but not participate in any discussion relating to this item.

3. Notes of the meeting held on 07 March 2019 Following an amendment to include J Cass on the apologies and to note a new title for Dr Janjua, (GP and Acting Chair), the notes was agreed as a correct record.

4. Items of any other business None reported.

5. Chair’s action: Glucose Monitoring and Flash Glucose Monitoring to patients with Diabetes Mellitus The Chair reminded members that during the meeting on the 07 March, the Joint

2 Agenda item no. 3

Committee delegated responsibility to the Independent Chair, P Watson and ICS Executive Director of Commissioning, A Bennett, to sign off an amendment to the commissioning policy, in response to national guidance received that day for access to flash glucose monitoring consistently across England. In response to national guidance, the Chair invited E Johnstone, Service Director, Midlands and Lancashire Commissioning Support Unit to outline the basis for the changes made to the policy.

The Joint Committee was informed that following a review of the local policy and new national criteria for access, an amendment had been made to enable more patients to benefit from this technology. The Commissioning Policy Development and Implementation Working Group (CPDIG) will continue to support CCGs to embed the policy in clinical practice.

E Johnstone asked the Committee to endorse the decision of the Independent Chair and the ICS Executive Director of Commissioning to ratify the updated policy.

RESOLVED: that the Joint Committee endorsed the ratification of this updated policy. Improving Population Health

6. The Children and Young People’s Emotional Health and Wellbeing and Mental Health (CYPEWMH) programme: Transformation Plan and Business Plan A Bennett informed members that the CYPEWMH is an established programme of work and the information provided is based on previous presentations to the Joint Committee.

A Bennett welcomed R Snow-Miller and H Bryan to the meeting and R Snow-Miller gave an update on the CYPEWMH programme of work for 2019/20, including the refinements and developments that draw local authority, health commissioners and providers into a collaborative programme.

The Collaborative Commissioning Board (CCB) had received the Lancashire and South Cumbria (L&SC) Transformation Plan in April 2019 and recommended that the same is presented to the Joint Committee for final approval. R Snow-Miller described the main achievements to date and the key challenges to meet the requirements of the Long- Term Plan (LTP), published on 07 January 2019. The following key priorities were highlighted for this financial year:

• Digital THRIVE on-line platform - an evidence-based training programme that teaches people the skills and resources to overcome mental health issues and learn to thrive, ultimately becoming part of the self-referral process • Redesign of Children and Adolescent Mental Health Services (CAMHS) to be delivered in-year and in line with the THRIVE model • To define and deliver appropriate specialist in-patient community support

R Snow-Miller also presented the Business Plan 2019/20. It was reported that L&SC CCGs had aligned a percentage of their budgets against the Transformation Plan objectives and from April 2020 the CCGs had agreed to a percentage of alignment and local spend.

The Chair asked if there were any questions or comments.

D Soper requested clarifications on the allocated spend in 2018/19. It was agreed that Mr Soper would receive a written response outside the meeting on the services available around the 7-day CAMHS response.

3 Agenda item no. 3

Dr R Robinson inquired about the advantages of having a single point of access and whether this was part of the nationally recognised digital model, THRIVE.

R Snow-Miller informed members that as part of CAMHS redesign, work was ongoing towards a single point of access, including looking at how this can be brought into the neurodevelopmental pathway that is part of the Special Educational Needs and Disability (SEND) work; the aspiration is for a single digital access point into services. Focus is currently on joining CAMHS redesign single point of access and also making sure that digital THRIVE promotes self-help and mental wellbeing.

From a question raised on the challenges created by the national access target and the year-end position, R Snow-Miller confirmed that the Business Plan allows for the delivery of the access targets for children’s mental health services.

It was reported that later in the year the Joint Committee is to consider the clinical model coming out of the work from providers. R Snow-Miller was asked to highlight how providers are working together and to identify the biggest risks in the programme.

R Snow-Miller informed members that providers are calling themselves a ‘Care Partnership’. Providers are working with Northumberland Tyne and Wear Trust in making sure the ICS has an effective pathway to meet the needs of children and their families. In July, a model will be proposed and considered through a formal evaluation process, chaired by the Chief Operating Officer at Morecambe Bay CCG. Risks in the programme will continue to be monitored.

RESOLVED: that the Joint Committee approved the Transformation Plan refresh 2019/20 and the Business Plan.

7. Individual Patient Activity (IPA) programme M Williams, Executive Lead for the IPA programme, provided an update on IPA activity across the system to support case for change.

It was reported that the paper had been endorsed in April 2019 by the Commissioning Oversight Group (COG), the Collaborative Commissioning Board (CCB) and shared with executive teams and CCG Governing Bodies. M Williams described the key objectives set against NHS England standards and the need to incorporate a system- wide collaborative approach and funding mechanism with multiple providers of IPA.

The Chair asked if there were any questions or comments.

A number of questions were raised around funding and patient eligibility. D Soper indicated that delays in patient assessments could result in over-provided packages of care. M Williams informed Mr Soper that one of the objectives of the L&SC IPA Programme Board is to address detailed finances and funding of services and to also review success measures of alternative IPA models outside the current system that could potentially add value.

L Riley informed members that Midlands and Lancashire Commissioning Support Unit (M&L CSU) is supporting seven of the eight L&SC CCGs (excl. Blackpool) to review the costs of individual packages of care.

A number of members queried the timeframe of the new ways of working and further detail was requested on the split between Continuing Health Care (CHC) standards of care and the percentage of CCG and IPA components. It was pointed out that the system needed to realise the impact and risk in the system in relation to the 28-day Out of Hospital (OOH) discharge. M Williams informed members that a future delivery 4 Agenda item no. 3

model will be developed within the next 12 months.

A Bennett asked if there is sufficient resource available to proceed as proposed. M Williams informed the Joint Committee that there is enough resource to commence the programme. Future resource may be required as the programme progresses.

A Bennett asked how local authorities would play in to the IPA Programme Board. M Williams recognised that local authority colleagues need to be involved to support the commitment to future modelling and improvements and reiterated that each Integrated Care Partnership (ICP) needs to ensure that they have nominated representatives on the current IPA Programme Board, including local authority representation.

P Kingan raised a question on the scope and process and if this included initial investment of patients prior to eligibility. M Williams informed members that the eligibility of patients will continue to be assessed.

M Williams asked the Joint Committee to endorse the specific requirement to nominate one representative from each ICP to sit on the Lancashire and South Cumbria IPA Programme Board to strengthen the new IPA governance structure.

The Chair asked the Joint Committee to:

• Note and endorse the approach presented in the report • Confirm support for the proposed Governance arrangements and responsibilities of the IPA Programme Board • Note the urgent need for all CCGs to review with partners and propose nominations for ICP representatives on the board • Endorse the recommendation that the IPA programme Board will take single responsibility for overseeing and implementing a performance improvement plan with NHS England (and M&L CSU) to deliver the required improvements in National quality standards • Note the initial draft work programme set-out in section 6.0.

RESOLVED: that the Joint Committee agreed the recommendations, and endorsed the specific requirement to nominate one representative from each ICP to sit on the Lancashire and South Cumbria IPA Programme Board.

8. Commissioning Policies: A Bennett reintroduced E Johnstone to set the context for the commissioning polices.

E Johnstone informed members that a decision has been made within Lancashire and South Cumbria to adopt the same clinical policies across the ICS to ensure equity of access to treatments for all patients; CCGs have been charged to set resources and to deliver maximum benefits. It was noted that CPDIG is responsible for the oversight of this process and ensuring policies are based on the best quality and clinical evidence. The financial impact of any change is also recognised and robust processes are in place with the clinical community and the public. E Johnstone informed members that CPDIG agrees the final versions of all policies that come to Joint Committee for approval and went on to explain the following two specific policies:

Policy for the treatment of varicose veins E Johnstone reported that all patients across L&SC will have the same access for eligibility. The main difference between the historical policies and what is presented today, around the stage at which varicose veins can be treated, was explained. Evidence-based recommendation within NICE Guidance and subsequent NHS 5 Agenda item no. 3

Evidence-Based Intervention (EBI) Guidance was discussed, along with the impact of potentially widening the access criteria for patients to be treated sooner than they currently are. The ICS Finance and Investment Group (FIG) have been apprised of the implementation of the new criteria coming in line with NICE guidance and EBI guidance and how this would impact financially. At an ICS level, it is believed that this policy, when fully implemented through all vascular services, will enable the support of more patients earlier in the care pathway for less expenditure and more patients will have a faster recovery through the less invasive procedure.

The Chair asked if there were any questions or comments relating to this policy.

D Soper raised a question around the feasibility of potentially harmonising effective clinical practice to achieve these expectations. E Johnstone informed Mr Soper that part of CPDIG’s remit is to monitor the impact of policies. Processes are in place to monitor the results of policies and this particular policy, following extensive clinical engagement, lists the order of intervention that ought to be considered. Colleagues on the L&SC Vascular Programme Board will also be made aware of decisions and expectations.

From a number of questions raised on the interpretation of clinical policies available for patients, it was reported that appropriate literature was being considered for use in general practice. E Johnstone informed members that as with all policies, CCGs will be notified, as part of the communications and engagement process, that a policy is available and as part of that, specific literature will be signposted.

S Mukerji informed members that his CCG did have straightforward clinical policies listed on their website and suggested that the same should be listed on all CCG’s websites, located in one section.

D Bonson raised a question on a potential increase in cost and demand for services where CCGs have had existing policies. E Johnstone informed members that there is an expected cost for each procedure and cost effectiveness will continue to be reviewed.

RESOLVED: that the policy for the treatment of varicose veins was agreed by the Joint Committee.

Policy for Hysteroscopy E Johnstone explained the history of the policy that had recently been harmonised for L&SC (March 2018). E Johnstone explained that shortly after ratification, NICE updated a piece of non-mandatory NICE Guidance about the use of hysteroscopy as an investigative and treatment intervention. The final published guidance had slightly changed recommendations that moved hysteroscopy up the treatment pathway to be used as a first-line of investigation in certain circumstances. The clinical benefit is to have one appointment and one cost to achieve a diagnosis and treatment. The implementation of the policy is confirmed.

The Chair asked if there were any questions or comments relating to this policy.

G O’Donoghue raised a question on the decrease in variation from one area to another when following NICE Guidance across the country and to what extent are we close to neighbouring CCGs and their policies for people outside Lancashire and South Cumbria. E Johnstone informed members that the principle is about reducing inappropriate variation in access or use of interventions. Business Intelligence colleagues within Midlands and Lancashire Commissioning Support Unit are carrying out modelling on behalf of CPDIG, to enable benchmarking with other geographical 6 Agenda item no. 3

areas. E Johnstone was not aware of a systematic national benchmarking process.

G Jolliffe thought the variation was dependent on clinician behaviour, patient expectations and demographics and raised his concern on where allotted increases in activity should be.

A Doyle added that commissioners have to prioritise how we spend allocated resource for improvement in outcomes for our population. D Soper requested that the paper includes decisions on how we are prioritising resource effectively and showing the biggest improvement in outcomes for our population.

The Chair asked member to vote on the policy.

RESOLVED: that the policy for the treatment of Hysteroscopy was ratified by the Joint Committee.

9. Draft work programme for the Joint Committee Following conversations with executive colleagues around the system, A Bennett presented the latest draft work programme for the Joint Committee.

Members were informed that further discussions will be scheduled on the issues at the point the work comes to fruition and for this to become live, A Bennett will write to Accountable Officers to present the same through each Governing Body. Chief Officers will also receive an email requesting appropriate delegation for specific areas of work to come through Joint Committee; he restated that appropriate information would only come to Joint Committee once all the usual involvement from colleagues in CCGs had taken place.

G Burgess welcomed the report and requested that a timescales of actions are included on when Joint Committee can expect policy report-backs. A Bennett agreed that the next iteration would include timescales.

RESOLVED: that the Joint Committee noted the proposed work plan for 2019/20.

10. Any other business A Bennett informed members that as part of the ICS review of governance and partnership arrangements, a questionnaire has been circulated requesting feedback on the JCCCGs. For those who have not received this information, an appropriate email will be circulated in due course.

11. Questions from the public The Chair asked members of the public present if they had any questions relating to items on the agenda. There were no questions raised.

Date and time of next meeting: Thursday 04 July 2019 13:00-15:00, Blackpool Central Library, Queen Street, Blackpool, FY1 1PX Dates of future meetings held in public: 05 September 2019 07 November 2019 02 January 2020 05 March 2020

7 Item 5.3 REPORT

Reporting Group: Integrated Health and Care Partnership Leaders’ Forum Meeting Date: 16 October 2019 Report Title: Pennine Lancashire A&E Delivery Board Highlight Report: October 2019 Agenda Item: 065/19 For: To receive and comment  For approval and sign off For discussion and recommendations Lead: Damian Riley Acting Chief Executive Officer East Lancashire Hospitals Trust

Recommendations

Members of the Partnership Leaders’ Forum are requested to note the content of this report, provide any comments and raise any questions to the Chair of the Pennine Lancashire A&E Delivery Board.

Chair’s Update

The Chair welcomed members and introductions were made. It was explained that this was a short business meeting as there followed a longer workshop for the remainder of the morning. This was to focus on safely avoiding ambulance hospital conveyances. The workshop involved a wide group of stakeholders and had the aim of exploring what opportunities there are locally to develop alternatives to conveyance over the next year. It had a specific focus on mental health, health care professional bookings and intermediate tier issues.

Performance

The system Plan on a Page was presented along with the performance report relating to August 2019. In relation to 4 hr performance the system achieved 82.71% for August and 85% for September, which is an improvement on 2018-19 year. It was however acknowledged that this is an upward trend since April and the positive impact of new staff rotas was noted.

Longer length of stay (LLOS) has been identified as a key area of action and a number of plans are in place. These include the ECIST recommendations and the ELHT LLOS programme action plan. In addition a LLOS review process is established consistent with national guidance. Divisional LLOS teams are running weekly deep dive reviews at ward level and an executive led LLOS panel will also run weekly.

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REPORT

Winter Planning

A further draft of the Winter Plan was presented by Stuart Hayton. An earlier version of the Winter Plan was discussed at A&E Delivery Board on 5th September 2019 and since then a further re-prioritisation exercise has been undertaken, in relation to the ELHT in- hospital schemes. The total cost of the plan presented on 3rd October 2019, is £3,605,000, of which in-hospital schemes amount to £2,575,000 and out of hospital schemes £1,030,000. Funding sources are identified for all the out of hospital schemes and £1.5million of the £2,575,000 is identified within the CCG financial plans. The majority of the ELHT schemes were not funded within the existing contract. The circa £1.0 million financial gap is being considered in the context of the system control total and discussions are underway in the Pennine Lancashire Finance and Resources Group to identify disinvestment options to meet the funding gap.

Mental Health

An update on Mental Health developments was provided by Suzanne Thornber which covered the imminent closure of the MHDU and the mitigation plans locally to cater for this cohort of patients in other settings.

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BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

Blackburn with Darwen CCG Governing Body & East Lancashire CCG Governing Body Meeting in Common

EPRR Core Standards Final Submission Report Agenda Report Title: 5.4 2019-2020 No: Meeting Date: 13 November 2019 Summary of Report: This report provides detail in relation to the progress with the Pennine Lancs CCGs’ compliance against the NHS England Core Standards (in relation to Emergency Preparedness, Resilience and Response). It provides a rationale to support the submissions of the CCGs and their Providers to NHS England on 24th October through the Local Health Resilience Partnership. Report Recommendations: Members are asked to receive this final submission report (giving ‘Full Compliance’ based on the rationale within this report). Financial Implications: None Procurement Implications: None Report Category: Tick Support and recommend/forward the report. Approve the recommendations outlined in the report. Debate the content of the report. Receive the report for information.  Author: Liz Ottley, Assurance and Delivery Manager

Report supported & approved by your Senior Lead? Y Presented By: Mrs K Hollis, Chief Finance Officer Other Committees LHRP (Local Health Resilience Partnership) Consulted: Has a PIA been completed in respect of this report? Privacy Impact Assessment N (PIA) If Yes, please attach If No, provide reason below. Has an EIA been completed in respect of this report? Equality Impact Analysis N (EIA) If Yes, please attach If No, provide reason below. Data Protection Impact Is a Data Protection Impact Assessment Required? N Assessment Risks: Have any risks been identified / assessed? Y Conflict of Interest: Is there a conflict of interest associated with this report? N Has any clinical engagement/involvement taken place as part N Clinical Engagement: of the proposal being presented. Patient Engagement: Have patients been involved in the drafting of this report? N Privacy Status: Can the document be shared Y

CCG Corporate Objectives :

To commission the best quality and effective services to deliver optimal healthcare CO1  outcomes for our local population. Ensure the balance of our health investment reflects our population’s needs and keeps CO2 the population well. CO3 Deliver the 10 year strategy by engagement with the population we serve and ensure we commission services that meet local needs with a clear focus on population health management strategies.

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CO4 We will focus on population health outcomes through helping to deliver successful Integrated Care Partnerships and ensure decisions, provision and access to local services is based on the needs of our population. CO5 As local health leaders, we will focus on increasing life expectancy across Pennine Lancashire to be at, or about the national average in the next 10 years.

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BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

NHS Blackburn with Darwen CCG and East Lancashire CCG Governing Body Meeting in Common 13th November 2019

EPRR Core Standards – Final Submission

1. Introduction

1.1 The CCG is required to submit an annual assessment of its compliance with the NHS England Emergency Preparedness Resilience and Response (EPRR) Core Standards and to give assurance on the extent of compliance with the Civil Contingencies Act 2004 (CCA). Clinical Commissioning Groups (CCGs) are defined as Category 2 Responders under the CCA, meaning that there is a duty to cooperate with the Providers as Category 1 Responders, in support of their continued provision of effective patient care during a Major Incident.

In addition to meeting these legislative duties, CCGs are required to comply with guidance and framework documents, including but not limited to:  NHS England Emergency Planning Framework 2015;  NHS England Core Standards for Emergency Preparedness, Resilience and Response 2018;  NHS England (Operating Framework) Everyone Counts: Planning for Patients 2015/16.

This is achieved through the publication, testing and exercising of plans for critical functions and key services in accordance with the aforementioned guidance.

2. Purpose / Background

2.1 In July 2019, NHS England issued the revised Emergency Preparedness, Resilience and Response Core Standards documentation. The progress towards becoming fully compliant with these standards across the Pennine Lancashire Clinical Commissioning Groups (PL CCGs) is achieved through the process of gathering assurance from colleagues that builds into the picture provided here. NHS England also requests that CCGs directly receive the compliance statements, and improvement plans, of its providers which is a continuation of the requirements placed on CCGs in 2015.

2.2 There are 43 core standards against which the CCG had to review its current arrangements in terms of its level of compliance. In undertaking this review the Assurance and Delivery Manager considered the core standard detail, the arrangements currently in place against the standard and the expectation of the CCG specifically in terms of the Civil Contingencies Act and the NHS England Emergency Planning Framework. Obviously key to this has been the policy and plans in place around Emergency Preparedness Resilience and Response. These being the: Emergency Preparedness Resilience and Response Policy, Major Incident Plan (including the detailed on-call manager resource pack), Business Continuity Plan, Operational Response plan, Pandemic Influenza Plan and the Severe Weather Plan.

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2.3 Following a detailed review the CCG considers itself to be ‘Fully Compliant’ with the 43 core standards and therefore is suggesting submitting a statement to reflect this, which has been endorsed by the Accountable Emergency Officer of both CCGs, to NHS England.

2.4 In line with NHS England requirements the CCGs have received the compliance statements, and any required improvement plans, from Lancashire Care NHS Foundation Trust and East Lancashire Hospitals NHS Trust. The CCG also received the compliance statement from Mersey Care NHS Foundation Trust and this has been included, along with the others, in section 5 below for completeness.

3. Improvement Plans

3.1 From a CCG perspective we are not required to submit an improvement plan as we are fully compliant with the core standards.

3.2 In relation to any provider improvement plans this is detailed in section 5 below.

4. Severe Weather

4.1 As detailed a ‘deep dive’ on Severe Weather has been implemented as part of this year’s review. The CCG has identified no areas within this which require any current changes. As previously detailed this does not form part of the CCG statement of compliance.

5. Health Economy Assurances – Organisation Compliance Levels

5.1 The compliance levels and the results of the self-assessment are as follows:

Compliance Organisation Level Standards Standards Standards Standards Standards Rated Red Red Rated Number of of Number of Number Number of of Number Rated Green Rated Rated Amber Rated Improvement Improvement and reviewed Plan received Plan received Pennine Lancashire CCG (incorporating East Lancashire and Blackburn with Darwen CCGs) Full 0 0 43

East Lancashire Hospitals NHS Trust Substantial 0 5 59 * Lancashire Care NHS Foundation  Trust Full 0 0 54  Mersey Care NHS Foundation Trust Substantial 0 1 53  * LCFT has submitted an Improvement Plan, however this is not identifying actions against areas of none compliance but areas of continued improvement.

5.2 The CCGs Assurance and Delivery Manager will continue to ensure systems and processes are in place to maintain compliance with the core standards and the CCGs requirements under the Emergency Planning Framework.

5.3 In relation to provider assurances the Assurance and Delivery Manager will continue to meet with providers on a quarterly basis to monitor implementation of any improvement plans and to ensure ongoing compliance is maintained.

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6. Conclusions

6.1 The Assurance and Delivery Manager has reviewed the core standard requirements and has assessed the CCG as being fully compliant. In addition the compliance statements, along with any improvement plans, have been received from providers and regular meetings will take place over the coming 12 months to ensure their continued progress against their roles and responsibilities.

6.2 The CCG will, following Executive endorsement, submit a health economy compliance report to NHS England.

7. Recommendations

7.1 The Governing Body is requested to:  Agree the submission of full compliance against the core standards requirements for the CCG  Review the health economy update and agree for onward submission to NHS England.

Liz Ottley Assurance and Delivery Manager 1st October 2019

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BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

BLACKBURN WITH DARWEN CCG GOVERNING BODY AND EAST LANCASHIRE CCG GOVERNING BODY MEETING IN COMMON

Blackburn with Darwen Borough Council Agenda Report Title: Leisure, Health and Wellbeing Annual Report 5.5 No: 2018/19 Meeting Date: 13th November 2019 Summary of Report: Summary of the activity and outcomes delivered across Leisure, Health and Wellbeing services within Blackburn with Darwen. Ranging from universal provision population health prevention through to targeted interventions and long term condition specific services. Report Recommendations: Report is for noting Financial Implications: None. Procurement Implications: None. Report Category: Tick Support and recommend/forward the report. Approve the recommendations outlined in the report. Debate the content of the report. Receive the report for information. Author: Richard Brown - Blackburn with Darwen Borough Council

Report supported & approved by your Senior Lead? Y Presented By: Professor Dominic Harrison Other Committees Consulted: Has a PIA been completed in respect of this report? Privacy Impact Assessment N (PIA) If Yes, please attach If No, provide reason below. Has an EIA been completed in respect of this report? Equality Impact Analysis N (EIA) If Yes, please attach If No, provide reason below. Data Protection Impact Is a Data Protection Impact Assessment Required? N Assessment Risks: Have any risks been identified / assessed? N Conflict of Interest: Is there a conflict of interest associated with this report? N Has any clinical engagement/involvement taken place as part N Clinical Engagement: of the proposal being presented. Patient Engagement: Have patients been involved in the drafting of this report? Y Privacy Status: Can the document be shared Y CCG Corporate Objectives: To commission the best quality and effective services to deliver optimal healthcare CO1 X outcomes for our local population. Ensure the balance of our health investment reflects our population’s needs and keeps CO2 X the population well CO3 Deliver the 10 year strategy by engagement with the population we serve and ensure we commission services that meet local needs with a clear focus on population health management strategies CO4 We will focus on population health outcomes through helping to deliver successful Integrated Care Partnerships and ensure decisions, provision and access to local X services is based on the needs of our population. CO5 As local health leaders, we will focus on increasing life expectancy across Pennine Lancashire to be at, or abote the national average in the next 10 years. X

Leisure, Health & wellbeing Annual Report 2018-2019 Where it all started CONTENTS

In 2006/07 Blackburn with Darwen had one A lot has changed since re:fresh started back in 2008 with FOREWORD 4-5 shifting priorities and ever challenging local government budgets, of the lowest levels of adult participation all of which required a proactive and responsive approach to delivery approach 6-7 in physical activity in the whole country, ensure services remained fit for purpose throughout. Over the measured through the Sport England Active years this has resulted in commissioning reviews and changes What We’re About and WhY People Survey. which required adaptations and developments of the re:fresh model of delivery. A major change came in August 2016 when Blackburn with Darwen 8-9 the large scale free leisure programme moved to a nominal As a result Blackburn with Darwen Borough Council and the Wellbeing Service charge of £1 per session / attendance. Care Trust Plus entered into a unique partnership, investing £6m Performance Overview 2018/19 over three years in the re:fresh initiative, reflecting the desire A significant change in overall approach and delivery for Leisure, Delivery Model to bring a substantial improvement in the health and wellbeing Health and Wellbeing was the creation of The Wellbeing Service of those within the borough. The approach included a large which was launched in early 2014 and has continued to develop scale free leisure offer across the borough for anyone aged 16 and grow since that time. The design and implementation of Physical Activity and 10 -13 years and over who lived, worked, had a GP or was currently in the service came after a significant council wide engagement Health Improvement Delivery education within Blackburn with Darwen. This was a bold and and consultation process with the objective to drive service ground-breaking decision at the time. This was a population (RE:fresh) improvement and maximise positive health outcomes for local wide approach with the aim of improving health and physical Delivery Model people. activity levels which included increased capacity for community Performance Overview 2018/19 engagement and delivery teams to enable people to make The Wellbeing Service created a more effective pathway to positive changes. support people who live and work in the borough to make re:fresh volunteers 14-15 positive changes in their lives via a broad range of non-clinical, Following the success of this three year initiative and the proven community interventions; all sitting behind a single point of health outcomes it achieved re:fresh gained further funding access. and has since become an established part of Public Health universal Provision: 16 improvement initiatives and is embedded within the Health and leisure participation Achieving the fundamental goals of developing existing links, Wellbeing Strategy. creating new partnerships and establishing closer working relationships with Primary Care health professionals have been online engagement: 17 the key reasons for the success to date. Another crucial factor leisure, health and wellbeing of success has been developing a broad range of new working relationships across the third sector and wider partners. Looking Ahead: 18-19 2019/20

Case Studies AND FEEDBACK 20-23

2 3 FOREWORD

Dominic Harrison of investment across Pennine to develop innovatory approaches Councillor Damian Talbot received the support they needed to make positive changes in Director of Public Health to improving physical activity rates in our local population who Blackburn with Darwen Council’s their lives that improved their health and wellbeing. at Blackburn with Darwen Council currently are least active. Executive Member for Public Health and Wellbeing The re:fresh programme of heavily discounted leisure remains This innovation in strategy, delivery and research for public an integral part of our overall offer, reducing the price barrier to “The Leisure Health and Wellbeing team health improvement helps to reduce the risks for our citizens of “As the Executive Member for Public Health participation and ensuring that leisure plays a key role in reducing have continued to make an outstanding heart disease, respiratory disease and Type2 Diabetes and it and Wellbeing I’m proud to have been health inequalities. This report shows that re:fresh continues contribution to the quality of life of local helps to improve mental wellbeing. This improves the quality of involved with Leisure, Health and Wellbeing to demonstrate its strength and ability, through qualified, experienced staff and trained volunteers to engage with and residents in Blackburn with Darwen over life for our citizens and reduces the cost of physical inactivity on for a number of years and seen first-hand the our hard pressed health and social care system leaving those support local people to make healthier choices and improve their the past year-and their successes have now services more able to deal with health problems that are not impact of the work they do. own health and wellbeing.” made a major contribution to national UK preventable or avoidable. evidence and policy. Evidence demonstrates that our approach of balancing a We are now also working with the local health and care system successful universal offer and targeted approach ensures that re:fresh continues to achieve a range of Public Health objectives This year the National Institute of Health Research (NIHR) has to help them increase their investment into ‘social prescribing’ of for improving health and wellbeing and reducing inequalities published a landmark review of the evidence base for improving effective programmes to increase physical activity rates in the across the borough. rates of physical activity in the UK population. Academic general population. research on the effectiveness and efficiency in both improving The positive outcomes achieved by the Wellbeing Service as a physical activity rates in the general population and improving Most importantly this will seek to shift NHS investment away more effective way of engaging and enabling citizens to improve health inequalities by generating “significantly greater impacts from treating avoidable diseases with medication and invest their health continues to show that it was the right thing to do for more disadvantaged socioeconomic group” was central to in preventing diseases that require such medication in the first and continues to go from strength to strength. By simplifying the that guidance. Blackburn with Darwen’s re:fresh programme is place. process with a single point of access, one telephone number, one highlighted as a case study in this review. The challenge for all public services in the future will be to move website, one email and working hard with key partners, many more people contacted us to get help, advice and guidance and The NIHR Guidance says:“Being active matters because it is away from a service delivery model that ‘detects and manages’ an important way of staying healthy. We know that people can problems and to develop one which ‘predicts and prevents’ reduce their risk of many serious diseases by staying physically problems in the first place. This will reduce costs and improve active. Activity is also important for mental wellbeing and keeping social, economic and environmental outcomes of public sector socially connected. Finding enjoyable ways to be active can spend for residents. benefit people in so many ways. But it is often hard for people to start and keep the habit of regular activity. Around a quarter of If you want to know what this looks like in practice – then I invite people are inactive and less than two thirds meet recommended you to read the rest of this report.” activity levels. We need to know more about what works in getting people active and sustaining this, particularly for those who are least active now.”

We are therefore also delighted to have built on our Leisure Health and Wellbeing teams success with partners across a wider Pennine Lancashire footprint in our Sport England Together an Active Future programme which will bring in up to £10 million

4 5 delivery approach What we’re about and Why One You, Public Health England

One You is an adult focussed programme that provides individuals tools, support and encouragement to help improve people improve their health the right way. The overarching theme is that ‘you are not alone’ and One You can help you make small changes yourself, or with friends and family. Our approach is guided and influenced by a huge range of evidence and policy at both a national and local level. This section provides a brief overview of how One You focusses on a specific set of behaviours as part of the overall initiative and campaigns, tools and messages all revolve a specific group of national strategies and frameworks guide the fundamental around these key themes. approach of our teams and how services are delivered. These seven key behaviours from One You are incorporated directly into the promotion of the Wellbeing Service and all Towards an Active Nation, Sport England marketing materials. This provides clear, evidenced based behaviour change and health improvement messaging and This strategy was launched in May 2016 and remains a The graph below shows the value of getting people active and branding to both professionals and the public; articulating what significant influence on the approach in Blackburn with Darwen clearly illustrates the greatest health benefits are gained when the service is and how it can help. Co-branding with One You to increasing physical activity levels. Towards an Active Nation someone makes the change from being inactive to active. also allows us to amplify and maximise national campaigns and highlights that focusing on the inactive population is a key Further increasing activity levels still brings additional health messages locally. driver to increasing overall physical activity levels and that benefits, but not the same rate. The health benefits referred to the biggest area of health impact is achieved where people in this chart include reducing the risk of many chronic conditions make the change from being sedentary (doing nothing) to doing such as type 2 diabetes, coronary heart disease, some of the something. most common cancers and many mental health conditions.

Area of HIGHEST IMPACT

The Five Ways to Wellbeing, New Economics Foundation

Health Benefits Health (on behalf of the Mental Capital and Wellbeing Foresight Project)

Sedentary 100 200 300 400 500 600 This is a simple and fundamental underpinning of all work areas to ensure health and wellbeing is always viewed in its most holistic sense. Weekly physical activity (min) Towards an Active Nation – Sport England

Increasing Physical Activity Levels – key considerations for success:

— As well as targeting the inactive population, the strategy — Mass participation events have an important role to play also states that particular focus needs to be given to in attracting and engaging people to try new activities and underrepresented groups in order to change physical have fun. activity participation rates. These are defined as: — Taking an Asset Based Approach, building social Long Term Conditions connections and trying to create a social movement for Connect: Be Active: Take Notice: Keep Give: Older People health are themes to incorporate. with your family, go for a walk, have an interest Learning: do something Certain Ethnic Groups friends and garden, in the world try something for others — Harnessing the power of volunteers Disabled neighbours dance around you new Lower socio-economic groups — Any effective initiative, intervention or programme must be Women and girls founded upon using customer insights and applying behaviour change principles in order to be effective.

6 7 Blackburn with Darwen people local developing & sustainability building Communities, Wellbeing Service Enabling & Engaging Volunteers: re:fresh

Physical Activity and Health Improvement The service creates a simple, single entry point for public and professionals alike and allows service provision to embody a Darwen delivery teams sit behind Blackburn with universal philosophy, tailored with a personalised care approach Darwen’s nationally recognised and acclaimed to help improve the wellbeing, physical activity and quality of

Wellbeing Service; a single point of access life for local people.The simple visual on page 9 illustrates the Learning & Employment built on strong relationships with health operating model of the Wellbeing Service and where different components fit within that system. professionals and partners.

wellbeing Performance Overview 2018/19 West wellbeing service activity Targeted/Condition-Speci c Health Improvement Services Improvement Health Housing groups, oldergroups, people, & BME disabilities Achievements Measured & Followed Up Measured & Followed Achievements Ongoing Support Holistic AssessmentHolistic & Goal Setting Mental health & wellbeing impactsMental health & wellbeing measured throughout Of the 8920 contacts into the Wellbeing Service in 2018-19, 2050 Health Trainers: to Face Support Face Long Term Conditions, Weight Management, Weight Conditions, Long Term Subsidised & targeted delivery leisure provision (Universal Health & Wellbeing Programmes) Wellbeing & Health (Universal Community Physical Activity, Leisure & Sport were referrals with 56% coming from Primary Care Professionals. socio-economic lower & girls, women areas: Focus Falls Prevention, Ante/Post Natal, Cardio-Pulmonary Natal, Ante/Post Prevention, Falls East

GP/NHS Health Professional Help & Support for the wider determinants of health 798 1143 Wider Partners (e.g. Health and Social

(39%) (56%) Opportunities acrossSocialising & Volunteering neighbourhood all areas Care, 3rd Sector etc) BwDBC CommunityBwDBC Community Connectors: Linking to Groups, Local Support, Achieving Self North Goals Community Connections across Voluntary, Community & Faith Sector Organisations/Groups Sector Community Faith & Voluntary, Community across Connections

109 Wellbeing Service Single point of access of point Single Shared decision making interviewing, & motivational health coaching approach (Wellbeing Advisors Hub Triage) up Brief intervention & follow Blackburn with Darwen Blackburn (5%) & Debt Advice Bene ts, Welfare

Health Trainers: 121 Behaviour Change Outcomes fROM 1152 INDIVIDUALS

Wellbeing Service Delivery Model Delivery Wellbeing Service Achieving Goals Deprivation Ethnicity health mental & physical improving support: & interventions based community Non-clinical,

Clients from within Clients to achieve all 52% of clients who BME population top 20% most deprived goals within their access services were within represented 23% of wards within borough to wellbeing plan within 6 the top 20% of the most clients accessing the achieve goals within plan months = 84% deprived wards within Health Trainer service within 3 months = 78% Blackburn with Darwen East INT referrals West INT Long term changes North INT self-referral referrals & referrals Clients demonstrate Darwen INT signposting Key PartnerKey Care referrals Care Direct Primary Clients who achieve Clients who achieve Secondary Care

an improvement in their & Awareness, Marketing their goals to maintain their goals to maintain community engagement, behaviour after 6 months behaviour after 12 months mental Health & wellbeing =

(after sign off) = 80% = 84% Areas Neighbourhood Care Primary Darwen with Blackburn

70% four all across delivers and embedded Service Wellbeing BwD Blackburn with Darwen Blackburn

8 9 Physical Activity and RE:FRESH PHYSICAL ACTIVITY & HEALTH Health Improvement IMPROVEMENT DELIVERY MODEL: Delivery (RE:fresh) a lifecourse approach

Additional to the large scale, subsidised re:fresh provides a comprehensive physical activity offer across leisure offer, the focus of re:fresh delivery the community at all points of the life course with emphasis on ensuring targeted groups are catered for, including; older adults, Start Well Live Well Age Well teams is on proactive prevention rather ante/post-natal women, early years and women and girls. than reactive intervention, encouraging Sustainability is critical to the success of re:fresh; mainstream, ‘any movement counts’ and ‘moving more universal leisure provision, community links and partnerships at any intensity’. and a robust and successful volunteer model assist in creating a smooth transition from structured and supported physical activity Wellbeing Service into independent activity and self-management in the long term. Single point of access for referral, self-referral, information & signposting

Special Populations Targeted Provision Universal Provision Independent Exercise Referral Ante/Post Natal Health Walks Physical Weight Management Early Years Cycle Sessions/Bike Hire Activity Falls Prevention Learning Disabilities Community Exercise Classes - subsidised and Pulmonary Rehabilitation Older Adult Engagement Mass Participation Events Stroke Rehabilitation mainstream leisure Cardiac Rehabilitation

Structured Supported Sessions Activity Sessions Programme Aqua Natal Health Walks Balance & Strength Active Bumps Cycle Hire Aqua Stride Buggy Buddies Learn to Ride Supervised Gym Wheely Fit Pedal Around the Park Back Builders Mini Movers Community Pilates Functional Circuits Balanceability Healthy Eating Pilates Biker Tots Chair Based Exercise Weight Management Disability Swim Light Exercise Archery Multi Activity Gardening Functional Fitness MOT Fallstop Roadshows

Evaluation Evaluation Evaluation Review & Post Measures Attendance Data Participation Data at 3, 6 & 12 Months Routine Evaluation Routine Evaluation Case Studies Case Studies Email Surveys Satisfaction Questionnaires Case Studies

10 11 Physical Activity and Health Improvement Performance Overview 2018/19

Of the 1543 referrals into the Wellbeing Service for exercise referral, weight management or falls prevention 776 went on to a telephone assessment for a structured programme of support. 516 Targeted Provision Summary Community Physical Activity Exercise Referral 516 — Over 10,000 attendances by almost 400 individual — Weekly average of 14 light exercise classes Weight Management 123 adults with a variety of disabilities at 15 activity delivered across the borough including Pilates, Falls Prevention 137 sessions each week – daytime and evenings, plus Ladies Only sessions, Balance and Strength for the additional one off events and special activities. over 50s and Chair Based Exercise. An excellent next 137 123 step for people completing 12 or 16-week referral — 110 older adults have completed a Functional schemes to ensure they continue with their positive Fitness MOT at community engagement events Special Populations changes and form enjoyable, lifelong habits. with signposting to services appropriate to their Exercise Referral & Weight Management – individual need. — The Health Walks programme complements the referral programmes perfectly and are ideal for people 12-week referral programme — Delivery of weekly activity and healthy eating sessions new to physical activity. All walks are graded from within Blackburn Birth Centre and attendance at the easy paced 30 minutes, walking workouts which Bumps, Birth and Beyond sessions delivered by include some low impact exercises along the way, midwives at Burnley General Hospital. 95% reported an 96% accessing a to more strenuous progression walks led by volunteers demonstrated increase in their 86% — Eight Balanceability courses delivered with 33 children for those ready to advance to the next step. weight Management aged 2 – learning how to ride a balance bike. activity level an improvement in their — Developments at Witton Park Cycle Centre continue, intervention lost betweeN New Biker Tots free play sessions added so children by an average of mental wellbeing welcoming anyone new to cycling with Learn to 2-10% of their body weight can continue to practice the skills they have learnt. 300 minutes per week Ride courses for adults and children, weekly — The WRENS (older ladies volunteer group) Pedal Around the Park led rides for adults to practice created and started delivering an informative their cycling skills and increase their confidence as well and fun falls prevention sketch performance; as conventional bike hire. Falls Prevention – 16-week referral programme in a range of community venues to raise — A number of inclusive sessions have taken place awareness and post people into services for support throughout the year on the running track using a and advice.. variety of adapted bikes which can be used by adults 73% reported an with a range of disabilities, allowing users to feel the 79% demonstrated improvement in their 84% reported a benefits of riding a bike in a safe place away from the busy paths of the park. an improvement in their ability to carry out DECREASE IN THEIR mental wellbeing independent FEAR OF FALLING activities

Active Living: Improved CARDIO-PULMONARY clinical outcomes REHAbilitation such as systolic blood pressure and recovery heart rate

reduction in ANXIETY Improvements 271 referrals in physical with 11,433 functional capacity attendances across Improved across a wide range of mental health and all sessions measures wellbeing

12 13 re:fresh Volunteers re:fresh Volunteer Performance Summary in numbers

SUPPORTING AND DEVELOPING Total number of registered volunteers: 9 3 Active volunteers in 2018-19: 83 PHYSICAL ACTIVITY AND HEALTH New volunteers recruited in 2018-19: 29 Volunteers to complete Level 1 or 2 qualification: 22 IMPROVEMENT Volunteers to attend other qualification: 80 Volunteer hours delivered: 4,800

The re:fresh volunteer delivery model below identifies a broad communities while at the same time supporting overall service BUDDYING workplace champions range of roles to allow people to gravitate to what appeals to delivery objectives of getting more people, more active, more them, based on their interests and ambitions. Each role has often. — Number of clients being supported on a regular basis: 12 There are now 36 workplace health and wellbeing champions a distinct remit and function which helps to build assets in our within Blackburn with Darwen. They have promoted a number — Total number of clients who have been paired with a buddy of different health campaigns throughout the year and helped to this year: 16 organise the week of activities throughout Health & Wellbeing — Activities include: badminton, walking, gym, swimming week.

RE:FRESH VOLUNTEERS IMPact assessment ENGAGING ENABLING

physical economic personal social cultural

Health Promtion Health Improvemnt Goods & services received Benefits & costs with a Knowledge, skills & health Building relationships Understanding of own & financial value benefits to the individual between people others identity

Training courses Out of pocket expenses Develop personal skills & Brings people together from Adopt a greater understand- knowledge all walks of life ing of different cultures Support and mentoring Employment prospects Workplace Gardens & sessions linked to training & Develop employability skills Increase social networks Involvement re:fresh Campaigns Focus activity Session Session Health allotment experience of volunteering in local community activities Volunteer social events Increase confidence & self Celebration evenings &

Rep & Events Groups Buddy Support Leader lunteers Champions worker esteem social meetings through Vo Certificates & awards of volunteering recognition Improved health & wellbeing

Admin Role Toddler Trails Workplace Groups Assist Group Support for Support a Lead a group Health focusing on Sessions individuals to member of session with Engage people who are 462 sessions led by Greater workforce means Develop a good connection Reduce barriers E.g. Preparing Mass Champions engaging with: access staff to deliver no staff hard to reach volunteers. greater outputs between the organisation & info packs to Participation Lead Growing sessions e.g. a session e.g. support e.g. Estimated cost £10,000 the community Brings communities together be sent to Events Internal People with Workshops Improves the outputs & Personal development of workplace BwDBC Staff Disabilities Walking Activities for Walk Leader quality of services staff May attract more staff & Developing services & health Fitness Testing & Plot people with volunteers schemes linked to local Ability to offer a variety of needs champions/ Events External Women & Girls Maintenance Cycling learning Swim/Gym/

Organisation activities sending out Businesses disabilities ETM volunteer Falls Older People Fitness Instructors newsletter Prevention Classes Walking & Roadshows BME Cycling Sports One to one support to Reduced rate physical Improve physical & mental Greater involvement in local Sense of belonging to a Population Gym enable people to attend activity sessions under health activities group Gym/Fitness sessions re:fresh Swimming Classes Feel part of society Reduce social isolation Access to services they Clients Swimming would alternatively have to Builds trust pay for

Community members take Enhanced value for money Better health & wellbeing & Partnership working Community cohesion pride in the physical area in public services self-care through social networks & they live in communities coming Reduced anti-social A more employable together behaviour community as a whole COMMUNITY

14 15 UNIVERSAL PROVISION: ONLINE ENGAGEMENT: Leisure Participation LEISURE, HEALTH AND WELLBEING

As well as mainstream leisure provision across a range of facilities, BwD Leisure continues to www.refreshbwd.com is Blackburn with It’s the place to find out about a wealth of local leisure activities, community events, health and wellbeing services and offer a wide ranging programme of significantly discounted leisure as a fundamental element Darwen’s online resource for all leisure, health information, plus additional links to a range of other services, of re:fresh which underpins the team delivery previously described, improving access and and wellbeing information and services. clubs and organisations within the borough. reducing barriers to participation for all. As part of a balanced range of leisure opportunities, the BwD Leisure programme includes sessions targeted at parents with young children, ladies only, disabled adults and children and the over 50s. The graph below shows the number of users of the site and how many pages they have viewed between April 2018 and March 2019.

Subsidised leisure activities across multiple leisure facilities is reporting of activities across the borough. A re:fresh membership available to anyone aged 16 years or older who lives, works, has is then allocated to any adult who qualifies for our programme of 60,000 a registered GP or is in education within the borough for just £1 subsidised leisure to access the reduced rates. The table below per session. shows the total number of members registered in Blackburn with 50,000 Darwen and how many of them have used their card for some A leisure card is required to attend sessions at leisure facilities form of physical activity between April 2018 and March 2019 and community sessions which allows effective monitoring and 40,000 and also defines how many have been allocated the re:fresh membership and their participation rates. 30,000

20,000

Leisure Participation 10,000 Summary 2018-19 0 r y t v r c g p b n Total Leisure Card holders 72,550 Leisure Card holders with a 33,681 (46%) n

re:fresh membership Ap Ma Ju Ju l Au Se Oc No De Ja Fe Ma

Total Active Leisure Card Holders 24,119 Total Active re:fresh Members 8,481 Page Views Users New Leisure Card Holders 11,999 New re:fresh Members 4,397

Total Leisure Attendances 381,515 Total re:fresh Attendances 79,749 TOP 10 VISITED PAGES Social Media

Social Media remains an important means for the Leisure, Target Groups Participation page Visits Health and Wellbeing team to engage and communicate with re:fresh has physical activity participation — Female participation Blackburn Sports and Leisure Centre 131,233 the residents of Blackburn with Darwen about a wide range of issues, events and activities. Facebook and Twitter continue to — Most Deprived (health inequalities) related objectives specifically targeted at hard Darwen Leisure Centre 95,847 be the two main channels for engagement, highlighted in the to reach groups which are defined as: — Black and Minority Ethnic (BME) participation summary data below. Activities Search 30,533 — Older Adults (55+) BwD Leisure Membership Options 23,599 Facebook likes: My Health and Wellbeing 22,403 The following figures show the total number of active members in the specified categories taking part in both main stream leisure and @blackburnsportsandleisurecentre 11,582 subsidised physical activity opportunities: Witton Park Arena 19,187 @darwenleisure 6,445 Total Members Active Members % Active Members re:fresh Homepage 19,135 @wittonparkarenabwd 4,926 Activities 7,009 @refreshblackburnwithdarwen 4,105 Female 35,838 12,234 34% Shadsworth Leisure Centre 4,635 Most deprived 10% 17,363 5,103 29% Twitter followers: Frequently Asked Questions 4,162 BME 17,955 5,445 30% @BwD_Leisure 529 Older Adults (55+) 10,800 4,232 39% @refreshbwd 2,765

16 17 Looking Ahead 2019/20

NHS Long Term Plan Increased focus on prevention, personalised care and social prescribing

The NHS Long Term Plan has a clear, increased focus on prevention and an ambition for personalised care to become business as usual across the health and care system. The increased focus on prevention is already influencing local discussions and shaping potential future developments with Leisure, Health and Wellbeing services proactively involved in evolving dialogue. The relevance for Leisure, Health and Wellbeing can be seen within the summary of the NHS Comprehensive Model for Personalised Care below, which states: whole-population approaches to supporting people of all Sport England Local scalable, sustainable, whole system change that increases level ages and their carers to manage their physical and mental of physical activity amongst those for whom activity is currently health and wellbeing, build community resilience, and make DeliverY Pilot not on their radar. The Pennine Lancashire Accountable Care informed decisions and choices when their health changes Towards an active future Partnership will provide the strategic governance and leadership for the Local Delivery Pilot with Blackburn with Darwen Council a proactive and universal offer of support to people with Sport England has chosen Pennine Lancashire as 1 of 12 as the accountable body. long-term physical and mental health conditions to build grassroots projects to work with on bold new approaches to knowledge, skills and confidence and to live well with their Sport England has worked closely with all the 12 pilots during build healthier, more active communities across England. health condition 2018/19 to better understand what areas need, starting vital Around £100 million of National Lottery funding will be invested insight and local engagement, establishing a clear evaluation The Model has six, evidence-based components or through these pilot areas to create innovative solutions that framework to demonstrate impact and then issued their programmes, each of which is defined by a standard set of make it easier for people in these communities to be more investment guidance in January 2019 to inform local planning. practices: physically active. Sport England’s aim is to make positive From 2019/20 Blackburn with Darwen’s delivery plan will be changes locally and to help break down the barriers that stop 1. Shared decision making implemented to ‘test’ new ways of doing things and learning people getting active. Across the nation this model will see local what works to benefit local people, to increase activity and 2. Personalised care and support planning partners develop evidence based delivery plans, co-designed improve mental wellbeing and health. with communities and individuals themselves. They will test 3. Enabling choice, including legal rights to choice and embed innovative ways of working which demonstrate 4. Social prescribing and community-based support 5. Supported self-management 6. Personal health budgets and integrated personal budgets. The statements and details above are likely to influence service delivery and developments over the upcoming financial years as prevention and health care continues to evolve.

18 19 Case Studies and Feedback

CLIENT’S story MRS B’s story from her (a very inquisitive lady asking numerous questions JOANNES’s story about the stroke scheme and sounding keen but needing (re:fresh on referral): (Active Living – STROKE Rehab): encouragement to attend our sessions). When we arranged (re:fresh VOLUNTEER): an assessment date, I met her at the taxi and supported her I joined the re:fresh referral service in 2018. I had become Mrs B is 76 years old and was referred in June 2018. Mrs After taking part in the re:fresh on Referral 12-week exercise for the 50 metres from the taxi to the venue. a very anxious person, the thought of having to interact with B who has type 2 diabetes had a stroke in August 2017. programme I feel I have a new lease of life and I am proud other people worried me a lot. She was discharged from hospital eight weeks later. Her After three sessions attending the circuit class once per week, to say I am now a Volunteer with BwD re:fresh, aiming to communication skills were maintained, but the stroke affected Mrs B became much more confident, to the point where help others in these classes. I will help to take them forward I was booked in for an induction session, the refresh activator peripheral vision in the right eye and her gait. She has a drop she would mention that she had practiced replicating sit after their twelve weeks, to a class I now take to keep these made me feel very comfortable; he completed all of the right foot. to stands, stepping, and upper arm mobility at home on people happy and active. I have always enjoyed helping paperwork, showed me around and set me a gym programme numerous occasions throughout the week. people and this is what I was used to doing in my career. to follow, taking into account my bad knee and back. When Mrs B has lived alone in the same first floor flat for the last 30 I’m nervous I don’t always ‘take in’ what someone says but years. It has 13 steep steps leading up to it. Mrs B is head Mrs B is a role model for the stroke class as she practices Being given this opportunity has been amazing, I love it, but the way he explained everything really put me at ease and his strong and would not accept external help. Initially she found the movements most days at home and has shown great what makes it all the more satisfying is not only knowing how friendly approach gave me the courage to ask questions. it very difficult to manoeuvre with the aid of a walking aid. This improvement over the course of her attendances. far I have come personally, but knowing I can help others caused her to feel anxious and she seldom left her home. because of my own experiences. I can engage with people My confidence and self-esteem have definitely improved • Sit to stand improved by 143% and was her greatest Unable to drive, she relies on family members for transport. honestly by saying I was in their position and show them what over the 12-week course. When I wake up on a gym day improvement over the first three months. they can achieve. I want to give them confidence and hope I now have something positive to focus on and I actually Mrs B was seen by the community stroke team for sessions • Timed up and go time improved by 29% and encourage them to join these schemes and for me to be look forward to going to the gym. On days when I have still to improve her confidence accessing the kitchen and visiting an ambassador to help people get some of their lives back managed to go the gym despite not feeling 100% I have felt the local supermarket via taxi with a stroke therapist. Upon • 6-minute walk time improved by 61% and remain as active and healthy as they can be, whatever a huge sense of achievement, which feels good. I like the referral, Mrs B was reluctant to attend the exercise sessions • Mrs B can now walk up her 13 steps to her flat with ease their conditions are. Exercise I feel needs to be fun, never a familiarity of routines and despite being very anxious about via taxi as she was anxious about the transition from the taxi and her right arm and leg have improved to the point where chore, encouraging and motivating for people and I certainly starting something new, I found that coming to the gym made to the centre and feeling unstable. I received a phone call she is more independent around the house. Mrs B is also found these classes to be just that, thanks to the fantastic staff me feel more positive about myself. It soon became a very contemplating accessing an additional session each week. and how the classes are set out and run. comfortable new routine for me and I am even thinking of joining the gym on a more permanent basis. I feel so lucky thanks to the re:fresh Team, I feel useful again with a purpose and at the same time keeping myself as active Although the gym is very well equipped, in my opinion it is as I can be, but even more so... I’m enjoying myself. Thank the refresh staff who are responsible for ensuring that my you to you all for helping me achieve and for this fabulous experience has been very positive and successful. worthy opportunity being a Volunteer, I’m so grateful.” All of the staff that I have met at Blackburn Sports and Leisure Centre are friendly, helpful and approachable. It’s lovely to be met with a cheerful smile on arrival and I feel very comfortable talking to any of the staff about gym related things or even a little chat. I am very sensitive to atmospheres and I worried that being in a gym it would be full of tension, very intimidating and uncomfortable. However, due to the personalities of the staff I have always felt safe, comfortable and supported in the gym which is why I have continued to attend regularly.”

20 21 Case Studies and Feedback CONTINUED

The Wrens JP’S STORY PARTNER FEEDBACK – Developing Peer Champions (MOTIVATE): (HEATLH TRAINERS): Older people who have experienced the benefits of our strength and balance programme first JP is a 58-year-old man living in Blackburn who has been I just wanted to let you know how valuable the service of all hand, and believe in the difference regular attendance can make to their quality of life, are the attending Motivate sessions since 2013. He initially attended the Health Trainers is to our participants at Bootstrap. the Motivate evening swim at Darwen Leisure Centre after In particular, Damien has worked with a number of our most valuable of messengers. someone at a hydrotherapy session he attended recommend participants, many of whom have complex needs as well as it. This was a new challenge for JP as he hadn’t swam low motivation to improve their health and wellbeing. Damian Training a group of peer volunteers to deliver talks, Wrens, to develop a sketch show explaining how falls can be since being diagnosed with multiple sclerosis in his 20’s, a has achieved some really good results with these people. presentations and roadshows at local community and prevented. This includes demonstrating how to get up from the condition that now means JP is a full time wheelchair user. neighbourhood groups and events, in residential and care floor after falling, giving out copies of ‘Get up and Go: A guide to JP has found the swimming session a good way to ease I saw one recently referred participant yesterday, who I gather home settings and in hospitals, has been of mutual benefit for staying steady’ as well recruiting people onto our programme. back into swimming and now swims four times a week, Damien has seen once or twice where they have discussed all involved, the volunteers, and their audiences. As part of the The Wrens were chosen as a case study in a research piece by the advice and instruction provided by Motivate staff at the diet and nutrition. He stated that the change in his diet has re:fresh Balance and Strength and Volunteer programme, we the Centre for Ageing Better titled ‘Raising the bar on strength time allowed JP to improve his stroke and breathing and he had a huge impact on the rest of his health…mental have worked with a group of active champions, known as The and balance: The importance of community-based provision’. appreciates the benefits of the exercise. Swimming has helped health, sleep pattern, motivation etc. We were even him with his exercise stretches (which he does at home with discussing ‘work plans’ yesterday!! He really was a completely his resistance bands, as well using his exercise bike) and his different young man…much more positive and making plans stamina has increased, he can now swim well over a mile. for his future.

After gaining confidence at the Motivate swim he learned that I appreciate he has a way to go, but to see the change in him Carly’s Story Motivate run an integrated archery session at Witton Park so quickly was really amazing and it seems that Damien has (re:fresh Volunteer): Arena on a Thursday morning. JP welcomed the opportunity a way of motivating and getting these participants to engage. to learn a new skill and meet new people. The social aspect He sends me regular updates which is really helpful and which I originally started volunteering back in April 2018 after being a If you yourself are thinking of starting a career in the health is one of the main reasons JP likes to attend these sessions, I forward to the relevant Key Worker.” member of the Blackburn with Darwen Regency gyms. Initially and wellbeing industry, or even if you are just passionate saying that “before I started to attend I’d had no real I was interested in getting involved with re:fresh because I about fitness and helping other people, joining re:fresh as a experience of people with a learning disability and the whole wanted to share my new found passion for fitness with other volunteer is a great opportunity. Being part of re:fresh is like experience has been quite a learning curve for me.” Today people. I got in contact with the volunteers co-ordinator Helen being part of one big family, everybody is so welcoming and JP welcomes the idea of integration and cannot praise the and she was so friendly and helpful. We met up for an informal enthusiastic. On going support and training is always provided Motivate sessions enough.” chat about the different volunteer roles that are available at and there are lots of activities and events to get involved re:fresh and she made me feel at complete ease when I was with.” deciding what I wanted to get involved with.

Throughout my time with re:fresh, I have had the opportunity of being a gym buddy with three visually impaired clients, helped out with local fitness based events (80s themed dance night) and most recently have been able to complete my level 2 exercise to music qualification.

Since qualifying in March 2019 I have gone on to become a volunteers leader. I now regularly instruct a weekly over 50s dance/aerobics class of which is well attended. Being a re:fresh volunteer is very rewarding. Since being involved with the organisation I have gained experience, a qualification, met people from all walks of life who I now consider friends but most of all it has done wonders for my self esteem.

Having been a stay at home parent for the last 4 years getting back into the world of employment can be a very daunting experience. I have found that by volunteering I have been able to learn new skills, reignite my passion for dance and be able to gain the confidence to move back into paid work.

22 23 CONTACT US

CALL 01254 682 037 VISIT www.refreshbwd.com EMAIL [email protected]