NHS Coventry and Rugby CCG and NHS Warwickshire North CCG Governing Body Meetings in Common to be held in Public on Wednesday, 17th July 2019, 2:45pm to 4:00pm in Endeavour Meeting Room, Heron House, Nuneaton A G E N D A

No Time Item Presenter Enclosure 1. Standing Items 1.1. 2.45 Welcome and Apologies Received Chair Verbal

1.2. Declarations of Interest: Where possible, any conflict Chair Enclosure A of interest should be declared to the Chair of the meeting in advance of the meeting. See guide below. 1.3. Minutes of the last Meeting held in common on 22nd Chair Enclosure B May 2019 1.4. Matters Arising/Action Schedule Chair Enclosure C 1.5. 2.50 Chair’s Report a) Coventry and Rugby CCG Sarah Raistrick Enclosure D b) Warwickshire North CCG David Allcock Enclosure E 1.6. Chief Officer’s Report Andrea Green Enclosure F 2. Strategy and Planning 2.1 2.55 Update on the future of healthcare commissioning Chairs Enclosure G 2.2 3.00 Coventry, Rugby and Warwickshire Public Health Liz Gaulton Enclosure H Report Helen King 2.3 3.05 Pre Consultation Business Case - Improving Stroke Andrea Green Enclosure I Outcomes 3. Quality, Safety and Performance 3.1 3.15 Integrated Safety, Quality and Performance: Jo Galloway • Safety and Quality Report Steve Jarman- Enclosure J • Performance Report Davies 3.2 3.25 Looked After Children Annual Report for Coventry Jo Galloway Enclosure K 4. Assurance and Governance 4.1 3.30 Annual Audit Letters: a) Coventry and Rugby CCG Clare Hollingworth Enclosure L b) Warwickshire North CCG 4.2 3.35 Future arrangements for Coventry Safeguarding Children Partnership; Warwickshire Safeguarding Jo Galloway Enclosure M Children Partnership; and Child Death Review 5. Financial Performance 5.1 3.40 2019/20 Financial Plan - Update Clare Hollingworth Enclosure N 5.2 3.45 Finance and Contract Report: Month 2 Clare Hollingworth a) Coventry and Rugby CCG Enclosure O No Time Item Presenter Enclosure b) Warwickshire North CCG Enclosure P 6. 3.50 Policies for Decision 6.1 Complaints Policy Anita Wilson Enclosure Q 6.2 Secondment Policy Anita Wilson Enclosure R 7. Committees in Common Reports Committee Chairs Enclosure S a) Clinical Quality and Governance Committees in th Common: 25 April 2019 b) Finance and Performance Committees in Common: 2nd May and 6th June 2019 8. For Information 8.1 3.55 Communications and Engagement Report Jenni Northcote Enclosure T 9. Questions from Visitors Chair Verbal 10. 4.00 Any Other Business Chair Verbal

Future Governing Body Meetings in Common held in Public: Date Time Venue 26th September 2019 2:45pm to 4:00pm Parkside House, Coventry

20th November 2019 2:45pm to 4:00pm Heron House, Nuneaton

22nd January 2020 2:45pm to 4:00pm Venue TBC, Coventry

18th March 2020 2:45pm to 4:00pm Heron House, Nuneaton

o

Declarations of Interest

Under the Health and Social Care Act 2012, there is a legal obligation to manage conflicts of interest appropriately. Where possible, any conflict of interest should be declared to the Chair of the meeting as soon as it is identified in advance of the meeting. Where this is not possible, it is essential that at the beginning of the meeting a declaration is made if anyone has any conflict of interest to declare in relation to the business to be transacted at the meeting. An interest relevant to the business of the meeting should be declared whether or not the interest has previously been declared.

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 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 (of more than 5% of the issued shares), partner or owner of a private or not for profit company, business or consultancy which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations. • A consultant for a provider; • In secondary employment; • In receipt of a grant 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-Financial This is where an individual may obtain a non-financial professional benefit from the Professional consequences of a commissioning decision, such as increasing their professional reputation or Interests status or promoting their professional career. This may include 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 CQC or NICE; • A medical researcher. Non-Financial This is where an individual may benefit personally in ways which are not directly linked to their Personal professional career and do not give rise to a direct financial benefit. This could include, for Interests example, where the individual is:

• 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; • A member of a political party; • Suffering from a particular condition requiring individually funded treatment; • A financial advisor. 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). This should include: • Spouse / partner; • Close relative e.g., parent, [grandparent], child, [grandchild] or sibling; • Close friend; • Business partner.

Blank Page NHS WARWICKSHIRE NORTH CCG AND COVENTRY AND RUGBY CCG - Register of Interests for Governing Bodies in Common Meeting

Current position (s) held- i.e. Governing Declared Interest- (Name of the organisation and Title First Name Surname Type of Interest Date of Interest Body, Member practice, Employee or other nature of business)

Declared To Indirect Interests Professional Professional Non-Financial Non-Financial Non-Financial Personal Interests Personal Financial Interests

Lay Member for Audit and Governance Nil Mr David Allcock (previously Lay Member for Public and Patient Engagement)

Clinical Director, Coventry and Rugby CCG 1. Senior Partner, Walsgrave Health Centre, Dr Steven Allen  Apr-15 Current Governing Body Coventry

Clinical Director, Coventry and Rugby CCG Dr Steven Allen 2. Practice is member of GP Alliance  Nov-16 Current Governing Body

1. Director Align Performance Ltd. 100% Mrs Sharon Beamish Lay Member for Patient and Public Involvement  Apr-12 Current shareholder.

Mrs Sharon Beamish Lay Member for Patient and Public Involvement 2. Daughter is a Matron at UHCW  Apr-19 Current

 Dr Alistair Bryce Godiva Clinical Lead GP Partner at Woodend Surgery 2009 Current

Lay Member Public and Patient Engagment, Mrs Claire Forkes Nil Coventry and Rugby CCG Governing Body

Chief Nursing Officer, Coventry and Rugby Ms Jo Galloway Nil CCG and Warwickshire North CCG

Director of Public Health Coventry and Ms Liz Gaulton Coventry and Rugby Governing Body Member Nil (Co-opted participant, non-voting)

Ms Andrea Green Chief Officer Honary Member of the Faculty of Public Health  Jun-18 Current

Mr Andrew Harkness Chief Transformation Officer 1. Member of the Faculty of Public Health  2011 Current

Mr Andrew Harkness Chief Transformation Officer 2. Member of the UK Public Health Register  2014 Current

3. Spouse is Managing Director of East Mr Andrew Harkness Chief Transformation Officer  2017 Current Staffordshire CCG NHS WARWICKSHIRE NORTH CCG AND COVENTRY AND RUGBY CCG - Register of Interests for Governing Bodies in Common Meeting

Current position (s) held- i.e. Governing Declared Interest- (Name of the organisation and Title First Name Surname Type of Interest Date of Interest Body, Member practice, Employee or other nature of business)

Chief Finance Officer, Coventry and Rugby Mrs Clare Hollingworth Nil CCG and Warwickshire North CCG  GP at Camphill GP-Led Health currently operated Dr Godwin Igodo Clinical Lead Oct-10 Current by Malling Health/IMH Group

Director of Acute Contracting and Mr Steve Jarman-Davies Nil Performance. IFR Panel Member.

Lay Member, Coventry and Rugby CCG 1. Senior Manager, South Central Ambulance Mr Ludlow Johnson  Sep-09 to date Governing Body Service

Lay Member, Coventry and Rugby CCG Mr Ludlow Johnson 2. Specialist Advisor, Care Quality Commission  Apr-14 to date Governing Body

Lay Member, Coventry and Rugby CCG Mr Ludlow Johnson 3. Magistrate  Sep-08 to date Governing Body

Secondary Care Consultant, Coventry and 5. Local Negotiating Committee Member, Dr Prashant Kakodkar  Dec-16 to date Rugby CCG Governing Body Northampton General Hospital

Secondary Care Consultant, Coventry and 8. Clinical Director of Anaesthetics, Critical Care Dr Prashant Kakodkar  Jan-19 to date Rugby CCG Governing Body and Theatres, Northampton General Hospital

Secondary Care Consultant, Coventry and 9. Regional QI Lead (Leicester, Kettering and Dr Prashant Kakodkar  Apr-18 to date Rugby CCG Governing Body Northampton)

Secondary Care Consultant, Coventry and 1. Consultant Anaesthetist, Northampton General Dr Prashant Kakodkar  Oct-02 to date Rugby CCG Governing Body Hospital

Secondary Care Consultant, Coventry and 2. Consultant Anaesthetist, Three Shire Hospital, Dr Prashant Kakodkar  Dec-02 to date Rugby CCG Governing Body Northampton

Secondary Care Consultant, Coventry and Dr Prashant Kakodkar 3. Special Advisor, Care Quality Commission  Sep-16 to date Rugby CCG Governing Body

Secondary Care Consultant, Coventry and Dr Prashant Kakodkar 4. Examiner, The Royal College of Anaesthetists  Oct-11 to date Rugby CCG Governing Body

Secondary Care Consultant, Coventry and Dr Prashant Kakodkar 6. Member Q - Network, Health Foundation  Nov-17 to date Rugby CCG Governing Body

Secondary Care Consultant, Coventry and 7. A&I Reference Panel NICE - This involves Dr Prashant Kakodkar  Jun-18 to date Rugby CCG Governing Body commenting on draft guidance NHS WARWICKSHIRE NORTH CCG AND COVENTRY AND RUGBY CCG - Register of Interests for Governing Bodies in Common Meeting

Current position (s) held- i.e. Governing Declared Interest- (Name of the organisation and Title First Name Surname Type of Interest Date of Interest Body, Member practice, Employee or other nature of business)

2. GP Partner at Station Street Surgery   Dr Arshad Khan Clinical Lead 2011 Current

3. GP Partner at Torcross Medical Centre, Coventry   Dr Arshad Khan Clinical Lead 2011 Current

1. GP Locum at Khan Medical Practices Ltd   Dr Arshad Khan Clinical Lead 2011 Current

Interim Director Public Health, Warwickshire 1. Non Executive Director, Coventry, Solihull and Ms Helen King  2016 2020 County Council Warwickshire County Sports Partnership

Interim Director Public Health, Warwickshire 2. Non Executive Director of United Kingdom Public Ms Helen King  2017 2020 County Council Health Register  Dr Mark Lawton Inspire Clinical Lead 1. Partner in Kenyon Medical Centres 1991 Current

 Dr Mark Lawton Inspire Clinical Lead 2. Shareholder Contego Solutions Ltd 2017 Current

3. Wife is a CQC inspector for  Dr Mark Lawton Inspire Clinical Lead mental health services in the 2016 Current midlands

Ms Jenni Northcote Chief Strategy and Primary Care Officer Nil

1. 50% Shareholder of Graham Nuttall Associates  14/09/2015 Mr Graham Nuttall Lay Member for Primary Care Ltd (former interest - to be removed in August 2019) Feb-19

2. Trustee and Board Member at Bulkington Village 14/09/2015 Mr Graham Nuttall Lay Member for Primary Care Centre Current 

Chair, Coventry and Rugby CCG Governing Dr Sarah Raistrick 1. GP Partner Willenhall Primary Care Centre 1  Jul-15 Current Body

Chair, Coventry and Rugby CCG Governing Dr Sarah Raistrick 2. Practice is a member of the GP Alliance  Current Body

Chair, Coventry and Rugby CCG Governing 3. Husband is a leader (I am a member) of a church Dr Sarah Raistrick  Current Body in Coventry supporting Hope Coventry initiatives.

Chair, Coventry and Rugby CCG Governing Dr Sarah Raistrick 4. Practice is a member of Sowe Valley Cluster  Current Body NHS WARWICKSHIRE NORTH CCG AND COVENTRY AND RUGBY CCG - Register of Interests for Governing Bodies in Common Meeting

Current position (s) held- i.e. Governing Declared Interest- (Name of the organisation and Title First Name Surname Type of Interest Date of Interest Body, Member practice, Employee or other nature of business)

Chair, Coventry and Rugby CCG Governing 5. Former employer and mentor (2010-14) is bidding Dr Sarah Raistrick  Jul-15 Current Body for a contract with CCG – Online consultations.

Chair, Coventry and Rugby CCG Governing 6. Met once with Rugby interest group for coffee to Dr Sarah Raistrick  Current Body discuss NHS in Rugby.

Chair, Coventry and Rugby CCG Governing Dr Sarah Raistrick 7. Non-voting Member of Coventry GP Board  Jan-19 Current Body

Lay Member Audit and Governance, Coventry Mr Chris Stainforth Nil and Rugby CCG Governing Body

Dr Imogen Staveley Clinical Lead 1. Salaried GP at Bedworth Medical Centre  04/09/2017 Current

Dr Imogen Staveley Clinical Lead 2. CEO PregnaPouch (Pregnancy related app)  Current October 2015

Consultant at Northampton General Dr Jonathan Timperley Secondary Care Doctor  Hospital

Practice Nurse at Bulkington Surgery  Mrs Sue Turner Practice Network Lead Jul-05 Current

Mother works part time at Bedworth Health Centre Associate Director of Governance and Mrs Anita Wilson and is employed via NHSP as Band 7 ED Nurse at  Jul-18 Current Corporate Affairs GEH

Clinical Lead, Rugby Locality, Coventry and Dr Deepika Yadav 1. Salaried GP, Forrest Medical Centre  Dec-14 Current Rugby CCG, Pathology Services Lead

Clinical Lead, Rugby Locality, Coventry and Dr Deepika Yadav 2. Husband is GP, Locum  Apr-14 Current Rugby CCG, Pathology Services Lead

Clinical Lead, Rugby Locality, Coventry and 3. NHSE Medical Advisor for Workforce Dr Deepika Yadav  Mar-18 Current Rugby CCG, Pathology Services Lead Development

Clinical Lead, Rugby Locality, Coventry and Dr Deepika Yadav 4. Member of Coventry LMC  Apr-17 Current Rugby CCG, Pathology Services Lead

Clinical Lead, Rugby Locality, Coventry and 5. Resident in local area with children who go to Dr Deepika Yadav  Mar-04 Current Rugby CCG, Pathology Services Lead school locally

Clinical Lead, Rugby Locality, Coventry and 6. Director Futuraesthetics Ltd, providing aesthetic Dr Deepika Yadav  Jul-19 Current Rugby CCG, Pathology Services Lead treatments

Unconfirmed Minutes of the Governing Body Meetings in Common Held in Public on Wednesday, 22nd May 2019 at 2.45pm

Venue: Dame Ellen Terry Suite, Coventry City Council, Coventry

Present: Dr Sarah Raistrick Chair – CRCCG Mr David Allcock Chair – WNCCG Ms Andrea Green Chief Officer Mrs Clare Hollingworth Chief Finance Officer Ms Sue Turner Practice Network Lead: North Warwickshire - WNCCG Dr Steve Allen Clinical Director Dr Prashant Kokodkar Secondary Care Specialist Consultant - CRCCG Ms Jo Galloway Chief Nurse Dr Jonathan Timperley Secondary Care Doctor – WNCCG Mr Chris Stainforth Lay Member – Audit and Governance - CRCCG/WNCCG Dr Arshad Khan Clinical Lead – WNCCG Dr Godwin Igodo Clinical Lead – WNCCG Mr Ludlow Johnson Lay Member for Patient and Public Involvement and Equality - CRCCG Dr Deepika Yadav Rugby Locality Lead – CRCCG Ms Liz Gaulton Director of Public Health, Coventry City Council Ms Sharon Beamish Lay Member – Patient and Public Involvement - WNCCG

Apologies: Mr Graham Nuttall Lay Member - Primary Care – WNCCG Ms Claire Forkes Lay Member – Patient and Public Involvement - CRCCG Dr Helen King Director of Public Health, Warwickshire County Council

In Attendance: Mr Andrew Harkness Chief Transformation Officer Mrs Anita Wilson Associate Director of Governance and Corporate Affairs Mrs Tricia Lowe Senior Independent Advisor for Patient Engagement - WNCCG Ms Jenni Northcote Chief Strategy and Primary Care Officer Mr Steven Jarman-Davies Director of Acute Contracting and Performance (from 14:37) Mr Stan Orton Public and Patient Group Representative Mrs Julie Seaborne Governance Officer (Minutes)

Item Action No: 1. Standing Items:

1.1 Welcome and Apologies

Dr Raistrick welcomed Members of both NHS Coventry and Rugby CCG (CRCCG) and NHS Warwickshire North CCG (WNCCG) Governing Bodies and members of the public to the meetings in common. Apologies were noted as indicated above.

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Item Action No: 1.2 Declarations of Interest:

Members were reminded of the need to declare their interest in any items requiring a decision and to remove themselves from such decision making.

No other declarations of interest were made.

Dr Raistrick welcomed Ms Sharon Beamish (WNCCG Lay Member – Patient and Public Involvement) and Dr Jonathan Timperley (WNCCG Secondary Care Doctor) to their first meeting of the Governing Bodies.

1.3 Minutes of the Last Meeting: 20th and 28th May 2019

The minutes of the meeting held on 20th and 28th March 2019 were approved as a correct record of the meeting.

1.4 Matters Arising And Action Schedule:

Matters Arising:

There were no matters arising from the 20th and 28th March 2019 meetings.

Action Schedule: Members noted that all actions were either complete or not yet due.

1.5 Chair’s Report:

(A) WNCCG: Mr Allcock presented his WNCCG’s Chair’s report which confirmed that the recruitment of a Clinical Chair in March 2019 had been unsuccessful and therefore an emergency Members Council meeting was called to see a vote from Members on options for securing a CCG Chair in this circumstance. Members voted that in the absence of an appropriate nomination for Clinical Chair, to ask Dr Allcock to continue as Chair and to recruit a Clinical Leader to work with him, the Accountable Officer and other Governing Body Members. This process was underway and would aim to conclude by June 2019.

WNCCG Members NOTED the WNCCG Chair’s report.

(B) CRCCG:

Dr Raistrick presented her CRCCG’s Chair’s report and said that she was pleased that the CCG had appointed Dr Ali Bryce and Dr Mark Lawton, both GP’s practicing in Coventry, to the CRCCG Governing Body filling the vacancies for Locality Leads. She reported that the member practices had worked cohesively and maturely to form into Networks, building on the work of Primary Care Home, and formal submissions had been made to facilitate the population being covered by a Primary Care Network. CRCCG Members as well as key stakeholders and wider public had been involved in early engagement about the future shape of commissioning locally

CRCCG Members NOTED the CRCCG Chair’s report.

1.6 Accountable Officer’s Report Ms Green presented her Accountable Officer’s report and drew attention to item 7 in her report around the Better Care Fund priorities and budget in which she requested delegated authority to agree sign off, in order to ensure that national submission timelines could be achieved. Ms Green reported that it was not anticipated that budget contributions would differ significantly from 2018/19 nor the amounts set aside within the approved CCG budgets for 2019/20.

Ms Green asked Ms Northcote to update members on the Primary Care Networks and the good progress which had been made. Ms Northcote confirmed that the Primary Care Networks were groups of GP practices which would come together to support delivery of services and would work with providers to deliver a range of services around their community. The deadline

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Item Action No: to receive registrations for the Primary Care Networks had been 15th May 2019. Ms Northcote said that she was very pleased to report that for both Governing Bodies they had achieved 100% coverage of their patient population consisting of seven Primary Care Networks in Coventry, one in Rugby and four in Warwickshire North.

Ms Green said that there had been a very good response from Primary Care and it was positive that Accountable Directors had put themselves forward for the Networks and she thanked Ms Northcote and her team for their hard work. Dr Raistrick added her endorsement and also thanked the CCG team, the Primary Care Committee and the Members

CRCCG and WNCCG Governing Body both AGREED to delegate authority to approve the Section 75 work programme and budget contributions to their Finance and Performance Committee or, if necessary because of dates, to the CCG Accountable Officer and Chair.

2.0 Strategy and Planning

Proposal for Health Commissioning in Coventry and Warwickshire – Transition Case for Change

Dr Raistrick introduced the Transition Case asking Members to note that the Governing Body had been informing and discussing the future direction for the CCGs over the last 6 months.

Mr Johnson asked in relation to engagement, how the CCGs had involved Healthwatch. Ms Green confirmed that there had been engagement and a formal response from Healthwatch was expected to be received shortly. Representatives from both Coventry and Warwickshire Healthwatch had attended engagement sessions where a range of stakeholders and members of the public had been invited to hear and discuss potential scenarios going forward.

Mr Allcock and Mr Stainforth stressed the need for good sound due diligence on this piece of work particularly where finance was concerned. Mr Stainforth agreed and asked that greater details of the benefits and risks will be required before any final decisions for change could be supported. Dr Raistrick agreed and said that although the report makes reference to this, she would like this to be made more explicit. Ms Green said that through some of the engagement with both representatives of patients, voluntary groups and GP Members, it has been made very clear that they want to make sure that the positioning of the development of Place was foremost and central to any decisions. She said that this was also a requirement from NHS England and was a further detailed piece of work to do.

Ms Lowe asked about the approach that South Warwickshire CCG were taking. Ms Green confirmed that they were taking a report through their Governing Body which would have met this morning

Ms Gaulton suggested that in respect of “Place” and any firm proposals for changes a report could go to the Health and Social Care Overview Scrutiny Committee (HOSC) (for both Coventry and Warwickshire). Ms Green agreed and said that as work evolved in respect of the decision and recommended way forward involvement of HOSC was fundamental.

Dr Yadav confirmed that the Governing Body Clinical Leads all held the view that although there were discussions about CCGs becoming larger organisations, we must ensure that we do not leave behind the interests of the local populations in doing so. She said that different geographical areas have very different population demands and that any decisions must be taken based on population need. Members confirmed their support for the evidence of this in any final decisions.

Dr Raistrick asked Governing Body Members to agree the recommended options for the strategic direction of the CCGs advising that this would be for both CRCCG and WNCCG separately.

CRCCG voted unanimously for Option 3 with the following caveat: WNCCG voted unanimously for Option 3 with the following caveat: Option 3: A single commissioning voice, management team, constitution, and governance arrangements

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Item Action No: following merger; with a single, joint management team established following the immediate appointment of a single Accountable Officer for the three CCGs up to the date of merger

Recommended subject to:

• A fully worked up case for change with clear benefits, risks etc • Much more detailed future governance arrangements for each Place • Appropriate due diligence to be undertaken • Clarity as to the proposed timescales for change

Dr Raistrick confirmed that the Options would be taken out to the Membership with a summary of the rationale for the Governing Body recommendation of Option 3.

2.1 Summary Operating Plan 2019/20 Mr Harkness presented this report and confirmed that this summary version introduced the goals and priorities of the CCG in 2019/20 and outlined how it was anticipated that the structure of the system will change. It identified the key priorities for the CCGs and how these will enable the delivery of great care for our patients. Ms Green added that this was a more accessible document for the CCGs population to see the CCGs plan for this year and suggested the CCGs’ engagement team be asked to obtain some views through the Patient Group Forums. Ms Gaulton suggested it is also shared with Council Members. Mr Harkness confirmed that he would do this before it was finalised.

CRCCG and WNCCG Governing Bodies NOTED the Summary Operating Plan 2019/20.

2.2 Coventry, Rugby and Warwickshire Public Health Report Ms Gaulton presented this report to provide the Governing Body with an update on the Proactive and Preventative work stream of the Better Health, Better Care, Better Value programme.

CRCCG and WNCCG Governing Body Members NOTED the Coventry, Rugby and Warwickshire Public Health Report which was provided for assurance and information.

2.3 Communications and Engagement Report Ms Northcote presented this report to provide an overview of communications and engagement activities undertaken during April – May 2019. The report outlined how both CCGs have met their statutory obligations for communications, engagement and involvement in this reporting period.

Ms Beamish drew attention to the 360 degree feedback results within the report which had come back for both CCGs as demonstrating many improvements and congratulated the team for the huge amount of work which had taken place.

CRCCG and WNCCG Governing Body Members NOTED the Communications and Engagement Report which was provided for assurance and information.

3. Quality, Safety and Performance Integrated Safety, Quality and Performance

Performance Mr Jarman-Davies said that since writing the report he was pleased to confirm that at the end of March 2019 , figures for dementia were showing improvement and that IAPT (Early Intervention in Psychosis) figures were now on target.

Mr Jarman-Davies referred to the following within the report:

Referral to Treatment Times (RTT): 85.4% of CRCCG patients had been waiting less than 18 weeks from their GP referral date to be seen or treated by a hospital specialist against a target of 92%. The figure for WNCCG was 85.1%. There were no WNCCG or CRCCG patients waiting over 52 weeks.

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Item Action No:

Wheelchair Access In the second quarter 50% of WNCCG children requiring wheelchairs received the equipment within 18 weeks against a target of 92%. The figure for CRCCG was 67%.

A&E 4 hours waits A & E hour performance continued to waiver for both Trusts and the focus remained on managing minors to deliver 100% of minors seen within 4 hours.

Cancer waiting times The 62-day wait from urgent GP referral to first definitive treatment for cancer was not sustained and a more detailed report is being taken to the CCGs’ Finance and Performance Committee.

Ms Green said that the A&E wait performance was disappointing as there had previously been better performance but she understood some of this was in line with national trends. Mr Jarman-Davies said that in terms of delays of transfer for younger people, the reduction in respiratory issues had not reduced in April and May as had been seen in previous years. Ms Green said that there was now focus on respiratory disease in the NHS Long Term Plan and being reviewed for the CCG as part of the Operating Plan and Ms Green said that local issues around this should be considered.

Quality Ms Galloway highlighted the following within her report :

Coventry and Warwickshire Partnership Trust (CWPT): There were no additional concerns added to the Quality Assurance Framework, seven areas of concern at level two and no reported concerns at level three.

In respect of the Care Quality Commission (CQC) Inspection the action plan from the final report was taken to the CCG’s Clinical Quality Review meeting and will continue to be reviewed at each meeting.

For Child and Adolescent Mental Health Service (CAMHS) follow up waiting times, CWPT was invited to the CCG’s Clinical Quality and Governance Committee where they provided assurance on waiting times

There has been sustained focus for CWPT on recruitment and retention of staff and a recruitment fayre for medical staff was held in March 2019. A recruitment fayre for nursing staff is scheduled to take place in May 2019.

In respect of identified performance issues for looked after children, there had been an improvement in performance associated with a recovery plan and recovery trajectory that is in place to ensure that more assessments are completed within statutory timescales. Compliance is expected to be achieved and the backlog addressed by the end of August 2019.

George Eliot Hospital (GEH) GEH has one concern at level three of the Quality Assurance Framework (QAF) relating to mortality which had escalated following three consecutive data reporting periods of within the ‘higher than expected range’ for Hospital Standardised Mortality Ratios (HSMR) and two consecutive data reporting periods for Summary Hospital-level Mortality Indicator (SHMI). GEH has developed a Mortality and Deteriorating Patients Improvement plan which has been shared and monitored. GEH continues to attend the UHCW SHMI group and has contacted the CCG to request a joint local SHMI meeting with GPs to review and focus on local pathways and to share best practice.

The CCGs are represented within the membership at the GEH Mortality and Deteriorating Patients Group.

GEH has one concern at level three of the Quality Assurance Framework which is. Mortality

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Item Action No: and four areas of concern remain at level two:

• Serious Incidents – recognition of the deteriorating patient • Care Quality Commission (CQC) inspection • Workshop to Raise Awareness of Prevent (WRAP) training • Emergency Department

University Hospitals Coventry and Warwickshire NHS Trust (UHCW) UHCW has two concerns at level three and six concerns at level two of the Quality Assurance Framework. Mortality and CQC inspection have reduced to level two, and the Emergency Department has increased to a level three.

The Emergency Department escalated to level three following triangulation of a range of data. The CCGs identified an increase in reported ED Serious Incidents for sub-optimal care and sepsis. UHCW is working with the CCGs to review the ED serious incidents that have been reported over the last two years to identify themes and trends.

In relation to mortality this concern has been de-escalated to level two following three data reporting periods of ‘within expected range’ for the HSMR.

Children and Young People in Crisis, over recent months there has been an increase in the number and severity of behaviours of children and young people presenting in crisis at Accident and Emergency Departments across the system and requiring admission. There are a number of actions that are in place to manage and mitigate the identified risk.

All GP practices are now rated overall as either ‘Good’ or ‘Outstanding’.

In respect to Care Homes it has been reported in the press that Four Seasons Healthcare has entered an administration process. The CCGs are working closely with Coventry City Council regarding the care homes that are within this group within our locality.

In Coventry there are two nursing homes and one residential home that are on escalation and working to improvement plans. For Warwickshire North, there are currently three nursing homes and one residential on escalation and working to an improvement plan.

Dr Kokodkar said that in respect of mortality he had been involved in mortality reviews with UHCW for the last 9 months and there have been high SHMIs but these should be seen as a ‘smoke alarm’ rather than increased mortality. There are robust processes in place and he feels assured that they look at each area where there is increased mortality in great detail and this work is ongoing and will include GEH.

Mr Allcock asked about safer staffing at CWPT and does the total vacancy rate include clinical vacancies. Ms Galloway said that she would find out and let Mr Allcock know,

CRCCG and WNCCG Governing Body Members NOTED the Integrated Safety, Quality and Performance report which was provided for assurance and information.

4. Assurance and Governance

4.1 Assurance Framework and Corporate Risk Register Mrs Wilson presented the Assurance Framework and Corporate Risk Register which outlined the 2018-19 year end position with regards to managing risks to the CCGs achieving its principle objectives. Ms Beamish made an observation on the 4 hour waits within the report in light of the discussions earlier within the Performance Report. She noted that all controls are in place along with assurances, but results are not coming through in terms of experience of the patients and results. She questioned whether there needed to be a review on the controls in place and investigation of what is potentially changing. Ms Green suggested that this could be a timing issue but that it would be helpful as evidence is being received she agreed we should go back and reassess the programme.

Dr Raistrick confirmed that she had asked Mrs Wilson to include Assurance Framework and

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Item Action No: Corporate Risk Register at a future Governing Body Development session.

CRCCG and WNCCG Governing Bodies agreed to:

• RECEIVE the Assurance Framework and Corporate Risk Register; and were ASSURED that adequate actions are being taken by risk owners to mitigate the risks and that the assurances provided are satisfactory.

4.2 Information Governance Year-end Report - March 2019 Mrs Wilson confirmed that the purpose of this report is to inform the Governing Body in relation to year end submission of the Data Security and Protection Toolkit (DSPT) and to provide relevant assurance to the Governing Body around all aspects of the Information Governance agenda. Mrs Wilson confirmed that the Year-end submission status was “all standards met”

In terms of mandatory training for the CCGs, Mrs Wilson reported that Coventry and Rugby CCG had achieved 96.3% and Warwickshire North CCG 94.4% which was in line with the DSPT requirements.

In terms of incidents across the year Mrs Wilson confirmed there were no significant incidents for the CCG in 2018/19 which would require reporting to the Information Commissioners Office.

CRCCG and WNCCG Governing Bodies APPROVED the Information Governance year-end report at March 2019.

5. Financial Performance

5.1 Finance and Contract Reports: Month 12

Mrs Hollingworth confirmed that subject to the outcome of the CCGs statutory audit both CCGs had met their required control totals for 2018/19, this was a break even position for CRCCG and a £1.0m deficit for WNCCG. As WNCCG had delivered their control total this secured £1.0m from the Commissioning Sustainability Fund which enabled the CCG to report a break- even position.

The audited accounts must be submitted by 29th May 2019. The CCGs Audit Committee met yesterday and there are two outstanding issues which are being worked through with the auditors. One related to the Expert Determination process in relation to the UHCW contract. The CCGs are providing further assurance that their assessment of the likely outcome is reasonable. A second issue is one around Continuing Healthcare invoices where another CCG is seeking backdated payments to 2013/14.

The outcome of the Expert Determination, which is expected to report on the 31st May 2019, will inform whether the accruals made by the CCGs are adequate or whether a cost pressure is carried into 2019/20.

The failure to manage activity planned levels during 2018/19 which is reflected in the current QIPP achievement levels (acute activity and CHC activity) does mean a volume of growth has had to be used to recover that underlying position and that the challenge for 2019/20 is that much greater and those plans do remain high risk and we are still needing to work though mitigation to secure the budget plan which was approved.

Ms Beamish asked about the longer term financial plan over the next 5 years. Mrs Hollingworth said that targets for recovering the WNCCG cumulative were proposed by NHS England about 12 months ago but the focus is now shifting towards a trajectory for returning the Coventry and Warwickshire system to financial balance. All areas are working to agree 5 year plans by the Autumn and as part of this, the STP must challenge itself in terms of how it addresses rising demand and take real costs out of the system. Mr Stainforth observed that the CCGs Finance and Performance Committee go into great detail and that it would ensure, given the significance of Warwickshire North CCG’s position, that it reports adequately into the Governing Body meetings. Mr Allcock observed that in terms of due diligence and of the 3

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Item Action No: CCGs potentially merging, the underlying positions are very important. Ms Green suggested that Members who do not normally attend as Members of the CCG’s Finance and Performance Committee be invited to attend a meeting going forward to gain assurance and scrutiny of the finance issues in more detail.

Mr Allcock thanked Mrs Hollingworth and her team.

CRCCG Governing Body Members:

• NOTED that an overall balanced position is reported at Month 12 but with a reliance on securing contractual challenges; • NOTED that subject to the statutory audit, the CCG has delivered the 2018/19 control total (i.e. break-even) by NHSE; and • NOTED that the Finance and Performance Committee has asked that concerns re the CCG’s underlying position is highlighted to the Governing Body.

WNCCG Governing Body Members:

• NOTED that an overall balanced position is reported for Month 12; • NOTED that subject to the statutory audit, the CCG has delivered the 2018/19 control total required by NHSE (£1.0m deficit pre Commissioner Sustainability Fund allocation); and • NOTED that the Finance & Performance Committee is particularly concerned about the deteriorating recurrent underlying position and has asked for this to be escalated to the Governing Body.

6. Policies for Ratification

6.1 Approval of Information Technology Policies Mrs Wilson confirmed that CWPT provide IT services to both Coventry and Rugby CCG and Warwickshire North CCG. The policies below were recommended to the Governing Body for approval: o Email Usage o Home and Teleworking o Internet Use o Information Security o Removable Media and Devices o IT Asset Management

CRCCG and WNCCG Governing Body APPROVED these polices for adoption by both Coventry and Rugby, and Warwickshire North CCGs.

HR Policies 6.2 Mrs Wilson presented the following HR Policies to the Governing Body and confirmed that they had been considered by the CCG’s Senior Management Team and Clinical Quality and Governance Committee and were brought to the Governing Body approval.

• Absence Management policy • Dignity at Work policy • Learning and Development policy • Management of Work Performance policy • Personal Development Review policy

CRCCG and WNCCG Governing Body Members APPROVED these polices for adoption by both Coventry & Rugby, and Warwickshire North CCGs.

6.3 Policy for Conditions which over the counter (OTC) items should not routinely be prescribed Mr Harkness presented to the Governing Bodies the policy on ‘Conditions for which over the counter items (OTC) should not routinely be prescribed in primary care. He confirmed that NHS England partnered with NHS Clinical Commissioners after CCGs had asked for a nationally co-

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Item Action No: ordinated approach to the development of commissioning guidance in the area of OTCs to ensure consistency and address unwarranted variation. The resulting guidance ‘Conditions for which over the counter items should not routinely be prescribed in primary care: Guidance for CCGs’ was developed to provide a consistent, national framework for CCGs to use. The Policy presented to Governing Body members had been discussed in length at the CCG’s Clinical Executive Group and recommended for Governing Body approval by the CCG’s Clinical Quality and Governance Committee.

Dr Yadav asked what engagement work had taken place with stakeholders. Mr Harkness confirmed that some engagement work had taken place and further work would be done if the policy was approved today. He confirmed that the CCG was working closely with local pharmacies and the Local Pharmaceutical Committee. Dr Yadav said she was aware that some care homes would not administer OTC items but only medication on prescription. Dr Raistrick said that this was an issue which had been discussed when looking at the policy and there was a similar issue with schools. She said that the CCG should investigate the issues around this.

CRCCG and WNCCG Governing Body Members APPROVED the policy for ratification.

7. Committees in Common Reports

Members of BOTH Governing Bodies NOTED the following Committee reports:

• Clinical Quality and Governance Committees in Common: 23rd January 2019, • 27th February 2019 and 27th March 2019 • Finance and Performance Committees in Common: 28th February and 4th April 2019 Audit Committee in Common: 18th October 2018 and 31st January 2019

8. Committee Reports – Coventry and Rugby CCG

Primary Care Commissioning Committee Report Committee Reports – Coventry and Rugby CCG CRCCG Governing Body Members NOTED the Primary Care Commissioning Committee Report

9. Committee Reports – Warwickshire North CCG

Primary Care Commissioning Committee Report WNCCG Governing Body Members NOTED the Primary Care Commissioning Committee Report

10. Questions From Visitors: A representative from Coventry LPC asked for an update about engagement locally in respect of the Primary Care Networks. Dr Raistrick said that the Network Directors would be open to contact with them and they are most appropriate people to approach in respect of attendance as their meetings. She suggested to the representative that we put him in touch with them outside of this meeting. Dr Raistrick confirmed that the CCGs were ahead of the national trajectory and the networks are now in existence. Mrs Northcote said that the networks are meeting regularly and suggested an appropriate forum maybe the network leads meeting for the LPC to attend as an introduction.

The LPC representative also mentioned that there had been little communication about the OTC Policy. Mrs Green said that we would take this back to CCG lead but that prior to today the focus had been internally while the policy was being drafted. Dr Raistrick confirmed that there is a comprehensive engagement plan but this policy needed to be approved at Governing Body in the first instance before this could take place.

Dr Raistrick reported that this meeting was Dr Kokadhar’s last as his Governing Body term had come to an end and she thanked him for all his service to CRCCG.

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Item Action No:

10. Any Other Business

There was no other business.

The meeting was closed at 4pm.

Date of the Next Meeting Held in Public:

Date: Wednesday 17th July 2019. Venue: Heron House, Nuneaton Time: 2.45pm – 4 pm

Signature: (Chair CRCCG) Date:

Signature: (Chair WNCCG) Date:

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ENC C: ACTION SCHEDULE - WNCCG AND CRCCG GOVERNING BODY - MEETINGS IN COMMON TO BE HELD IN PUBLIC

WN / CR ACTION MEETING AGENDA ACTION RESPONSIBLE COMPLETION CURRENT UPDATE REF DATE ITEM OFFICER DATE STATUS Local Maternity System Transformation Plan Performance Report: Mrs Dillon CRCCG / 68 08-Nov-18 4.2 to provide a further update to the Governing Body during the middle of the next Jo Dillon 26/09/2019 Not Yet Due WNCCG year. Warwickshire County Council - Public Interest Debate Integrated Care CRCCG / 75 20-Mar-19 1.6 Systems: AG to forward Dr Linanne’s Integrated Care Systems report to Andrea Green 17/08/2019 Complete WNCCG members. Running Costs Allocation (RCA): CCGs were expected to deliver a 20% real CRCCG / terms reduction against their 2017/18 RCA in 2020/21. A report on how the CCG Clare Hollingworth / Chris 79 28-Mar-19 2.1 01/08/2019 Not Yet Due Scheduled for the August 2019 Finance and Performance Committee meeting. WNCCG planned to meet the requirement would be presented to the Finance and Lonsdale Performance Committee during July. Blank Page NHS Coventry and Rugby Clinical Commissioning Group Enc D

Report To: Governing Body Meetings in Common

Report Title: Coventry and Rugby CCG Chair’s Report

Report From: Dr Sarah Raistrick - Chair of NHS Coventry and Rugby CCG

Date: 17th July 2019

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report: To advise the Governing Body of activity since the May 2019 meeting of the Governing Body.

Key Points: • Outcome of Member’s Vote • Interim Accountable Officer • Joint Place Forum • Primary Care Networks

Recommendation: The Coventry and Rugby CCG Governing Body is requested to NOTE the report.

Implications

Objective(s) / Plans supported by this IAF Leadership Domain report: Conflicts of Interest: Not applicable Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: Not applicable Quality and Safety: Not applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable

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Engagement: Clinical Engagement: Not applicable Risk and Assurance: Not applicable

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Following our Member’s vote in early June we secured a majority support in favour of the option of exploring closer working or merger with Warwickshire North and South Warwickshire CCGs. Please see the attached stakeholder briefing. We are now pressing forwards to develop a robust case for change and due diligence process with a proposed further vote before the end of the year. I am confident we will be able to deliver a comprehensive case to allow the Governing Body and Members to make a fully informed decision about the future structure of Strategic Commissioning in our area. Through this process we will build on the engagement with the wider public and strengthen our relationship with Members and the Local Medical Committee as well as continuing to work closely with our colleagues at Warwickshire North and South Warwickshire CCGs.

Appointing an interim Accountable Officer has been at the fore of my role this month and we are making progress to secure a positive appointment who, alongside the strong Executive team, will lead us in transition through change while maintaining the CCG values of caring for our population, creating a culture of partnership, respect and pursuit of excellence.

On the 11th June there was a Joint Place Forum where both Health and Wellbeing Boards met to hear about and shape development of strategy to improve the health and lives of our populations. The voluntary sector spoke passionately and professionally about work in Moat House and through Grapevine highlighting need, community empowerment and holistic care. Member GP’s education continues to be delivered regularly through a diverse and interesting programme of lunch time events covering in the last month clinical and practical topics including a cardiology update and legal and ethical matters affecting practice.

Primary Care Networks have taken shape and are working collaboratively with their member practices, the CCG, GP Alliance and, in Coventry, through the GP Board.

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For information: Stakeholder update on the future of health commissioning

Sent on behalf of Dr Sarah Raistrick, Chair, NHS Coventry and Rugby Clinical Commissioning Group and David Allcock, Chair NHS Warwickshire North Clinical Commissioning Group

Dear Colleague,

As you know we recently asked for our Members’ views on the way we should determine our response to how commissioning should change in response to the NHS long term plan. This took place in both Coventry and Rugby and Warwickshire North.

Our members were asked to vote on two possible options, A or B.

Option A: Yes, explore Options 2 and 3

Option 2: Retain three CCGs but with a single management structure A single joint management team established following the immediate appointment of a single Accountable Officer for the three CCGs with retention of the three existing statutory bodies.

Option3: Merger of the three CCGs A single commissioning voice, management team, constitution, and governance arrangements following merger; with a single, joint management team established following the immediate appointment of a single Accountable Officer for the three CCGs up to the date of merger.

Option B: No, take no further action.

The result of the vote is that the majority of members who voted, voted for Option A. For a full breakdown of results contact the Communications Team on [email protected].

This is a mandate from our Members which means that we can start the work to develop a full case for change. This will include much greater clarity about the impact on our populations and our Members, what commissioning activities we would want, and what streamlined commissioning would look like in Coventry and Warwickshire.

Interim arrangements for the Accountable Officer

We are proceeding to recruit an interim AO. This role will cover both Coventry and Rugby and Warwickshire North and will be full time. We anticipate that this appointments will be made in the next six to eight weeks, allowing for handover.

Best regards,

David Allcock Dr Sarah Raistrick NHS Warwickshire North CCG NHS Coventry and Rugby CCG

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Report To: Governing Body Meetings in Common

Report Title: Warwickshire North CCG Chair’s Report – July 2019

Report From: David Allcock – Chair of NHS Warwickshire North CCG

Date: 17th July 2019

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report: To advise the Governing Body of activity since the May 2019 meeting of the Governing Body.

Key Points: The Chairs Report covers the following:

• Result of the Members’ vote; and • Interim arrangements for the Accountable Officer.

Recommendation: The Warwickshire North CCG Governing Body is requested to NOTE the report.

Implications

Objective(s) / Plans supported by this Report on – Mental Health Investment Standard 2019/20 report: Conflicts of Interest: Not applicable Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: Not applicable Quality and Safety: Not applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement:

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Clinical Engagement: Not applicable Risk and Assurance: Not applicable

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NHS Warwickshire North Clinical Commissioning Group Enc E

As you know we recently asked for our Members’ views on the way we should determine our response to how commissioning should change in response to the NHS long term plan. Our members were asked to vote on two possible options, A or B.

Option A:

Yes, explore Options 2 and 3

Option 2: Retain three CCGs but with a single management structure

A single joint management team established following the immediate appointment of a single Accountable Officer for the three CCGs with retention of the three existing statutory bodies.

Option3: Merger of the three CCGs

A single commissioning voice, management team, constitution, and governance arrangements following merger; with a single, joint management team established following the immediate appointment of a single Accountable Officer for the three CCGs up to the date of merger.

Option B:

No, take no further action.

I’m delighted to report that the result of the vote is that 100% of members who voted (77% turnout), voted to explore Option A. This gives us a clear mandate from Members which means that we can start the work to develop a full case for change. This will include much greater clarity about the impact on our populations and our Members, what commissioning activities we would want, and what streamlined commissioning would look like in Coventry and Warwickshire.

Interim arrangements for the Accountable Officer

We are proceeding to recruit an interim AO. This role will cover both Coventry and Rugby and Warwickshire North and will be full time. We anticipate that this appointment will be made in the next six to eight weeks, allowing for handover.

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc F

Report To: Governing Body Meetings in Common

Report Title: Accountable Officer’s Report

Report From: Andrea Green, Accountable Officer

Date: 17 July 2019

Previously Considered by: Not applicable

Action Required (delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report: The purpose of this report is to provide members of the Governing Bodies with information on key activities undertaken by the Chief Officer since the last Governing Body meeting in common in May 2019, and any pertinent issues not covered elsewhere on the agenda.

Key Points:

The Chief Officer’s Report covers the following:

1. NHS ten year plan – Implementation Framework published

2. Coventry and Warwickshire Place Forum

3. Better Health, Better Care, Better Value

4. CCG Assurance Ratings for Patient and Community Engagement Indicators – top marks for both CCGs

5. CCG Staff update

Recommendation: The Governing Body is requested to NOTE the report.

Implications

Objective(s) / Plans supported by this Constitution, Leadership IAF Domain report: Conflicts of Interest: None identified. Non-Recurrent Expenditure: Not applicable.

Financial: Recurrent Expenditure: Not applicable. Is this expenditure included Yes No N/A  within the CCG’s Financial

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Plan? (Delete as appropriate) Performance: None identified. Quality and Safety: None identified. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public None identified. Engagement: Clinical Engagement: None identified. Risk and Assurance: None identified.

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1. NHS ten year plan implementation framework

The implementation framework was published in June and sets out the requirement for each sustainability and transformation partnership, to develop a strategic delivery plan for making the phased improvements in NHS service and outcomes described in the ten year plan.

The framework is prescriptive about the need to make early measurable progress in some key areas and also gives freedoms beyond this to identify local priorities for improvement by 2023/24. The local delivery plan will need to be realistic about the workforce to achieve the improvements, demonstrate how the national funding guarantees will be met for primary, community and mental health services, and how the improvements are affordable within the five year allocations.

We are working with sustainability and transformation partners building from the existing actions and plans, taking the findings of the JSNA work in neighbourhoods, the emerging requirements from the new Health and Wellbeing Strategies being developed in Coventry and Warwickshire and using the insights and public and patient feedback gathered on • primary care, planned care, stroke care, frailty, urgent and emergency care, mental health, dementia, maternal and children’s care, • Place based Partnerships in Warwickshire North, Rugby and Coventry, • Neighbourhood JSNAs and action plans, • The report from Warwickshire Healthwatch who engaged local people about what they want from the NHS long term plan.

There are a small number of gaps in areas of the long term plan on which we need to complete further engagement, this work will be progressed by September to shape the draft.

Our commissioning intentions for 2020/21 will relate to the first year of the strategic delivery plan, in developing these we plan to follow a similar approach as in previous years a timetable for which is shown below.

Timetable Date Stocktake against existing intentions June – July Agreement of approach with SWCCG July Approval of approach by governing body 17th July First draft completed Mid August Warwickshire North Executive Group mid-August Coventry and Rugby Clinical Executive Group

Draft version presented to Finance and Performance 5th September Committee Draft version presented to both Health and Wellbeing Boards September for alignment with LA commissioning intentions and Health and Wellbeing Strategies Final draft presented to Joint Governing Body 26th September

Commissioning Intentions issued and available on CCG 30th September websites as final documents

2. Coventry and Warwickshire Place Forum

The Place Forum met in June to receive a report back on the excellent progress we have made across Coventry and Warwickshire on the Year of Wellbeing; receive an update on the new proposals for more inclusive Governance of the Better Health, Better Care, Better Value Page 3 of 6

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Partnership; a report developing a local strategic framework for future plans and to hear back from two projects aimed at tackling loneliness and isolation by building social value, the CCG and Coventry City Council co-funded these in our the iBCF programme this year.

The work of our Wellbeing Warriors and sign up by both CCGs to the Thrive at Work initiative, was celebrated as part of the report.

3. Better Health Better Care Better Value Partnership

The Independent Chair of the Partnership, Sir Professor Chris Ham, has led a review of the governance of the Partnership with the aim of developing a fully engaged proposal to come back to Governing Bodies, Health and Wellbeing and Provider Boards for adoption in September.

The Chair led on two development events for leaders, to bring learning from areas that are further ahead with their Integrated Care System (ICS) working, forward for local leaders to explore. This is helpful in determining our readiness for working as an ICS, NHSE/I have recently posted a maturity matrix aspirant ICS’s to use to assess their readiness.

4. NHSE Assurance Ratings for Patient and Community Engagement – top marks!

I’m delighted to advise members that both CCGs’ received their rating and achieved the top marks from the assurance process. This is one facet of assurance that will be used in our annual assurance ratings which are expected imminently.

5. CCG Staff

CRCCG and WNCCG are committed to promoting equality, diversity and human rights for the population that we serve - and for our staff. I’m delighted to advise Members that we are the first CCGs to implement the rainbow badge initiative. This is a national initiative that originated at the Evelina Children’s Hospital in London to make a positive message of inclusion for LGBT+

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patients and colleagues. You may start seeing some of our staff wearing NHS rainbow badges, in order to begin to increase awareness of these issues.

For more information please contact Anita Wilson, Associate Director of Governance and Corporate Affairs. [email protected]

I am also pleased to announce that CRCCG and WNCCG have jointly signed up to the Time to Change Mental Health Employer Pledge. This means that we have an action plan to raise awareness of mental health in the workplace and ensure staff feel supported and comfortable in discussing mental health.

End of report

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc G

Report To: Governing Body Meetings in Common

Report Title: Update on the future of healthcare commissioning within Coventry and Warwickshire

Report From: Dr Sarah Raistrick, Chair CRCCG Mr David Allcock, Chair WNCCG

Date: 17 July 2019

Previously Considered by: Executive Team Coventry Health and Overview Scrutiny Committee 10 July 2019

Action Required

Decision: Assurance: Information:  Confidential

Purpose of the Report: To provide the Governing Bodies with information regarding the implementation of the NHS Long Term Plan in relation to the commissioning function of the Clinical Commissioning Groups (CCGs) within Coventry & Warwickshire, and to provide an update on the outcome of the membership vote and next steps.

Key Points:

The Long Term Plan (LTP) states that local NHS organisations will increasingly focus on population health, moving everywhere to Integrated Care Systems (ICSs) each covering a population of c1m by April 2021 growing out of the current network of Sustainability and Transformation Partnerships (STPs). These will have a key role in working with Local Authorities at ‘place’ level, and through them commissioners will make shared decisions with providers on how to use resources, design services and improve population health In Coventry and Warwickshire we are on a journey towards becoming an ICS by 2021 as required in the LTP. The Clinical Commissioning Groups (CCGs) have set out to determine their response to achieving ‘streamlined commissioning’, and the requirement to deliver during 2020, a 20% administrative cost reduction in the CCG. In this context the Governing Bodies asked that a transitional case for change be developed, with the facts known so far, and potential options for the strategic direction of the CCGs. In our CCGs, determining the strategic direction of the CCG is a matter reserved for GP Members. Since the last meeting of the Governing Bodies on 22 May 2019, the executives have responded to the outcome of the vote by members and taken action to address the concerns raised by both members and by the Governing Bodies. The vote concluded with overwhelming support to explore Options 2 and 3 as detailed in the case for change. A considerable amount of work will now be required with colleagues and stakeholders to co- design what commissioning at Place entails, and what strategic commissioning entails.

Recommendation:

Governing Bodies are asked to receive the report for INFORMATION and ASSURANCE noting the Next steps in Section 4 of the report.

Implications

Objective(s) / Plans supported by this NHS Long Term Plan requirements for strategic commissioning arrangements report: Conflicts of Interest: None Non-Recurrent N/A Expenditure: Recurrent Expenditure: N/A Financial: Is this expenditure included within the CCG’s Yes No N/A Financial Plan? Performance: N/A Quality and Safety: N/A General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line Equality and with any equality analysis or due regard. Any decision that is finalised without being Diversity: influenced by appropriate due regard could be deemed unlawful. Has an equality impact assessment been Yes No N/A undertaken? √ Patient and Public Engagement plans will be determined Engagement: Members will be engaged with throughout the process Clinical Engagement:

There is a risk to engagement activities with stakeholders and members, as well as Risk and Assurance: the pace of the development work around Place and Place governance.

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1. Purpose

To provide the Governing Bodies with information regarding the implementation of the NHS Long Term Plan in relation to the commissioning function of the Clinical Commissioning Groups (CCGs) within Coventry & Warwickshire.

2. Information / Background

The NHS Long Term Plani (LTP) published in January 2019 by NHS England (NHSE) was developed with input from patients’ groups, professional bodies and frontline NHS leaders who since July 2018 shaped it through over 200 separate events, over 2,500 separate responses, through insights offered by 85,000 members of the public and from organisations representing over 3.5 million people.

The LTP sets out how the NHS will move to a new service model in which patients get more options, better support, and properly joined-up care at the right time in the optimal care setting. It sets out: • how the NHS will strengthen its contribution to prevention and health inequalities; • the NHS’s priorities for care quality and outcomes improvement for the decade ahead; • how current workforce pressures will be tackled, and staff supported; • a wide-ranging programme to upgrade technology and digitally enabled care across the NHS; and • how to return the NHS onto a sustainable financial path.

The LTP states that local NHS organisations will increasingly focus on population health, moving everywhere to Integrated Care Systems (ICSs) each covering a population of c1m by April 2021 growing out of the current network of Sustainability and Transformation Partnerships (STPs). These will have a key role in working with Local Authorities at ‘place’ level, and through them commissioners will make shared decisions with providers on how to use resources, design services and improve population health (other than for a limited number of decisions that commissioners will need to continue to make independently, for example in relation to procurement and contract awards).

Every ICS will need streamlined commissioning arrangements to enable a single set of commissioning decisions at system level. This will typically involve a single CCG for each ICS area. CCGs will become leaner, more strategic organisations that support providers to partner with local government and other community organisations on population health, service redesign and LTP implementation.

In Coventry and Warwickshire we are on a journey towards becoming an ICS by 2021 as required in the LTP. The Clinical Commissioning Groups (CCGs) have set out to determine their response to achieving ‘streamlined commissioning’, and the requirement to deliver during 2020, a 20% administrative cost reduction in the CCG. In this context the Governing Bodies asked that a transitional case for change be developed, with the facts known so far, and potential options for the strategic direction of the CCGs. In our CCGs, determining the strategic direction of the CCG is a matter reserved for GP Members.

To shape and inform the transitional case for change, there have been briefings and engagement events for staff, GP Members and Governing Body Members since December

1 2018. Other events were held with key stakeholders between March and May 2019. The purpose of this engagement activity was to bring together a wide range of stakeholder views from across Coventry and Warwickshire, including colleagues working in health and social care, voluntary and community organisations, councillors, carers and patients and their representatives with the aim of:

• providing clarity that this piece of engagement was specifically around the future of health commissioning as it pertains to meeting the needs of a future integrated care system for Coventry and Warwickshire. • giving attendees background information and putting things in context to help them understand why we are considering changing health commissioning. • capturing their initial thoughts and reactions to this information to input into the a high level case for change document which was presented to the Coventry and Rugby CCG Governing Body in May.

3. Considering the Case for change

The Governing Bodies considered the transitional case for change at the meeting in May and were clear that, with the development of a single strategic commissioner, about 80% of the current CCG work will be aligned with “Place”, and that we have 4 “Places” defined namely Coventry, Warwickshire North, South Warwickshire and Rugby. 20% of the current CCG activity will align with strategic commissioning at a Coventry and Warwickshire level.

The Governing Body agreed that they would make a recommendation to GP Members that to create streamlined commissioning, the strategic direction would be a merger of the 3 local CCGs but that this was subject to development of a full case for change that described benefits/ disbenefits, risks and mitigations. They asked that the future arrangements at each Place be clearly set out, that a detailed timeline for how and when such a merger or any change might occur, and an appropriate due diligence assessment.

In line with the CCGs’ constitutions, GP Members were asked to vote on the way forward, initially using the document the CCG Governing Body had used to make their recommendation. The Local Medical Committee Officers, in Coventry, Rugby and Warwickshire North asked for greater clarification, stating that the transitional case for change had insufficient information about impact at Place for the GP Membership to use to vote.

An additional briefing was developed and issued and GP Members have voted on this. The result was that the majority of members voted for the CCG to explore two options, which were a) a single management team working for each of the 3 CCG’s b) a merger of the 3 CCG’s with a single management team.

4. Next steps

A considerable amount of work will be required with colleagues and stakeholders to co- design:

• what commissioning at Place entails, and what strategic commissioning entails; • the staff and skills required in the Places and in the strategic commissioner.

2 We are committed to working closely with stakeholders from across the system throughout this process of development. The CCGs will also need to ensure they can meet all the other requirements in relation to merger set out in April 2019 guidance from NHSE prior to making any application for change in their legal status to NHSE. This includes very clear requirements in relation to stakeholder and Member engagement.

5. Recommendations

Governing Body members are asked to receive the report for information and assurance, and note the requirements for engagement of stakeholders during the developmental phase.

i https://www.longtermplan.nhs.uk/online-version/ NHS England

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4 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc H

Report To: Governing Body Meetings in Common

Report Title: Public Health Report: Better Health, Better Care, Better Value Partnership: Coventry & Warwickshire Local Maternity System (LMS) Partnership: Progress Report Health and Wellbeing Workstream

Report From: Helen King, Interim Director Public Health, Warwickshire County Council Liz Gaulton, Director of Public Health and Wellbeing, Coventry City Council

Date: 17th July 2019

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report: The purpose of this paper is to provide a brief update to the Governing Body on progress with Coventry & Warwickshire’s Local Maternity System (LMS) Health and Wellbeing Workstream.

Key Points: LMS Vision

The LMS was established to specifically focus on transforming maternity and neonatal services to deliver improved outcomes for mothers and babies through a healthy pregnancy and safe birth in the preferred place, supported by a known midwife. This is to be achieved through delivery of: • The recommendations of Better Births; • The recommendations of ‘Saving Babies’ Lives’; • The recommendations of the West Midlands Neonatal Review for which the LMS is responsible. Delivery of the LMS vision is underpinned by a set of commitments being taken forward through three work-streams as follows: • Quality and Safety • Choice and personalisation • Health and well-being Aligned to the LMS work programme the Maternity, Children and Young Peoples (MCYP) Strategic Programme that has a much broader scope that extends from the antenatal period to adulthood (from 0- 25); mental and physical health; prevention and early intervention, recognising the impact of the wider determinants of health. Whilst there has been collaborative working across the two programmes there is now a recognised need to improve alignment and consequently a joint governance structure is being introduced to allow the activities of both programmes to be co-ordinated and dependencies managed.

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Recommendation: Governing Body Members are requested to COMMENT and NOTE the update on the LMS Health and Wellbeing Workstream and CONSIDER how opportunities to enable the work of the LMS is progressed to the benefit of women and families across Coventry and Warwickshire.

Implications

Objective(s) / Plans supported by this Better Health, Better Care, Better Value Partnership strategic priority report: Conflicts of Interest: N/A Non-Recurrent Expenditure: N/A Recurrent Expenditure: N/A Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: N/A LMS promoting the recommendations of ‘Saving Babies Lives’ and the Quality and Safety: recommendations of the West Midlands Neonatal Review General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Each maternity service has a voluntary Maternity Engagement Group consisting of Patient and Public service users and professional. These local groups feed into the strategic LMS Engagement: Maternity Voices Partnership (MVP). Clinical Engagement: Via LMS Board and Regional Maternity Network Risk and Assurance: N/A

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Health and Wellbeing Work-stream:

The core aim is to optimise the health and wellbeing of mothers to be, mothers and infants through effective practice and integrated working across the system.

Anticipated Outcomes:

• Reduction in Maternal and Neonatal Mortality and Morbidity

• Reduction in smoking in pregnancy

• Reduction in maternal obesity and gestational diabetes

• Increased Breastfeeding rates – at birth and at 6 weeks

• Reduction in perinatal mental health issues, such as depression in the antenatal and postnatal

Periods considering outcomes for both the mother and the father.

• Reduction in Neonatal care admissions and lengths of stay.

This work stream includes seven strands of work as follows:

During pregnancy, and in the year after birth, at least 10% of women are affected by a Parent-Infant range of perinatal mental illnesses. If left untreated, this can have a devastating impact Mental Health on mothers and their families. Through early identification and expert management, it & Well-being is possible to prevent the onset and escalation of perinatal mental illness and much can (PIMHW be done to support women preventing negative impacts on the family.

A specialist team, comprising perinatal psychiatrists, psychologists and community psychiatric nurses has been commissioned but further work is being taken forward through an LMS Perinatal Infant Mental Health and Wellbeing (PIMHW) Steering Group. A 5 year strategic plan has been developed and progress includes:

• Work is underway to develop and strengthen PIMHW Pathways across the LMS and to plan a mulit-agency workforce development programme. • Implementation of a training programme for evidence-based video interactive guidance (VIG) provision (seven health visitors to become accredited VIG Guiders by end 2091-20). • A Business Case for a cadre of specialist mental health midwives and health visitors developed. Work underway within the LMS, Coventry & Warwickshire Mental Health Commissioning and WCC to try and identify funding. • A local 3rd sector organisation is working with Parent Infant Partnership (UK) to look at the potential of establishing a Parent Infant Partnership (PIP) across the LMS (with support from a local benefactor).

Smoking in pregnancy is a key risk to both the health of the mother and the unborn Stop Smoking child. Women who smoke in pregnancy are more likely to experience intra-uterine in Pregnancy growth restriction, pre-term birth and/or stillbirth. It poses the single largest risk to a (SSiP) healthy pregnancy and as such all women are encouraged to quit at booking and if necessary at subsequent points along the antenatal pathway.

Substantial work has been undertaken in improving pathways to SSiP services and

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midwives and other staff have been trained to offer women brief advice. There is however variability in smoking rates at delivery across the County and Coventry, further work is required to address this. Current work includes: • A Task & Finish Group which is close to finalising SSiP guidelines for implementation across the LMS. • A 2019/20 LMS funding bid has been submitted to support a strategic and operational review of smoking in pregnancy, with an audit to benchmark provision against guidelines and to help identify gaps and priorities/next steps. There is also a need for place-based Lower Super Output Area (LSOA) data capture and analysis to consider the need for targeted interventions.

Universal There is good evidence that well designed perinatal parenting education programmes perinatal help parents understand and shape positive relationships with their infants. This in turn parenting helps their infants to develop emotional and behavioural self-regulation skills - education increasing their long-term resilience and mental wellbeing.

In Warwickshire, Smart Start research (involving 1,135 Warwickshire parents) found a paucity of free or low cost perinatal parenting education opportunities and inequity in access. These findings are echoed in Coventry. In developing the Coventry Parenting Strategy (2018-23), a consultation with 364 parents found 75% said they needed support before the baby was born in terms of preparing for the birth. In response, the LMS has prioritised the need to develop and implement place-based Universal perinatal parenting education offers. Current activities include: • Work underway at South Warwickshire to begin to pilot a delivery of universal antenatal parenting education as part of SWFT’s Continuity of Care model. • Development of this model will include the creation of social connections and ‘peer to peer’ educators who will work alongside professionals. • Additional capacity/resource required by GEH and UHCW midwifery to work with public health to drive forward place-based universal antenatal parenting education offer in North, Rugby and Coventry. A bid has been submitted for 2019-20 LMS transformational funding. • Recognition that to succeed in offering a universal antenatal parenting education in the north of Warwickshire and Rugby there will be a need to take an asset-based approach to delivery with third sector and peer to peer provision.

Around 1 in 5 women attending antenatal care in the UK are obese. In some areas of Obesity in the LMS this reaches 1 in 4. Having a higher body mass index at the start of a Pregnancy pregnancy, and excessive gestational weight gain, increases the health risks to both the mother and infant. A LMS ‘partnership approach to physical activity and reducing obesity’ workshop in November 2018 recognised that there are inconsistencies in the LMS ‘obesity in pregnancy’ pathways, and there is a need to review and strengthen these pathways. • Before the pathways can be reviewed and benchmarked there is a need to develop up to date guidelines for the identification and management of obesity during and after pregnancy. The timeline for guidelines development is not yet confirmed but is anticipated to be in the next 3 or 4 months.

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There is a large body of evidence that shows that conflict between parents can have a Parental negative impact on children’s long-term mental health and future life chances. Parental conflict and conflict can then in turn act as a precursor to poor parenting practices. domestic violence In most recent estimates (2013/14), the proportion of children living in couple-parent families whose parents had ‘distressed relationships’ was 11.4%, and 28% of children living in workless families live with parents in a distressed relationship. This is almost three times higher than for children where both parents are working (10%). Parental conflict is a potent pre-cursor to domestic violence and as such is an issue that needs to be addressed through LMS pathways. With this in mind: • A LMS scoping meeting was held on 23 May to decide on next steps for this strand of work. • The meeting explored: key data for domestic abuse and what is collected by maternity staff; pathways which need to be explored further around maternity staff recording domestic abuse and signposting for support; staff confidence, competence and training needs; and limited capacity within maternity services to drive the LMS priorities. • Coventry has received national funding to complete workforce development with early help and protection services to reduce parental conflict. In order to secure the training, a multiagency review of current practice within Coventry of work across organisations regarding reducing parental conflict has been completed using a scoping tool. • Within Warwickshire a strategic review is underway of domestic abuse including consultations with partners/services which will provide further information re need. • A follow up meeting wll be held in September when the strategic plan for Warwickshire will be in place.

There is a vast body of evidence to support the importance of breastfeeding for short Infant and longer term health of the mother and the infant. Feeding Since 2015, we have seen a downward trend in breastfeeding rates in Warwickshire. In 2018-19, the average rate of breastfeeding at 6-8 weeks was 47.9% (England 46%). This is lower than many of our statistical neighbours. In Coventry, 2017/18 data showed 78.3% of mothers initiate breastfeeding. By 6 to 8 weeks after birth, 48.3% of mothers are breastfeeding (England 42.7%). Coventry parents reported the need for support with breastfeeding. Warwickshire parents report insufficient support in the early days of breastfeeding, and midwives express concerns about a lack of capacity to offer quality support. • There is an acknowledged need to improve infant feeding support for parents. This will include an LMS review of infant feeding support pathways to identify good practice and geographical variance. • Recognition that – given midwifery services capacity - to succeed in strengthening breastfeeding support and outcomes there will be a need for an asset-based approach to delivery with third sector and peer to peer provision.

Better Births identified that maternity services should be organised around the woman Community and her family and that Community Hubs should be identified to enable access to Hubs/Family services needed. It was recognised that the LMS will need to identify a range of Hubs services to be brought together through the community hub based on the needs of the local community, infrastructure available and the pathways/services commissioned

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Provisional work was undertaken across Warwickshire with a view to identifying potential Community Hubs for LMS services and whilst venues have been agreed in the South of the county there was a view that the model of care (to be agreed through the Choice and Personalisation work programme) would need to be clearer before hubs in Rugby and in the North of the county can be identified. Alongside this NHSE (Maternal and Perinatal Clinical Networks) has undertaken a mapping exercise of hubs across the country with a view to identifying hub locations across geographical boundaries. The findings of this work will help inform the future identification of hubs elsewhere in Warwickshire. . In Coventry, there are 8 family hubs which operate in the most deprived areas of the city which includes delivery of community based antenatal care.

Conclusion

As this report demonstrates, there are multiple work programmes, supported by a wide range of multi- disciplinary / multi-agency groups. Each group requires leadership and participation from CCGs, Local Authorities, Third Sector, clinicians from all Trusts. Sustaining the contribution of staff, who are also responsible for the delivery of clinical services, is challenging. In this context, the recommendations of this report are that the Committee:

• Notes the objectives and current work programme of the LMS

• Recognises that aspects of the work programme are yet to be addressed

• Identifies any opportunities to enable the work of the LMS to progress to the benefit of women

and families across Coventry and Warwickshire

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Report To: Governing Body Meetings in Common

Report Title: Pre Consultation Business Case - Improving Stroke Outcomes

Report From: Andrea Green, Accountable Officer

Date: 17th July 2019

Previously Considered by: Finance and Performance Committee 4th July 2019 Better Health Better Care Better Value Board, 20th May 2019 Joint Strategic Commissioning Committee, 13th February 2019

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report: The purpose of this report is to seek Governing Body approval of the Pre- Consultation Business Case (PCBC) - Improving Stroke Services, prior to submission to NHSE/I for the assurance and determination of readiness for public consultation.

Key Points: This final draft PCBC contains a write up of the work completed to co-produce the future “pathway of excellence” for stroke care that will also support delivery of the improvements set out for stroke care, in the NHS Long Term Plan.

Comparisons of the performance and outcomes of current local stroke services with best practice standards and the achievements of other health systems in England, show we can achieve better health outcomes for patients and more effective and efficient services. It is clear from the analysis of current service provision that there is also considerable unwarranted variation and inequity in the range of services available for patients across the system.

Options for the future delivery of stroke care have been co-produced and appraised through a process involving extensive professional, patient and public engagement. The resultant Pre-Consultation Business Case (PCBC) describes the process and outputs in detail, proposing the implementation of a new service configuration that would see: • Removal of the current inequities in service provision across Coventry and Warwickshire • Prevention of c.230 strokes in 3 years by bringing anticoagulation prescribing to best practice levels • Centralisation of hyper-acute and acute care at UHCW • The provision of 2 sites for bedded rehabilitation at GEH and Leamington Rehabilitation Hospital for the 30% of the population experiencing a stroke who cannot go home with Early Supported Discharge or Community Stroke Rehabilitation • The provision of new community services to deliver consistent Early Supported Discharge and Community Stroke Rehabilitation services at home for 70% of stroke patients, enabling them to return directly home after hyper acute and/or acute care.

It is unusual for us to bring a PCBC to the Governing Body that only proposes one option to achieve the improvements however, this is a proposal for a whole stroke pathway improvement and not just a business case for as single service improvement. The complexity and interdependencies of handover of care, and need for an integrated workforce approach across the pathway, has led to the proposed option and pathway.

Introduction of the proposed new pathway presents cost pressures and financial risks to the system. All contributing provider organisations and commissioners have signed up to delivering the proposed model within the financial envelope in the case, and have included this within their financial plans and agreed to jointly mitigating the financial risks.

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Once signed off, commissioners must submit the PCBC for NHSE assurance review to determine the readiness for public consultation and assess whether the NHS five key tests for significant change have been passed, and Members can find the evidence of compliance with these in section 5.10.5.

Detailed modelling and remodelling has been undertaken throughout the development of the PCBC to quantify the projected demand for stroke services, this has taken full account of forecast population and housing growth. The activity projects have then been used to derive costs of the proposed new model.

The table below summarises the current and future additional cost of the proposed stroke pathway/service. It must be noted that the increase in acute/bedded costs to CCGs identified is due to national tariff changes that are already within contractual baselines. On that basis, the additional funding required above the baseline and previous approval levels is £983k for CRCCG and £246k for WNCCG relates to the community service costs only.

All provider organisations have signed up to delivering the proposed model within the financial envelope identified and have included this within their financial plans, with this forming a part of the developing five year plan. Whilst financial risks have been identified, all commissioning and provider organisations involved have signed up to jointly mitigating these risks.

Current Investment Cost of by CCGs Proposed Model £000s £000s Community - ESD and Rehab 1663 4,775 Ambulance additional journeys 171 AF Community investment 128 Community elements 1,663 5,074

Additional cost of community model 3,411 Additional cost of Acute model 374 Less savings on CHC packages -700 Net additional CCG investment required 3,085

Agreed split by CCG: CRCCG 300 1,283 SWCCG 440 547 WNCCG 1,008 1,254 1,748 3,085

Recommendation: The Governing Body of each CCG is asked to; • APPROVE the submission of the PCBC for an assurance review by NHSE/I; • APPROVE the additional full year investment of £1,254k for WNCCG in 2020/21, with an estimated £125K in 2019/20; and • APPROVE the additional full year investment of £1,283k for CRCCG in 2020/21, with an estimated £128K in 2019/20.

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Implications

Objective(s) / Plans To improve stroke services, which are part of both CCGs plans and the health and supported by this care system improvements identified in the Better Health; Better Care; Better Value report: programme The CCG Accountable Officer is the SRO for the project and Director of Finance as Conflicts of Interest: Finance lead Non-Recurrent Expenditure: NA £1,254k for WNCCG Recurrent Expenditure: Financial: £1,283k for CRCCG Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) The preferred future stroke pathway and delivery model will create services that Performance: meet the NHS Midlands and East Stroke Service Specification and will enable providers to deliver an “A” rating on SSNAP performance targets for stroke care. The preferred future stroke pathway considerably improves the quality of outcomes Quality and Safety: and clinical care and removes the current significant unwarranted variation in access to care provision across Coventry and Warwickshire. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non- discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised without being influenced by appropriate due regard could Equality and Diversity: be deemed unlawful. Has an equality impact assessment been Yes  No N/A undertaken? (Delete as appropriate) Extensive public and patient engagement and co-production of the pathway has Patient and Public taken place over the last 4 years (details included within the Business Case). Engagement: Further public engagement will be required via a public consultation process on the proposed future stroke pathway. Clinical engagement with acute and community stroke clinicians has taken place in Clinical Engagement: developing the pathway options to ensure that any proposals are deliverable and achieve the best practice clinical outcomes. Clinical and operational delivery risks and mitigation have been identified within the Business Case. Key risks for implementation of the future care pathway are: • Workforce – ability to recruit the necessary staff and reconfigure existing Risk and Assurance: staff as required by the new stroke pathway • Capacity – whether sufficient capacity at UHCW can be developed and sustained to manage any peaks in demand for the HASU

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Coventry and Rugby CCG South Warwickshire CCG Warwickshire North CCG

Improving Stroke Outcomes for Coventry and Warwickshire

Pre-Consultation Business Case

Contents 1.0 EXECUTIVE SUMMARY ...... 1 1.1 Purpose of this Document ...... 1 1.2 Stroke and TIA Definition ...... 1 1.3 Governance Arrangements ...... 2 1.4 The Case for Change ...... 2 1.5 Summary of Current Stroke Service Provision ...... 5 1.6 Proposed Future Clinical Model ...... 8 1.7 Financial and Activity Impact ...... 13 1.8 Implementation ...... 16 2.0 BACKGROUND AND CONTEXT ...... 18 2.1 Current services ...... 18 2.2 Hyper Acute Stroke Unit ...... 19 2.3 Local Acute Stroke Units ...... 20 2.4 Rehabilitation, Outreach and Early Supported Discharge ...... 20 2.5 TIAs ...... 21 2.6 Conclusion ...... 21 3.0 THE CASE FOR CHANGE ...... 22 3.1 NHS Midlands and East Stroke Services Specification ...... 22 3.2 Primary Prevention ...... 23 3.3 Access ...... 23 3.4 Performance and Outcomes...... 24 3.5 Length of Stay ...... 25 3.6 Best Practice Standards of Care ...... 26 3.7 Findings from Local Stroke Review ...... 26 3.8 Workforce Challenges ...... 27 3.9 Benefits ...... 27 3.10 Conclusion ...... 28 4.0 SUPPORTING EVIDENCE AND BEST PRACTICE ...... 29 4.1 The Midlands and East Stroke Services Specification ...... 29 4.2 Equity of access ...... 31

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4.3 Clinical best practice evidence ...... 31 4.4 Local strategy ...... 36 4.5 National strategy ...... 36 4.6 Conclusion ...... 38 5.0 OPTIONS DEVELOPMENT AND APPRAISAL ...... 39 5.1 Assurance & Governance Arrangements ...... 39 5.2 Stakeholder Engagement ...... 40 5.3 Long-List of Scenarios - Hyper Acute and Acute Services ...... 43 5.4 Short-List of Scenarios - Hyper Acute and Acute Services ...... 44 5.5 Long list of Scenarios – Rehabilitation Services ...... 46 5.6 Short list of Scenarios – Rehabilitation Services ...... 47 5.7 Options Appraisal ...... 49 5.8 Risk Assessment of Options ...... 51 5.9 Integrated Impact Assessment and Equalities ...... 55 5.10 Quality Assurance ...... 60 5.11 Conclusion ...... 64 6.0 FUTURE CLINICAL MODEL ...... 65 6.1 Future Clinical Model & Pathway ...... 65 6.2 Workforce ...... 69 6.3 Conclusion ...... 73 7.0 FINANCIAL AND ACTIVITY IMPACT ...... 74 7.1 Financial Appraisal of Remaining Options ...... 74 7.2 Bed Modelling ...... 75 7.3 Activity Impact ...... 76 7.4 Financial Modelling ...... 77 7.5 Conclusion ...... 83 8.0 IMPLEMENTATION ...... 84 9.0 CONCLUSION ...... 90

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APPENDICES 1 Midlands and East Stroke Specification 2 SNNAP Data 3 C&W CRG recommendations 4 Benefits Realisation 5 Stroke Engagement feedback report (2015) 6 Engagement Report (2017) 7 Consultation Document 8 Options Appraisal Report 9 Risk Assessment of Bedded Rehabilitation Options 10 Integrated Impact Assessment 2018 11 Integrated Impact Assessment – Technical Working Documents 12 Letter of Approval from Clinical Senate 13 Data Protection Impact Assessment 14 Model Inputs and Assumptions 15 WMAS Modelling for Warwickshire 16 Rehabilitation Modelling Plans 17 Sensitivity Modelling 18 Implementation Gantt

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1.0 EXECUTIVE SUMMARY

1.1 Purpose of this Document This document aims to describe the process through which we have worked with all key stakeholders since the outset of the programme in 2014, to develop a proposed new clinically and operationally sustainable model for stroke services across Coventry and Warwickshire that: • meets nationally and locally defined requirements and guidance for the provision of stroke services • has considered the growing bank of evidence for the most effective treatment and care services/pathways and lessons from other systems developing best practice care models • has been shaped by substantial stakeholder engagement throughout the journey • has had clear and consistent multi‐agency governance and assurance • has undergone open and transparent appraisal both financially and non‐financially to ensure the long‐term viability of the model • is aligned with local and national strategy This document also describes how stroke services are currently provided across Coventry and Warwickshire, sets out the issues and inadequacies with the current services and our proposal for change. We recognise that stroke services across Coventry and Warwickshire can achieve better health outcomes for patients by being set up in line with established best practice guidance. In so doing, they can also be more effective and efficient. As system leaders it is our role to present the community with a clear service pathway and proposal for change. This will require us to make changes to the structure of the existing services, including enhancing some services and reducing or stopping others when they are no longer appropriate. We believe that through delivery of this business case we will create services that contribute to a more effective health and social care system.

1.2 Stroke and TIA Definition Stroke is the leading cause of disability and fourth largest cause of death in the UK. Just over 1,200 people a year in Coventry and Warwickshire have a stroke and are taken to one of our three local hospitals. In 2016/17 there were over 15,000 stroke survivors on local GPs stroke registers and over 320 people were diagnosed with a Transient Ischaemic Attack (TIA). A stroke occurs when the blood supply to part of the brain is cut off and is therefore unable to carry essential nutrients and oxygen to the brain, causing brain cells to become damaged or to die. The damage caused can have different effects on the body and how people think, feel and communicate, depending on where the damage occurs.

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There are two types of stroke: • Ischaemic stroke – most strokes are an ischaemic stroke, caused by a blockage that cuts off the blood supply to the brain; and • Haemorrhagic stroke – these are caused by bleeding in or around the brain. A Transient Ischaemic Attack (TIA) is also known as a mini‐stroke; whilst the same as a stroke, the symptoms last for a short amount of time and no longer than 24 hours, as the blockage that stops the blood getting to the brain is temporary. As people age their arteries become harder and narrower and are at more risk of becoming blocked, causing ischaemic strokes. Certain medical conditions and lifestyle factors however – including high blood pressure and obesity ‐ are known to speed up this process and increase the risk of a stroke.

1.3 Governance Arrangements The development of the Pre‐Consultation Business Case has been a Commissioner‐led process overseen initially by the Warwickshire and Coventry CCG Federation and now by the Strategic Commissioning Joint Committee (comprising CCG Clinical Chairs, Accountable Officers, Chief Financial Officers and other key members of all three local CCGs). However, it has extensively involved key stakeholders through a multi‐agency project governance structure. This structure was established at the beginning of the programme in 2014 and has been in place throughout. Local acute and community service providers, as well as ambulance, Local Authority and patient representatives, have been represented at various levels, including via: • Stakeholder Board – comprising provider strategy and medical leads; • Clinical Review Group – comprising Medical Leads to support the development of the clinical model; and • Activity and Finance Workstream. • Clinical and Operations Group – comprised of Clinical and Operational Leaders A full description of the governance and assurance structure and arrangements can be found in section 5.1.

1.4 The Case for Change There is a strong and growing evidence base, that the organisation and timeliness of stroke specialist assessment and treatment significantly affects outcomes. The following key issues have been identified with the current service organisation and provision which results in locally increased mortality and morbidity following a stroke: • The current service provision across Coventry and Warwickshire does not meet the requirements of the NHS Midlands and East regional Stroke Services Specification, particularly in ensuring that all patients suffering a stroke receive appropriate hyper acute care within the first 72 hours. Currently, on average 4 patients per day do not receive hyper acute assessment;

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• The HASU/ASU beds and rehabilitation services for Coventry and Warwickshire patients do not universally meet all of the national performance standards for best practice care. Indeed, the latest published data in the NHS Atlas of Variation (2015) showed that the number of patients in Coventry and Warwickshire directly admitted to an Acute Stroke Unit within 4 hours of onset of a stroke was amongst the lowest in the country; • There is variable service provision and inequality of access to key services for Coventry and Warwickshire patients which must be corrected; particularly to HASU beds, inpatient rehabilitation, specialist community rehabilitation and Early Supported Discharge (ESD). Cohorts of patients in Warwickshire North and South Warwickshire currently have no access to some of these services; • Inadequate provision exists in primary prevention, in the form of gaps in anticoagulation therapy for those with atrial fibrillation to reduce the risk of stroke, with evidence that we could avoid c230 strokes over 3 years by bridging this gap; • The Sentinel Stroke National Audit Programme (SSNAP) results between Dec 2017- Mar 2018 show that Coventry and Warwickshire services are poor when compared to national average performance in delivering rapid access to appropriate services. The most significant issues arising from the SSNAP audits in support of the case for improvement are: o The proportion of patients scanned within 1 hour – in one of the local units 13% of patients are scanned within an hour, in comparison to a national average of 52.4%; o The median time taken for patients to be scanned – most recent results show it takes just over 2 hours and 43 minutes at one of our hospitals for patients to be scanned, against a national average of just under an hour; o The time taken for patients to be admitted to a Stroke Unit – whilst the national average time for patients to be admitted to a Stroke Unit is 3 hours and 52 minutes, it takes between 6 and 11 hours for patients in Coventry and Warwickshire; and o The proportion of patients assessed by a Stroke Specialist Consultant Physician within 24 hours is below the national average for two of the three acute providers in Coventry and Warwickshire. • There is considerable variation in the acute care provided across the three sites, particularly in relation to lengths of stay. It is clear from review work undertaken that, due to a lack of specialist stroke ESD and community stroke rehabilitation services, patients are currently staying longer in the available acute stroke beds than is in their best interest; • Critically, there are insufficient Stroke Specialist Consultants to operate an improved and effective service within the current configuration of services, given the requirement to staff services on each of the three acute sites. At the outset of this work, there were only four permanent Stroke Specialist Consultants working across the three acute providers. Five years later this is still the case. There are known

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national shortages of these specialists and recruitment to vacant posts has been challenging for all providers. Given these issues, work is clearly required to improve local stroke care across Coventry and Warwickshire so that more patients can survive their stroke and achieve their optimum level of recovery and independence.

1.4.1 Clinical Best Practice The assessment of current services and design of the future clinical model and pathway has taken into consideration published evidence, guidance and observations of best clinical practice at other organisations in England. The NHS Midlands and East Stroke Specification sets out the criteria, as recommended by the External Expert Advisory Group, that different parts of the stroke pathway need to meet to deliver high quality care to patients. These are the expected standards that commissioners should adopt when commissioning stroke care services. The proposed clinical model has been developed with the NHS Midlands and East Regional Stroke Services Specification at the forefront of thinking.

Learning from other stroke service models in England Members of the Coventry and Warwickshire Stroke Clinical Review Group have learned from a number of other stroke units in the country which had been identified as demonstrating clinical best practice and from published evaluation findings. These included the London Stroke Model, Nottingham stroke service, Stoke on Trent stroke service and North Essex ESD service. The evidence is clear that centralising stroke treatment at a much smaller number of hospitals with specialist stroke care has considerable benefits. The Coventry and Warwickshire model proposed has been designed taking into account learning from the operation of each of these sites as well as wider documented evidence. This has included testing the capacity planning for the proposed new service provision; the capacity we have planned is broadly in line with the findings from research into stroke services at other best practice regions with similar demographics.

Early Supported Discharge (ESD) and Community Stroke Rehabilitation There is strong evidence nationally that a new and comprehensive ESD service will be able to reduce patient’s length of stay in hospital. Within Coventry, ESD services were piloted from December 2014 to May 2015 and following the success of the pilot, standard ESD has been substantively commissioned in Coventry only since September 2015. Data from the pilot and the current service provide strong evidence of the success and reach of the proposed model. Full details of this evidence can be found in section 4.3. The success of an ESD service rests on the provision of high quality, sustainable community stroke rehabilitation services. The community stroke rehabilitation element of the proposed model provides flow through the system that enables ESD to sustain high quality, high

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intensity, and timely discharges for those most likely to gain full or near to full recovery post stroke. It also provides interdisciplinary rehabilitation to support flow from bedded rehabilitation for those who have had a moderate to severe stroke, to enable appropriately supported discharge from hospital.

Atrial Fibrillation (AF) There is evidence that optimally treating high risk AF patients has the potential to avert 230 strokes over three years in Coventry and Warwickshire (‘The Size of the Prize on CVD prevention’, Public Health England and NHS England). This evidence indicates that there is significant clinical and financial benefit potentially from this intervention and it has been factored into the activity and financial modelling for the proposed new service.

1.4.2 Local and National Strategy The proposed new service model is in line with the following local and national strategy documents: • The National Stroke Strategy (2007), which advocated provision of specialist stroke units, rapid access for TIA patients, immediate access to diagnostic scans and thrombolysis (for those who need it) and Early Supported Discharge. • The NHS England Five Year Forward View (2014), which cited the centralisation of 32 stroke units in London to 8 units and the reduction in mortality rates and lengths of stay in hospital that resulted from this service change. • The NHS Long Term Plan (2019) which includes commitment to improved post‐hospital stroke rehabilitation models by 2020 • Coventry and Rugby CCG’s Commissioning Intentions (2017 – 2019) • South Warwickshire CCG’s Strategic Plan (2016 – 2020) • Warwickshire North CCG’s Vision for Quality Clinical Vision • The Coventry and Warwickshire Sustainability and Transformation Plan

1.5 Summary of Current Stroke Service Provision The current services in Coventry and Warwickshire for patients who suffer a stroke or have a Transient Ischemic Attack (TIA) are provided locally by three acute hospital trusts and a local provider of community physical and mental health services, as listed below: • University Hospitals Coventry & Warwickshire NHS Trust (UHCW) • South Warwickshire NHS Foundation Trust (SWFT), • George Eliot Hospital NHS Trust (GEH) • Coventry and Warwickshire Partnership NHS Trust (CWPT).

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The services currently provided are described in the table below.

Services UHCW SWFT GEH CWPT HASU beds 6 0 0 N/A 18 (+1 ASU beds 30 12 N/A assessment bed) Inpatient stroke 6 20 N/A N/A Rehabilitation beds Total beds 42 32 19 N/A 7-day TIA service 5-day service 7-day nurse-led N/A consultant-led Treated at Treated at Thrombolysis Yes N/A UHCW UHCW Carotid imaging Yes Yes 2 sessions N/A Carotid Treated at Treated at Yes N/A endarterectomies UHCW UHCW Stroke outreach N/A Yes Yes N/A team Early Supported Rugby residents Coventry Discharge (ESD) N/A N/A only residents only service Community Stroke N/A N/A N/A Yes Rehabilitation A more detailed description of the key services in the current system is provided below.

1.5.1 Hyper Acute Stroke Units There is a Hyper Acute Stroke unit (HASU) at University Hospitals Coventry & Warwickshire NHS Trust (UHCW). This offers 24‐hour, 7‐day cover with rapid assessment for patients on arrival to the Emergency Department. It includes rapid access to imaging and thrombolysis as appropriate and wider access to other specialist skills and diagnostics. The HASU sees all Coventry and Rugby patients who are suspected of having a stroke, and also patients from north and south Warwickshire who are assessed by a paramedic to be FAST‐positive within 4 hours of onset of symptoms. As soon as patients are assessed as having a stroke (this can sometimes be in the ambulance or in the Emergency Department in UHCW), all patients are seen by the Stroke Consultant‐ led Team for a multi‐disciplinary assessment. This assessment determines likely diagnosis and if confirmed as a stroke, they are admitted to the HASU. However, not all Coventry and Warwickshire patients suspected of having had a stroke are immediately taken or directed to the HASU. Therefore, not all patients have an immediate specialist assessment, where they will also have access to the full range of specialist skills and diagnostics. This is a significant gap in the current service provision when it is compared to the NHS Midlands and East regional Stroke Services Specification, which identifies that any patient within 72 hours of onset of stroke symptoms can benefit from assessment and treatment in a hyper‐acute centre.

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There is a cohort of patients from north and south Warwickshire who are either: • Taken to, directed to or who self‐present at their local general hospital; or • Assessed by a paramedic to be FAST‐positive after 5 hours of onset of symptoms and are then taken to their local general hospital Emergency Department i.e. George Eliot Hospital NHS Trust (GEH), or South Warwickshire NHS Foundation Trust (SWFT). After the hyper acute element of care at UHCW: • Patients are discharged home if medically appropriate; • Where further acute care is needed, Coventry and Rugby patients are transferred to the Acute Stroke Unit (ASU) at UHCW; • Patients from south and north Warwickshire needing further acute care are repatriated to the local ASUs at SWFT or GEH respectively, within 72 hours if possible, subject to bed availability. If there is no ASU bed available in their local hospital, they are admitted to UHCW ASU until a local bed becomes available.

1.5.2 Acute Stroke Units All three local acute providers deliver Consultant‐led Acute Stroke Care on a 24 hour, 7 day basis and have brain imaging available on all sites.

1.5.3 Rehabilitation, Outreach and Early Support Discharge There is considerable variation in the stroke specialist rehabilitation services available across the area, as described in the table below. South Warwickshire Rehabilitation service Coventry & Rugby CCG Warwickshire North CCG CCG Inpatient rehabilitation 6 beds at the Hospital of St Cross for patients 20 beds in No specifically from Rugby aged 65 Leamington Spa designated beds years and over ESD Available to all patients Not available Not available Community Community Stroke rehabilitation rehabilitation services Stroke Outreach for Coventry residents therapy service Stroke Outreach provided by CWPT. provided by GEH. therapy service Community general Community general provided by SWFT rehabilitation services rehabilitation services for Rugby residents provided by SWFT provided by SWFT

The lack of comprehensive access to specialist stroke rehabilitation services is a gap when comparing the current services to the requirements of the NHS Midlands and East regional Stroke Services Specification.

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1.5.4 TIA For those patients experiencing a TIA, carotid imaging is available on site at both UHCW and SWFT; it is available for two sessions each week at GEH. Patients presenting at GEH who require carotid imaging when carotid imaging is not available are transferred to UHCW. All patients from across Coventry and Warwickshire requiring a carotid endarterectomy undergo surgery at UHCW. Both UHCW and GEH provide onsite TIA clinics on a daily basis, 365 days a year. UHCW’s clinics are Consultant‐led, whilst GEH clinics are nurse‐delivered with Consultant leadership. Since January 2016, all high‐risk TIA patients in the south Warwickshire region, who previously would have been seen at SWFT, are now seen at UHCW.

1.6 Proposed Future Clinical Model A significant amount of work has been undertaken by clinicians from across the health economy to design a new model for stroke services that meets the clinical best practice outlined in the NHS Midlands and East Stroke Services Specification.

1.6.1 Public engagement. Over the last five years, the model of care has been co‐designed through public and patient representative engagement. The rationale behind the proposed model has been shared extensively, including with: • Local commissioners; • Health, social care and other key partners including the Stroke Association; • The Warwickshire and Coventry Adult Social Care and Health Overview and Scrutiny Committees and District and Borough Council Scrutiny Committees • The Public and Patient Advisory Group specifically established to advise on the development of proposals since the project started in 2014; • Stroke survivors in stroke clubs and • Health professionals and other key stakeholder groups (i.e. Local Authorities, Councillors). All of these parties have helped to shape and inform the development of the proposed stroke service model. During the engagement in 2017 they have been supportive of this proposed model assuming that a number of key access factors, particularly for carers and relatives, can be mitigated. We have taken this feedback on board and reshaped the proposals during 2018 to reach this final case. Further, engagement in 2018 helped to shape the process for appraising the options for bedded rehabilitation; coproducing the desirable criteria to be used for the non‐financial appraisal and culminating in stakeholder participation in the non‐ financial option appraisal.

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1.6.2 Options development and analysis

Development of the Options To develop the proposed model a range of options have been considered; initial development work focused on the acute stroke pathway only. A long list of scenarios was developed and explored for the provision of an acute pathway. The long list is as follows: • Scenario 1 ‐ Do Nothing • Scenario 2 ‐ HASU at UHCW / 1 ASU at UHCW • Scenario 3‐ HASU and ASU for Coventry and Rugby patients up to discharge at UHCW, and for North and South Warwickshire patients up to day 7, with repatriation to ASU and SWFT or GEH at day 8 as required. (discounted as clinically not viable) • Scenario 4 ‐ HASU at UHCW / 3 ASUs at UHCW, SWFT & GEH • Scenario 5A ‐ HASU at UHCW / 2 ASUs at UHCW & SWFT • Scenario 5B ‐ HASU at UHCW / 2 ASUs at UHCW & GEH An assessment based on clinical viability using the following criteria was undertaken: 1. Be capable of meeting the Midlands and East Stroke Service Specification; 2. Be clinically viable in terms of both activity and workforce. Local clinicians agreed that to be clinically sustainable, a Stroke Unit would require a minimum of 10 stroke beds being operational. Assessment of each of the long list options found that option 2 is the only option that would be capable of sustaining the expert workforce required to drive improvements to outcomes. As such all other options were clinically unsustainable. The details of the assessment are described in sections 5.3 and 5.4. A single preferred acute pathway clinical option was at this stage selected. This was discussed with local Councillors who are the Health portfolio holders and members of the Public and Patient Advisory Group during 14th to 17th September 2015. It was also considered at the Health Overview and Scrutiny Committees in Warwickshire and Coventry in September 2015. All groups were generally supportive of the model but asked that it be expanded to include comprehensive stroke rehabilitation services and interventions to prevent strokes. The model of care was therefore extended to include these. During June and July 2017, a further comprehensive public engagement process was undertaken on a proposal for a centralised hyper acute and acute service, bedded rehabilitation on two sites, ESD, community stroke rehabilitation at home and improvements in AF anticoagulation therapy. This resulted in some specific concerns being raised regarding access and travel, most of which are addressed through an action plan working with Council colleagues. Alongside this the stroke expert Clinical and Operations Group leading the clinical design of the future stroke service model was asked to revisit the work completed to date and to consider if there was another method of delivering bedded rehabilitation for the Coventry and Rugby population, to address the travel for carers concerns raised.

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This further work identified that there were a number of potential scenarios for providing the bedded rehabilitation aspect of the pathway. A long list of potential scenarios was developed by the Clinical and Operations Group. These scenarios were assessed against their ability to: • meet national guidance and the requirements of the NHS Midlands and East Regional Stroke Service Specification • demonstrate at least the minimum levels of delivery of: quality; being safe; being sustainable and better outcomes for patients Following these clinical assessments two viable stroke rehabilitation options remained: Rehab Option 1: Early Supported Discharge Service (ESD) and community rehabilitation in all areas. Bedded rehabilitation at South Warwickshire Foundation Trust (SWFT) in Leamington and George Eliot Hospital (GEH) in Nuneaton Rehab Option 2: ESD and community rehabilitation in all areas. Community bedded rehabilitation provision in Coventry with specialist therapy in‐reach. Bedded rehabilitation at SWFT in Leamington and GEH in Nuneaton These options were then taken forward for full non‐financial appraisal by all key stakeholder groups. Details of the options appraisal are provided within section 5.7 On the basis of this work, an options appraisal of the two viable options for providing bedded rehabilitation was carried out. The appraisal involved representatives from all key stakeholder groups, examples include; patients and carers, local councillors, voluntary sector and community support NHS clinicians, social care commissioner and managers.

The outcome of the options appraisal identified Rehab Option 1 as the preferred option: Early Supported Discharge Service (ESD) and community rehabilitation in all areas. Bedded rehabilitation at South Warwickshire Foundation Trust (SWFT) in Leamington and George Eliot Hospital (GEH) in Nuneaton.

Integrated Impact Assessment (IIA) Two Integrated Impact Assessments have been undertaken in 2015 and 2017/18 as proposals have developed. They were completed to estimate the possible implications of re‐ designing stroke services on patients and their carers and how these effects may be distributed amongst different groups and geographies. The impact assessment focused on three main areas; travel and access; health and determinants of health and equality. The IIA made recommendations to enhance potential positive outcomes and minimise negative impacts of the proposals.

The assessment and scoring from the IIA suggest that proposals for the centralisation of all acute care and proposed models for rehabilitation would have an overall positive impact on patients and carers compared to the do‐nothing scenario. Whilst the centralisation and community bedded rehabilitation options will invariably negatively impact on travel and access for some patients and carers, particularly from the North and South of Warwickshire, the expected health benefits, greater proportion of time recovering at home and a greater

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equity of exemplar service provision across the area, in the proposals would more than offset any negative impacts.

1.6.3 The proposed future model for stroke services We believe that the resulting proposed new pathway of excellence will be the best possible clinical model for stroke services in Coventry and Warwickshire for the following reasons: • It has been designed taking into account the requirements of the NHS Midlands and East Stroke Services Specification and the latest clinical best practice evidence; • It improves equity of access to stroke services across Coventry and Warwickshire; • It fits with local and national strategy; • It will create workforce development opportunities and improve recruitment and retention of stroke specialist staff; • It has been tested through a range of clinical quality assurance processes, including the West Midlands Clinical Senate and West Midlands Cardiovascular Network; • Significant stakeholder engagement and co‐production of the proposals through the engagement activities undertaken has provided support to proceed with this option. At a high level, the proposed future pathway is as follows:

The pathway has the following key features: • Provision of a single centralised Hyper Acute Stroke Unit (HASU) and Acute Stroke Unit (ASU) at UHCW, with the necessary infrastructure, support and workforce to assess and diagnose all patients suspected of having had a stroke from across Coventry and Warwickshire, within 72 hours of onset; • Home‐based stroke specialist ESD service across all of Coventry and Warwickshire; • Home‐based community stroke rehabilitation service across all of Coventry and Warwickshire; • Bedded stroke rehabilitation services for those patients that require more intensive support after discharge from the ASU and

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• A systematic focus on preventing stroke in the form of an integrated anticoagulation pathway that acts to reduce the risk of stroke. The CCGs are clear on the improved outcomes they wish to see delivered through this change. By ensuring a consistent, high quality service offer, improvement will be made against the following three key clinical outcomes: 1. Reduced levels of mortality for people who have suffered a stroke: case adjusted mortality rates for Coventry and Warwickshire will meet those of comparable population areas; 2. Reduced levels of dependency for those who have suffered a stroke: outcomes will be at least comparable with similar populations by improving and increasing access to the specialist stroke ESD and community rehabilitation services at home, and specialist bedded stroke rehabilitation, and 3. An improvement in cognitive function for people after suffering a stroke: outcomes will be at least comparable with similar population areas.

1.6.4 Equity of access to services Put simply, under the new model, all patients across Coventry and Warwickshire will be seen more promptly and in the right place by specialist skilled professionals, where they will receive the highest quality care. There will be no inequality of access to the appropriate specialist care. A consistent stroke service will be in place across all of Coventry and Warwickshire, removing the current inequity of access to services. This applies to all elements of the pathway, including HASU and ASU beds and stroke specialist rehabilitation services. Centralisation of acute care and standardised bedded rehabilitation will ensure a body of suitably qualified and experienced staff is available to see and treat all patients. The home‐ based rehabilitation will provide an extra 620 packages of care and the anticoagulation therapy will prevent 230 strokes over three years.

1.6.5 Quality assurance In order to ensure that the new model is appropriate clinically, the following quality assurance reviews and processes have been undertaken: Health Gateway Review 0; National Clinical Advisory Team Review; West Midlands Strategic Clinical Network Assurance; West Midlands Clinical Senate Review; Assessment of the fit against the “Five Tests” for Reconfiguration; Two Integrated Impact Assessments (IIA); and A Privacy Impact Assessment (PIA).

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The outcome from all of these tests has been supportive of the new model. In particular, external clinical advice has agreed that our preferred model is appropriate and based on best practice.

1.7 Financial and Activity Impact The preferred option for the proposed future clinical model for Coventry and Warwickshire has been agreed by all stakeholders to provide the best possible quality of care for stroke patients. However, given the finite resources within the health economy, it is also important to demonstrate that the proposed new model is affordable. Finance and activity modelling work has therefore been undertaken to estimate the likely impact on patient flows, costs and potential savings from the potential new models and is described in section 7.

1.7.1 Bed capacity modelling Modelling has been undertaken to establish the number of beds required to manage demand through the current service model (do nothing state) and to manage the flow of patients through each of the options under consideration for the proposed future state. Activity for 2017/18 was used to form the baseline for modelling, with growth of 1.07% assumed annually. In establishing the future bed base, the following assumptions were made: • HASU length of stay would continue to be up to 3 days; • ASU length of stay is expected to reduce from the current 18 days (spell average) to 11 days at day 1 of introduction of the full pathway; • the HASU will operate at 85% bed occupancy, the ASU and bedded rehabilitation will operate at 90% bed occupancy, to allow the future service to manage peaks in activity to deliver the necessary patient flow through the system; • 40% of patients on the Acute Stroke Unit will require a standard ESD package, with a further 30% of patients suitable for bedded rehabilitation provision and 30% discharged with community rehabilitation; • 30% of the patients discharged with ESD will go on to receive community stroke rehabilitation support. • 90% of the patients discharged from bedded rehabilitation will go on to receive community stroke rehabilitation support. • There will be no bed base reduction at any of the acute providers. Beds that are identified as not required for stroke care will be used to support the delivery of other acute hospital activity.

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The results of this work on bed modelling are shown in the table that follows:

Bed/Service Current Future Difference (Beds) provision

Hyper Acute Stroke 6 beds at UHCW 12 beds at UHCW + 6 beds beds

30 ASU beds at UHCW

12 ASU beds at SWFT

Acute Stroke beds 18 ASU beds plus 1 31 ASU beds at UHCW - 30 beds assessment bed at GEH

(Total 61 beds)

6 inpatient rehabilitation

beds at Rugby site, 17 for C&R CCG

UHCW for Rugby (preferred option 9 in patients aged 65+ + 13 beds Community Stroke SWFT/8 in GEH) (N.B. different 20 inpatient Rehabilitation beds 12 beds in SW (SWFT) specification of rehabilitation beds at 10 beds in NW (GEH) beds) Leamington site, SWFT

for SW patients only (Total 39 beds)

(Total 26 beds)

Total bed numbers 93 beds 82 beds - 11 beds

1.7.2 Financial modelling

The financial implications of the proposed model have been assessed. This assessment has been discussed at STP level and the following principles agreed by both Commissioners and Providers:

• The bedded part of the stroke pathway will continue to be covered by tariff under the current tariff cost envelope.

• The three CCGs will invest the required amounts in the additional ambulance transfers, elements of prevention and the community stroke rehabilitation pathway In line with these assumptions, estimates have been produced by Commissioners and Providers of income, activity and costs under the current model and the future model options. These estimates have been based on 2017/18 planned activity and prices to enable a consistent approach to be taken. Assumptions have been made for future demand driven by changes in population demographics and expected growth rates for Coventry and Warwickshire. It is important to note that there will be no savings to Commissioners from the planned bed base realignment outlined in the previous section. The table that follows provides the results of the financial analysis of the investment required by CCGs in the community elements of the pathway.

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Community pathway elements £000s Historic Investment by CCGs 1,663 Revised Investment by CCGs 5,074 Additional Investment by CCGs 3,411

Additional cost of Acute model 374 Less savings on CHC packages -700 Net additional CCG investment required 3,085

This analysis indicates that the CCGs will be required to invest a further £3.1m in the community pathway. It has been agreed how this investment will be split between the CCGs:

• Proposed investment levels are within CCG financial plans for 2019/20 (on a part year basis) and will be in 2020/21 (on a full year basis). The five-year financial plan being developed will include the impact of this service provision.

• The source of funding for stroke prevention (Atrial Fibrillation anticoagulation therapy) is savings delivered from elsewhere within CCG budgets. Section 7.3 provides full details of the financial modelling that has been undertaken.

1.7.3 Financial risks

A number of financial risks have been identified whilst undertaking the modelling and are described in full in section 7.4.4. Of those risks identified, all have in place mitigation plans and only two of the risks are identified as high.

The first, is the risk of failing to achieve an acute length of stay of 11 days. It is expected, based on clinical evidence nationally and locally, that the introduction of bedded rehabilitation, ESD and Community Stroke Rehabilitation across all geographical areas will achieve this reduction in the acute length of stay.

The second, is the risk that the realignment of use of the beds no longer required for stroke as part of the proposed model, will result in a reduction in provider income for those beds. A period of transitional activity and associated cost has been agreed to mitigate the potential impact should this risk materialise.

1.7.4 Conclusions

The financial analysis indicates that the CCGs would be required to invest £3.1m in the proposed model of care, to fund the delivery of the community elements of the pathway.

Some modest financial savings will accrue to the CCGs as a result of the new model: £0.7m from the impact of improved anticoagulation therapy for AF and reduction in long term NHS funded packages of care through the improved rehabilitation offer.

This is considered an appropriate investment to make to remove the current system inequality, increase the quality of services, improve outcomes and access, addressing the key issues outlined above.

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After the consultation process, and as part of mobilisation, further work will be undertaken on the timing of the required investments.

1.8 Implementation Implementation will be overseen by the formation of an Implementation Board, chaired by a Chief Executive of one of the provider organisations (to be nominated), with membership comprising at least one Executive from each of the provider and commissioner organisations. The Implementation Board will have responsibility and accountability for signing off progression through the implementation gateways defined. It is proposed that the already established Stroke Clinical and Operations Group will reconfigure to become the Implementation Team, with day to day responsibility and accountability for managing the delivery of the new networked clinical model.

1.8.1 Timescales Implementing the proposed new clinical model represents a significant change to current services and as such will be a complex process. We are currently in the early stages of implementation planning as the focus to date has been on comprehensively engaging with all key stakeholders to design the most appropriate service delivery model. Acknowledging that greater detail will be provided during and following consultation, the present outline implementation timeline is provided overleaf. A high‐level project plan Gantt chart illustrating the key tasks and project gateway decision points that will be used by the Implementation Board to determine whether implementation can progress has been developed.

Business Case Business case complete June 2019 NHS England Assurance process commences June 2019 Consultation period August 2019 – October 2019 Governing Bodies consider consultation results and decision made (BC updated November 2019 with consultation outcomes) Contract signed Late Feb 2020 Proposed Mobilisation and Implementation should pathway be agreed Community pathway mobilisation/ implementation Recruitment commences to ESD and CSR posts Jan 2020 Mobilisation of ESD and CSR May 2020 ESD and CSR fully implemented Jan 2021 Acute pathway mobilisation/ implementation Recruitment commences to acute posts Dec 2019 Adequate acute staffing in post. Go/No gateway decision Dec 2020 UHCW: additional HASU/ASU beds implemented SWFT: ASU beds closed / SWFT CSRB implemented April 2021 GEH: ASU beds closed / GEH CSRB implemented Complete pathway implemented April 2021

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A significant amount of work has been undertaken with regard to the future workforce requirements, identifying a proposed future workforce model and the potential actions required to implement such a model. This work is described in sections 6.2 and 8.1.4.

1.8.2 Risks This is a complex service reconfiguration and as such work has already taken place to identify the potential risks to delivery of the proposed new clinical model and to develop appropriate mitigation plans. The key risks include, workforce planning, capacity planning and maintaining affordability given these two risks. Full details of the risk analysis and mitigation plans are described in detail in section 8.1.5

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2.0 BACKGROUND AND CONTEXT This document describes how stroke services are currently provided across Coventry and Warwickshire, sets out the issues with the current services and our proposal for change. Just over 1,200 people a year in Coventry and Warwickshire have a stroke and are taken to one of our three local hospitals. In 2016/17 there were over 15,000 stroke survivors on local GPs stroke registers and over 320 people were diagnosed with a Transient Ischaemic Attack (TIA). Current stroke services in Coventry and Warwickshire have improved over time and are providing a good standard of care but, they are not meeting the latest national and regional guidance and evidence. Comparisons of the performance and outcomes of current stroke services across Coventry and Warwickshire with best practice standards and the achievements of other health systems in England, show we can achieve better health outcomes for patients, more effective and efficient services. The range of services currently available to our patients also varies considerably based on where people live. The Coventry and Warwickshire Sustainability & Transformation Plan (STP) defines the re‐ configuration of stroke services as outlined in this Business Case as a key priority as part of its Emergency and Urgent Care Workstream. It is important to note that each of the leaders within the STP has agreed that the model outlined in this business case is the right one and should be implemented. As system leaders it is our role to present the community with a clear service pathway that is easy to navigate. This will require us to make changes to the structure of existing services; enhancing some and reducing or stopping others when they are no longer appropriate. We believe that through delivery of this business case we will create services that contribute to a more effective health and social care system. We begin by outlining the current way in which stroke services are delivered.

2.1 Current services The current services in Coventry and Warwickshire for patients who suffer a stroke or have a Transient Ischemic Attack (TIA) are described in the table below. These services are provided locally by three acute hospital trusts: University Hospitals Coventry & Warwickshire NHS Trust (UHCW), South Warwickshire NHS Foundation Trust (SWFT), George Eliot Hospital NHS Trust (GEH) and a local provider of community physical and mental health services, Coventry and Warwickshire Partnership NHS Trust (CWPT).

Providers of Stroke, TIA & Related Services Provider Stroke / TIA Services • Hyper Acute Stroke Unit (6 beds); • Acute Stroke Unit (30 beds); University Hospitals Coventry & • Only site that undertakes thrombolysis; Warwickshire NHS Trust (UHCW) • Inpatient Stroke Rehabilitation Beds (6 beds in Rugby); – covering Coventry, Rugby and parts of Warwickshire • TIA Service (7‐day Consultant‐led service); • Carotid imaging available; • Only site to undertake carotid endarterectomies.

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Provider Stroke / TIA Services • Acute Stroke Unit (12 beds); • TIA (5‐day service); South Warwickshire NHS • Carotid imaging available; Foundation Trust (SWFT) • Stroke patients requiring thrombolysis treated at UHCW; – covering south Warwickshire temporary transfer of high risk TIA patients (in place population for acute care and from January 2016); Warwickshire population for • Inpatient Stroke Rehabilitation Beds (20 beds in general community services Leamington Spa); • Stroke Outreach team; • ESD service for Rugby residents. • Acute Stroke Unit (18 + 1 assessment bed); George Eliot Hospital NHS Trust • TIA (7‐day nurse‐led service); (GEH) • Patients requiring thrombolysis, or carotid – covering north Warwickshire, endarterectomies transferred to UHCW; south west Leicestershire and parts • carotid imaging, 2 sessions a week at GEH otherwise of north Coventry UHCW; • Stroke Outreach team. Coventry and Warwickshire • Community Stroke Rehabilitation and ESD service for Partnership NHS Trust (CWPT) Coventry residents. – covering Coventry for Community and Mental Health services (and Warwickshire for Mental Health)

2.2 Hyper Acute Stroke Unit A hyper acute stroke unit (HASU) offers 24‐hour, 7 day cover with rapid assessment for patients on arrival to an Emergency Department. This includes rapid access to imaging and thrombolysis as appropriate and wider access to other specialist skills and diagnostics. At UHCW, a single 6‐bedded HASU has been in operation since 2008 providing a Consultant‐ led service, with immediate on‐site access to vascular and cardiac imaging, radiology and neuro‐interventional and neuro‐radiology imaging. The HASU sees all Coventry and Rugby patients who are suspected of having a stroke and all patients from north and south Warwickshire for whom an ambulance has been called and they are assessed by a paramedic to be FAST‐positive, within approximately 4 hours of the onset of symptoms. However, not all Coventry and Warwickshire patients suspected of having had a stroke are immediately taken or directed to the HASU. Therefore, not all patients have an immediate specialist assessment, where they will also have access to the full range of specialist skills and diagnostics. There is a cohort of patients from north and south Warwickshire who are either:

• Taken to, directed to or self-present at their local general hospital; or

• Assessed by a paramedic to be FAST-positive after 4-6 hours of onset of symptoms and then taken to their local general hospital Emergency Department i.e. GEH or SWFT.

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Patients who are taken to UHCW are seen by the Stroke Consultant‐led Team for a multi‐ disciplinary assessment to determine likely diagnosis. If a stroke is confirmed, the patient is admitted to the HASU, as well as being assessed for their suitability for thrombolysis and their ongoing care needs. After the hyper acute element of care at UHCW:

• Patients are discharged home if medically appropriate;

• Where further acute care is needed, Coventry and Rugby patients are transferred to the Acute Stroke Unit (ASU) at UHCW;

• Patients from south and north Warwickshire needing further acute care are repatriated to the local ASUs at SWFT or GEH respectively, within 72 hours if possible and subject to bed availability. If there is no ASU bed available, they are admitted to the UHCW ASU until a local bed becomes available.

2.3 Local Acute Stroke Units All three local acute providers deliver Consultant‐led Acute Stroke Care on a 24 hour, 7 day basis and have brain imaging available on all sites. Their bed allocation is as follows:

Number of Acute Stroke & Related Beds Provider ASU Assessment Total Beds UHCW 30 0 30 GEH 18 1 19 SWFT 12 0 12 Total 61

2.4 Rehabilitation, Outreach and Early Supported Discharge There is considerable variation in the range of stroke specialist rehabilitation services that are available across Coventry and Warwickshire. The table below details the current service availability for CCG resident populations: South Warwickshire Warwickshire North Rehabilitation service Coventry & Rugby CCG CCG CCG Inpatient rehabilitation 6 beds at the Hospital of St Cross for patients 20 beds in No specifically from Rugby aged 65 Leamington Spa designated beds years and over ESD Available to all Not available Not available patients Community rehabilitation Community Stroke Stroke Outreach rehabilitation services therapy service for Coventry residents Stroke Outreach provided by GEH. provided by CWPT. therapy service Community general Community general provided by SWFT rehabilitation rehabilitation services services provided by for Rugby residents SWFT provided by SWFT

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2.5 TIAs For patients experiencing a TIA, carotid imaging is available on site at UHCW and SWFT and for two sessions each week at GEH. Patients presenting at GEH who require carotid imaging when carotid imaging is not available, are transferred to UHCW. All patients from across Coventry and Warwickshire requiring a carotid endarterectomy undergo their surgery at UHCW. Both UHCW and GEH provide onsite TIA clinics on a daily basis, 365 days a year. UHCW’s clinics are Consultant‐led, whilst GEH clinics are nurse‐delivered with Consultant leadership. Since January 2016, all high‐risk patients in the south Warwickshire region, who previously would have been treated at SWFT, are now treated at UHCW.

2.6 Conclusion Stroke is the fourth commonest cause of death in the UK each year. In Coventry and Warwickshire just over 1,200 people each year experience a stroke. Current stroke services in Coventry and Warwickshire have improved over time and are providing a good standard of care but, they are not meeting the latest national and regional guidance and evidence. It is clear from the analysis of current service provision that there is considerable unwarranted variation and inequity in the range of service provision for patients across each CCG footprint in Coventry and Warwickshire. For example, access differs to inpatient rehabilitation beds, specialist community rehabilitation and ESD.

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3.0 THE CASE FOR CHANGE There is strong and growing evidence, that prompt specialist assessment and treatment significantly improve a person’s chance of surviving with the least complications and disabilities following a stroke. The evidence shows that patients are 25% more likely to survive or recover from a stroke if treated in a specialist centre. Patients need fast access to high quality scanning facilities and some need fast thrombolytic treatment. Being within 30 minutes (by ambulance) from a hyper‐acute unit will permit a more expert assessment, quicker treatment and far higher chances of a full rehabilitation. The most recent clinical guidelines from the RCP Stroke Working Party in 2016, state that ‘patients with acute stroke should be admitted directly to a hyper‐acute unit….’. There are several issues with the current service provision in Coventry and Warwickshire. To investigate the current state of Stroke and TIA services we have undertaken reviews of our service provision, performance and outcomes. We have also reviewed and identified best practice to understand how local services compare and can be improved. This work has been undertaken by a Clinical Review Group comprising of local medical leads and a Clinical and Operations Group comprising of local clinical and operational leaders, supported by external clinical review and challenge from the National Clinical Director for Stroke and the West Midlands Cardiovascular Network. Their work is summarised through this section, the outputs of which have told us that a number of key improvements are needed. We have used these insights to develop our proposed future clinical model and priorities for action.

3.1 NHS Midlands and East Stroke Services Specification The Midlands and East Stroke Services Specification (Appendix 1) was developed by NHS Midlands and East in October 2012 and updated in 2015. The specification was developed by an External Expert Advisory Group in consultation with stakeholders, including Stroke Networks, clinical staff working in the field, commissioners, patients and carers who have experienced NHS services. It built on clinical best practice to describe the standards commissioners should adopt, setting out the criteria that pathways need to meet to deliver high quality care and outcomes. The specification states that a “whole pathway approach” to the provision of stroke services is crucial to maximising clinical outcomes for patients, to achieve the resultant quality of life and improve their experience of stroke services. In particular, the first 72 hours of care is vital. The specification defines components of the pathway with recommended timescales for each phase. The three CCGs that cover Coventry and Warwickshire need to commission stroke services in line with the Midlands and East Stroke Services Specification. However, the current Stroke and TIA service provision across Coventry and Warwickshire does not meet the requirements of this specification. In particular, not all patients suffering a stroke receive appropriate hyper acute care within the first 72 hours and there is a lack of comprehensive access to ESD services and specialist community stroke rehabilitation.

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3.2 Primary Prevention There is inadequate provision in primary prevention of stroke in Coventry and Warwickshire. Local data suggests patients with atrial fibrillation are going unidentified and improvements can be made to better manage atrial fibrillation, hypertension and diabetes locally. The clinical evidence shows that:

• Reducing blood pressure in all adults with diagnosed and undiagnosed hypertension by 5 mmHg reduces risk of cardiovascular disease (CVD) events by 10%

• Statin therapy to reduce cholesterol by 1 mmol in people with a 10 year risk of CVD risk greater than 10% reduces the risk of CVD events by 20-24%

• Anti-coagulation of high risk AF patients averts one stroke in every 25 treated NHS Commissioning for Value and Public Health England analysis identified that there are significant opportunities in Coventry and Warwickshire to prevent the occurrence of strokes through ensuring that Atrial Fibrillation is identified (to the right prevalence rate), anticoagulation treatment is optimised and patients at high risk of having a stroke are managed appropriately (see data below).

The Size of the Prize in Cardiovascular Disease Prevention – Coventry and Warwickshire

3.3 Access There is significant inequality of access to HASU/ASU beds and rehabilitation services for Coventry and Warwickshire patients.

3.3.1 HASU / ASU beds Not all patients suspected of having had a stroke from across Coventry and Warwickshire are immediately taken or directed to the HASU for an immediate specialist assessment, where they will have access to the full range of specialist skills and diagnostics. All Coventry and

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Rugby patients suspected of having had a stroke are treated in the HASU, whilst patients from the rest of Warwickshire will only be taken to the HASU if they are assessed by a paramedic to be FAST‐positive within 4 hours of the onset of symptoms. There remains a cohort of patients from north and south Warwickshire who are either:

• Taken to, directed to or self-present at their local general hospital; or

• Assessed by a paramedic to be FAST-positive after 5 hours of onset of symptoms and are then taken to their local general hospital Emergency Department i.e. GEH or SWFT. Once at their local general hospital, if they are assessed to be in the hyper acute phase of a stroke and will benefit from thrombolysis, they will be transferred to UHCW as an emergency patient. Otherwise, once confirmed as a stroke patient, their care will remain at their ASU. Thrombolysis is only delivered from one site as Coventry and Warwickshire only has sufficient numbers of patients having a stroke for one unit to operate safely. UHCW has the required staff and infrastructure to deliver this.

3.3.2 Rehabilitation Access to rehabilitation services is inequitable.

• Stroke inpatient rehabilitation beds are currently only available to south Warwickshire patients and a small cohort of patients from Coventry and Rugby.

• ESD services are only available to Coventry patients.

• Community stroke rehabilitative services are available to residents of Coventry and Rugby, with Outreach teams providing more limited post-hospital support to patients in north and south Warwickshire.

3.4 Performance and Outcomes The Sentinel Stroke National Audit Programme (SSNAP) measures stroke service performance against a range of key areas critical to delivering optimal outcomes for patients. The results for the period October 2018 to December 2018 (Appendix 2) show that Coventry and Warwickshire services need to improve. The most significant issues arising from the SSNAP audits in support of a case for improvement are:

• The proportion of patients scanned within 1 hour – two of the local units are more than 20% below the national average of 52.4%;

• The median time taken for patients to be scanned – across the system it varies from 26 minutes to just over 1 hour and 52 minutes for patients to be scanned, against a national average of just under an hour;

• The time taken for patients to be admitted to a Stroke Unit – whilst the national average time for patients to be admitted to a Stroke Unit is just over 3.5 hours, it takes between 3 hours 20 mins and over 11 hours for patients in Coventry and Warwickshire; and

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• The proportion of patients assessed by a Stroke Specialist Consultant Physician within 24 hours – two of the three acute providers are significantly below the national average. The most recent results against these four metrics can be found in the table below:

Key SNNAP Metrics - October 2018 to December 2018 England Domain Metric Time Period GEH SWFT UHCW Average Proportion of patients scanned Oct 2018 – 54.5% 31.9% 34.1% 67.4% within 1 hour of clock start Dec 2018 Median time between clock Oct 2018 – 0h 52m 1h 40m 1h 52m 0h 26m start and scan Dec 2018 Median time between clock Oct 2018 – 3h 37m 11h 34m 3h 58m 3h 20m start and arrival on Stroke Unit Dec 2018 Proportion of patients assessed Oct 2018 – by a Stroke Specialist Consultant 84.4% 88.4% 63.6% 75.2% Dec 2018 Physician within 24hours

3.5 Length of Stay The Clinical Review Group completed two separate point prevalence audits in October and December 2014, to ascertain the appropriateness of patients in acute hospital beds at the time of the audits. These audits found that of the 93 beds available across Coventry and Warwickshire, all were occupied in the first audit, with 77% (72 beds) occupied in the second audit. The audit was repeated by the clinicians in 2017, to test whether these findings were still relevant, the results confirmed the findings remain relevant. The audits identified a number of patients who were in acute stroke inpatient beds that could have been benefitting from rehabilitation support outside hospital, had those services been available. These included patients that could have been:

• discharged with support from either a standard or enhanced ESD service

• discharged to a residential or nursing care home

• discharged with a package of care including further community stroke rehabilitative care, or

• receiving onward support in a specialist stroke rehabilitation unit, this latter being the largest cohort of the patients. Analysis of current activity data still supports these conclusions. Average lengths of hospital stay for patients that have experienced a stroke vary between 17 and 25 days (average length of stay for the system is 18 days). This is significantly longer than the length of stay in areas where they have optimised the configuration of services such as London, who achieve an average length of stay of 11 days.

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3.6 Best Practice Standards of Care

3.6.1 HASU / ASU beds Whilst there have been improvements made in stroke care locally, there remains inequity of access to services for patients suspected of having had a stroke. In particular there is inequity of access to both hyper acute stroke care (for those outside of the 4 hour window) and adequate rehabilitation services, to meet the national best practice care standards. The latest published NHS Atlas of Variation data (published in September 2015 using 2013/14 data) showed the number of patients in Coventry and Warwickshire directly admitted to an acute stroke unit within 4 hours of onset of a stroke was amongst the lowest in the country.

Extract from Map 40, NHS Atlas of Variation Percentage of people with acute stroke who were directly admitted to a stroke unit within four hours of arrival at hospital by CCG, 2013/14 CCG Name Rate 95% Lower Limit 95% Upper Limit NHS Coventry and Rugby 43.00 38.20 47.94 NHS Warwickshire North 38.10 32.32 44.23 NHS South Warwickshire 34.20 29.64 39.06 This data highlights local variance from best practice standards and national performance in accessing the right care at the right time to help improve patients’ chances of survival, optimising their independence and in minimising the level of disability resulting from a stroke.

3.6.2 Rehabilitation As has been highlighted above, there is considerable unwarranted variation in the range of stroke rehabilitation services provided across Coventry and Warwickshire. In the north of Warwickshire and in Rugby, there is limited or no access to local stroke specialist rehabilitative care and there are varying levels of rehabilitative care in hospitals. This results in significant inequity in service provision for our population.

3.7 Findings from Local Stroke Review A significant work programme was undertaken by the Clinical Review Group (CRG), which was led by the nominated lead clinical representative for all three CCGs, with the clinical leads of stroke and rehabilitative care for all local providers involved. This work included a review of local stroke services, which concluded that:

• HASU: Not all patients with a suspected stroke are being seen in a specialist hyper acute stroke unit and therefore some may be missing the opportunity provided by a hyper acute assessment and/or unit;

• Service configuration: Local services are not configured in the best way to achieve the improved standards that other best practice areas have achieved, as demonstrated in the NHS Atlas of Variation;

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• Workforce: There are insufficient Stroke Specialist Consultants to operate an improved stroke service as currently configured and a national shortage of Stroke Specialist Consultants;

• Equity of service provision: There is a need to address the inequity of access to services, particularly stroke specialist rehabilitation;

• Length of Stay: Due to a lack of specialist stroke ESD and community stroke rehabilitation services, patients are currently staying longer in the available acute hospital stroke beds than is ideal; and

• Community services: Many patients are currently in stroke acute hospital beds whilst they are waiting for other community-based services, such as care packages. Appendix 3 contains the complete review document.

3.8 Workforce Challenges A workforce review undertaken by the Clinical and Operational Group has identified existing gaps and a high probability of long‐term workforce challenges and constraints, which make continuing with the current configuration of services a risk. There is a particular issue with respect to the Stroke Specialist Consultant workforce where there is an acknowledged national shortage of Stroke Consultants. The BASP 2011 report Meeting the Future Challenge of Stroke indicated a deficit of circa 163 posts. At the outset of this work, there were only four permanent Stroke Specialist Consultants working across the three acute providers and recruitment to vacant posts has been challenging for all providers. Five years later this remains the case. To respond to this challenge, the Clinical Review Group signed up to developing a new, networked clinical workforce model as part of the future service model to ensure sufficient medical cover across all three acute sites. There is also a potential challenge relating to stroke nurse staffing as there may be a change in nursing skills mix required, with an increase in the ratio of qualified nursing staff needed and a decrease in the numbers of unqualified nursing staff. Optimising the limited specialist workforce across the area will improve recruitment, retention, education and training and help to mitigate the workforce sustainability risk.

3.9 Benefits The key benefits being sought from these proposals mostly relate to access to services and clinical outcomes. A Benefits Realisation Plan has been developed (Appendix 4) identifying the key indicators that will be measured to monitor the improvements resulting from the new pathway. At a summary level, these are:

• More timely access to stroke‐related services, including a specialist assessment at the outset of a stroke;

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• Improved mortality rates overall;

• Reduced level of long-term disability;

• Increased number of patients admitted to a centralised Stroke Unit within 4 hours;

• Increased number of patients given a brain scan in a timely manner;

• The financial cost of the new proposals assumes financial savings resulting from reducing the incidence of strokes as a result of better prevention (i.e. improved diagnosis and treatment of AF). Whilst it can be assumed that there is likely to be financial savings resulting from reduced social care requirements (as a result of improved health outcomes/reduced disability following the onset of stroke) these benefits have not been included or quantified within either the benefits or financial analysis.

3.10 Conclusion The comprehensive review of local services has identified a range of significant issues with current service performance, access and outcomes against expected best practice and published guidance. Significant scope for improving the quality of services and delivering consequent benefits in patient outcomes and experience has been identified across the stroke pathway, from prevention to acute care. Given this range of access, quality and significant workforce issues, work is clearly required to improve local stroke care across Coventry and Warwickshire so that more patients can survive their stroke and achieve their optimum level of recovery.

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4.0 SUPPORTING EVIDENCE AND BEST PRACTICE This section further explains the work that has been done to ensure that we are proposing the best possible clinical model for Coventry and Warwickshire. We believe that the new service model proposed in this Business Case is the best possible clinical model for stroke services in Coventry and Warwickshire for the following reasons:

• It has been designed taking into account the NHS Midlands and East Stroke Services Specification and the latest available clinical best practice evidence;

• It ensures equity of access to services across Coventry and Warwickshire;

• It fits with local and national strategy;

• It has been tested through a range of quality assurance processes that have been undertaken and

• The range of engagement activities that have been undertaken have in general agreed that it is the best option, with some concerns from the public about travel for carers and relatives.

4.1 The Midlands and East Stroke Services Specification In 2011, following the benefits realised by the London Stroke Model, the then NHS Midlands and East Strategic Health Authority (SHA) set out its ambitions for regional improvements in Stroke and TIA healthcare, underpinned by a vision to provide fast access to the best standards of service possible. This resulted in the Midlands and East SHA commencing a review of stroke services in 2012, to help drive an improvement in the way that patients have access to high quality stroke, TIA and rehabilitation services. The underpinning aim of this was to deliver:

• Centralisation of Stroke Units;

• Reduced unwarranted variations in clinical outcomes and services and

• Services based on evidence and best practice. In response to the latter, the NHS Midlands and East developed the Stroke Services Specification, which used a comprehensive and current evidence base to agree best practice. The NHS Midlands and East Stroke Services Specification evidence base includes:

• National Stroke Strategy (2007) Department of Health;

• National Clinical Guidelines for Stroke (2016) Royal College of Physicians;

• Quality Standards Programme: Stroke (2010) National Institute for Clinical Excellence;

• Stroke Service Standards (2010) British Association of Stroke Physicians Quality and Outcomes Framework for 2012/13 (2011) NHS Employers;

• The NHS Outcomes Framework 2012/13 (2011) Department of Health;

• A Public Health Outcomes Framework for England 2013-2016 (2012) Department of Health;

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• The 2012/13 Adult Social Care Outcomes Framework (2012) Department of Health and

• Supporting Life after stroke (2011) Care Quality Commission.

The specification identified 7 phases of the stroke care pathway, as follows:

1. Primary 2. Pre- 3. Acute 4. Community 5. Long-term 6. Secondary 7. End of Life Prevention hospital Phase Rehabilitation Care Prevention

The specification defines components of the pathway with recommended timescales for each phase, as follows: Regional Specification Pathway and Lengths of Stay

The proposed future clinical model for Coventry and Warwickshire has been developed with the Midlands and East Stroke Services Specification at the forefront of thinking. In particular:

• All patients suffering from a stroke will receive appropriate hyper acute care within the first 72 hours,

• There will be comprehensive access to ESD services and specialist community stroke rehab, and

• There will be greater focus on primary prevention in the form of improvements in identifying atrial fibrillation and using anticoagulation to reduce the risk of stroke.

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4.2 Equity of access Achieving the best outcomes for patients experiencing a stroke requires access to the full range of specialist stroke rehabilitation services for the whole population. Equity of access is therefore a core requirement for high quality stroke services, with access to services being based on patients’ needs and not their home address. Under the new model, all patients across Coventry and Warwickshire will be seen more promptly and in the right place by specialist skilled professionals, where they will receive the highest quality care. There will be no inequality of access to the appropriate specialist care. Centralisation of acute care and standardised bedded rehabilitation will ensure a body of suitably qualified and experienced staff is available to see and treat all patients. The home‐based rehabilitation with provide an extra 620 packages of care and the anticoagulation therapy will prevent 230 strokes over three years. A consistent stroke service will be in place across all of Coventry and Warwickshire, removing the current inequity of access to services. This applies to all elements of the pathway, including HASU and ASU beds and stroke specialist rehabilitation services.

4.3 Clinical best practice evidence The Midlands and East Stroke Service Specification is based on a comprehensive evidence base and agreed best practice. However, given the time that has elapsed since its publication, in developing the future clinical model and pathway for Coventry and Warwickshire, we have also observed best practice in other organisations/health systems. London Stroke Model Evidence is clear that centralising acute stroke treatment at a much smaller number of hospitals has considerable benefits. The London Stroke Model was implemented in July 2010 and in their November 2010 stroke newsletter from the stroke clinical director Dr Tony Rudd, the London Cardiac and Stroke Networks reported that:

• The average length of stay for Stroke patients decreased from 15 days in 2009/10 to 11.5 days year-to-date at August 2010;

• The 2010 National Sentinel Stroke Audit evidenced that 84% of London patients were spending 90% of their time on a dedicated stroke unit against a national average of 68% for periods Q1 2009/10 – Q1 2010/11; and

• The 2010 National Sentinel Stroke Audit evidenced that 85% of high-risk TIA patients were being treated within 24 hours, against a national average of 56% for periods Q1 2009/10 – Q1 2010/11. The reconfiguration has been shown to have delivered an absolute reduction in mortality of 3% and enabled an additional 6% of people to achieve independent life at home after a stroke. More than 95 extra lives are saved every year in London alone as a result of concentrating specialist stroke care in eight HASUs. The London HASU model, which operates 24 hours a day, seven days a week, avoids £5.2 million each year.

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National Institute for Health Research Published Evaluation Findings On 28 May 2019, the National Institute for Health Research published “Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: a mixed‐methods study”. Earlier NIHR evidence published in 2014 showed that the London model appears to perform better on key indicators such as mortality. This study adds to the earlier published evaluations by evaluating the longer‐term results of the London model as well as the subsequent reconfiguration of Manchester services. The 2019 evaluation was a mixed‐methods study comparing the effectiveness of the different models of stroke service centralisation implemented in London, Manchester and the Midlands and East region with the rest of England. The paper concludes that:

• Centralised service models where all stroke patients are eligible for treatment in a hyperacute stroke unit seem to perform better than those with more selective admission criteria. If all patients went to a specialist unit for stroke, there were fewer deaths than if some patients went to units that were not specialist.

• Centralising stroke services led to fewer patient deaths, less time spent in hospital, provision of better care and overall good patient experiences and value for money.

• This should guide other urban regions looking to reconfigure their stroke care so that the changes can be made as effectively as possible.

Other models Members of the Clinical Review Group made contact with and/or visited a number of other stroke units in the country, which had been identified as demonstrating clinical best practice, or were in areas of similar demographics to Coventry and Warwickshire. These included the following services and key findings:

Nottingham stroke service

• There are two general hospitals, Nottingham City Hospital (NCH) and Kings Mills Hospital (KMH), which treat 2500 strokes per year, including 600 mimics;

• There are 16 HASU beds at NCH and four at KMH with an average length of stay of 2 days;

• There are 20 ASU beds at NCH and 16 at KMH with an average length of stay of 7 days;

• There is standard ESD capacity for c.30 patients in the south (NCH area) and a community Stroke team. ESD for the KMH team is unknown; and

• There are 40 rehab ward beds at NCH, of which 21 are for standard rehab and for which there is daily consultant input. The other 19 beds are for complex slower rehab with twice a week input from consultants, due to aiming for more therapist led care. There are 20 rehab beds at KMH.

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Stoke stroke service

• There is a Hub and Spoke model for the city and county. There is 1 HASU and 1 ASU at University Hospitals of North Midlands (UHNM), 1 ASU at Stafford Hospital, 1 ASU at Macclesfield Hospital and 1 ASU at Leighton/Crewe. 1,200 patients are treated per year;

• There are six HASU beds at UHNM;

• There are 26 ASU beds at UHNM, 10 at Stafford Hospital, 12 at Macclesfield Hospital and 10 beds at Leyton/Crewe. This is a total of 58 ASU beds and the average length of stay across HASU and ASU is 5-7 days.

North Essex ESD service

• The service is spread over four sites and is led by a stroke service lead that actively in-reaches every morning to the stroke ward to identify ESD candidates. The stroke co-ordinator then meets with the patient on the ward, introduces the service and arranges an initial visit for within 24 hours of discharge;

• On average 75% of acute strokes are discharged through the ESD service (349 patients in 2013-14);

• Approximately 50% of patients are referred for further rehabilitation with the community stroke team; and

• The ESD team has access to a community stroke team for longer-term rehabilitation and refers 50% of patients.

The capacity proposed for Coventry and Warwickshire, for each aspect of Stroke and TIA service provision is broadly in line with that expected from the results of the primary research into stroke services at other best practice regions with similar demographics. These included the Nottingham, Stoke and North Essex services outlined above.

Coventry ESD and Community Stroke Rehabilitation Pilot There is clear evidence nationally that an ESD service can reduce length of stay in hospital. The experience in Coventry from the development of an ESD service has supported this. In Coventry in December 2014 a pilot ESD service was established to support the discharge of appropriate patients over the winter period. Analysis of the impact of the service was undertaken, including consideration of the numbers of individuals who were supported to leave the Stroke Unit; the level of ESD support offered and what impact this had on the length of stay on the Stroke Unit. In the first 3 months of the ESD provision, the provider was able to evidence a reduction in the average length of stay by 9 days compared to the same time period in the previous year. However, this also included facilitating an earlier discharge of 12 patients from the Stroke Unit who were suffering from other neurological conditions or having had a recent TIA, as part of the team’s approach to free up capacity on the Stroke Unit.

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As a result of the positive outcomes of the pilot, the service was substantively commissioned for Coventry in September 2015. The service model in place in Coventry is a standard ESD service, matching the model proposed for the whole of Coventry and Warwickshire in this Business Case. The clinical performance and results of this service therefore offer strong evidence supporting the success of the proposed model. The length of stay for Coventry patients has reduced overall on average by 11 days. Analysis of the percentage of patients suitable for ESD from SSNAP has shown that on average 53% of patients were found to be suitable over the last year. The results are shown below: • Dec – Mar 2017 = 62.8% • Apr – Jul 2017 = 61.9% • Aug – Nov 2017 = 47.5% • Dec – March 2018 = 42% The numbers of patients during the last two financial years who have been discharged out of hospital supported by the Coventry ESD service are as follows: • Apr 2016 ‐ Mar 2017 = 281 • Apr 2017 – Mar 2018 = 274 • Apr 2018 – Mar 2019 = 267 The existing Coventry Community Stroke Therapy Team (CST) provides community stroke rehabilitation support to ESD patients needing ongoing therapy beyond the 6 weeks of ESD support (approximately 30% of all ESD patients) to enable them to achieve their potential and maximise gains and independence post stroke. The team also supports the 30% of stroke patients with moderate to severe stroke who are discharged from the HASU/ASU directly home. This team supports those with the highest levels of impairment and complexity; the majority of the patients will require 2 therapists for each and every therapy session. The success of the ESD service is dependent on the existence of sustainable, high quality community stroke rehabilitation. Community stroke rehabilitation supports: • Patient flow from ESD to enable response times within 24-48 hours and intensity of treatment for this cohort with the most potential for change to remove long term disability. The flow to community stroke rehabilitation enables ESD to sustain high quality, high intensity, timely discharges for those most likely to gain full, or near to full, recovery post stroke; • Patient flow from bedded rehabilitation for those who have had a moderate to severe stroke and who are now medically stable and able to return to the community. Community stroke rehabilitation provides: interdisciplinary rehabilitation to support discharge from hospital and meet a person’s maximal level of independence; carer and social care support for long term decisions regarding care and environment needs; goal setting based on participation in the community despite levels of disability, including consideration of return to work and meaningful roles for those affected by stroke. • Access to and availability of beds in the HASU/ASU by maintaining the flow of patients through the system

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The Coventry community stroke rehabilitation team sits alongside the ESD team as a sister service, facilitating timely handover from the ESD team to maintain patient flow into this early intervention team. The proposed model therefore includes plans to ensure equivalent provision across Coventry and Warwickshire. Existing service activity and outcomes have been used as the evidence base for our modelling. The chart below shows the annual volumes of patients supported to leave hospital by the existing Coventry CST team. A significant step change in activity can be noted from the point at which in‐reaching to hospital and the ESD service began in 2014.

The figures below show the CST service reported outcomes, taken from their latest Key Performance Indicator report (October to Dec 2018), which demonstrate on average: • 8% reduction in disability (using the Modified Rankin Score1); • Of the patients suitable for scoring there was on average a 25-point improvement per patient in increased functional independence on discharge from the service using FIM/FAM2 (Functional Independence Measure and Functional Assessment Measure). • 10% improvement in independence in Activities of Daily Living (using the Modified Barthel Score3) and; • 88% of patients achieved all of the agreed rehabilitation goals; a further 8% of patients partially achieved the agreed goals.

Atrial Fibrillation (AF) There is evidence that optimally treating high risk AF patients has the potential to avert 230 strokes over three years in Coventry and Warwickshire (‘The Size of the Prize on Cardiovascular Disease prevention’, Public Health England and NHS England referenced in Section 3.2 above). This evidence indicates that there is significant clinical and financial benefit potentially from this kind of intervention and it has been factored into the financial modelling below.

1 The Modified Rankin Score (mRS) is a 6 point disability scale with possible scores ranging from 0 to 5. A separate category of 6 is usually added for patients who expire. The Modified Rankin Score (mRS) is the most widely used outcome measure in stroke clinical trials 2 FIM+FAM is designed for measuring disability in the brain-injured population. FIM is an 18 item global measure of disability, FAM specifically addresses cognitive and psychosocial function, which are often the major limiting factors for outcome in brain injury. 3 The Barthel scale or Barthel ADL index is an ordinal scale used to measure performance in activities of daily living (ADL). Each performance item is rated on this scale with a given number of points assigned to each level or ranking

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4.4 Local strategy

4.4.1 CCG Commissioning intentions and work priorities Improving stroke care in the way proposed in this Business Case fits with the strategies of each of the CCGs in Coventry and Warwickshire as follows: Coventry and Rugby CCG’s Commissioning Intentions (2017 – 2019) Coventry and Rugby CCG’s Commissioning Intentions document for 2017/18 – 2018/19 sets out its seven key priorities. Stroke forms part of its Urgent & Emergency Care priority, with the CCG setting out its plan to work with partners to commission a single integrated stroke pathway that secures consistent specialist care, including rehabilitation. South Warwickshire CCG’s Strategic Plan (2016 – 2020) South Warwickshire CCG’s 2016 – 2020 Strategic Plan, translating our 2020 Vision into Reality, acknowledges that for some services where there is a strong relationship between the numbers of patients and the quality of care – including stroke – there is evidence to suggest improvements in outcomes and patient experience that are derived from having expertise, facilities and equipment in one place. As such, it sets out the vision to centralise stroke services to work towards the delivery of the NHS Midlands and East stroke pathway, given the evidence this will deliver better clinical outcomes. Warwickshire North CCG’s Vision for Quality Clinical Vision One of the four clinical priority areas for the CCG comprises urgent and emergency care, including emergency general surgery, stroke services and cardiovascular disease. The CCG’s plan for improved stroke care centres on:

• Improving identification of patients at risk of cardiovascular disease through primary and secondary care prevention and developing a pathway for heart failure, including cardiac rehabilitation services;

• Commissioning TIA services from a provider of specialist stroke care; and

• Commissioning additional stroke rehabilitation services in the local area.

4.4.2 Coventry & Warwickshire Sustainability & Transformation Plan The Coventry and Warwickshire Sustainability & Transformation Plan (STP) defines the re‐ configuration of stroke services as outlined in this Business Case as a key priority as part of its Emergency and Urgent Care Workstream. It is important to note that each of the leaders within the STP has agreed that the model outlined in this business case is the right one and should be implemented. The STP Board discussed and approved this Business Case at its meeting on 20 May 2019.

4.5 National strategy Every year over 100,000 people in the UK have a stroke. Stroke is the leading cause of disability and fourth largest cause of death in the UK, with costs to the NHS and economy of circa £7 billion a year. Whilst there has been a gradual decline in mortality rates, due to public campaigns such as FAST, stroke remains the single largest cause of severe acquired disability,

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driving the need for continued investment in delivering appropriate quality and timely services. The National Stroke Strategy (2007) previously set out a clear direction for the development of stroke services in England over a 10‐year period, with recommendations for the entirety of the patient pathway from prevention to end of life. The evidence‐based strategy advocated provision of specialist stroke units, rapid access for TIA patients, immediate access to diagnostic scans and thrombolysis and early supported discharge. The NHS England Five Year Forward View (2014) also advocated new models of care, including specialist care, citing examples of the centralisation of 32 stroke units in London to 8 units and the resulting reduction in mortality rates and lengths of stay in hospital. The NHS Long Term Plan set out a series of ambitions for improving stroke care, with key milestones for improved post‐hospital stroke rehabilitation models. The National Stroke Programme, developed jointly by NHS England and the Stroke Association, seeks to support local organisations to deliver better prevention, treatment and care and meet the ambitions for stroke set out in the Long‐Term Plan. The national programme aims to:

• Improve post-hospital stroke rehabilitation models for stroke survivors

• Deliver a ten-fold increase in the proportion of patients who receive a thrombectomy after stroke so that each year 1,600 more people will be independent after their stroke

• Train more hospital consultants to offer mechanical thrombectomy

• Deliver clot-busting thrombolysis to twice as many patients, ensuring 20% of stroke patients receive it by 2025 – the best performance in Europe

• Enhance the Sentinel Stroke National Audit Programme (SSNAP) to identify further need and drive improvements

• Ensure three times as many patients are receiving 6 month reviews of their recovery and needs – from 29% today to 90% The Sentinel Stroke National Audit Programme (SSNAP) June 2017 recognised overall continued improvement in the management of strokes within acute stroke units and discharge, but there are still notable variances across the country:

• Some organisations are still not providing 24 hour hyper-acute stroke care;

• Nearly 10% of applicable patients do not receive swallow assessments within 72 hours of admission;

• In-hospital stroke patients tend to be identified and managed slowly

• Approximately one 5th of stroke admissions are not seen by a specialist stroke physician within 24 hours of admission;

• At least 50% of stroke patients will suffer from depression or cognitive impairments in the weeks following their stroke and will require psychological support.

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The proposed new model set out in this Business Case aligns to the ambitions and commitments set out in the Long Term Plan and National Stroke Programme. It has been developed recognising the local variations from accepted clinical best practice set out within SSNAP and the national direction of travel. This includes the centralisation of HASU services. The model also has the values, principles and pledges within the NHS Constitution at its core, ensuring that the population of Coventry and Warwickshire receive improved access, equity and quality of care to further improve the quality of their lives.

4.6 Conclusion There is an established and increasing evidence base establishing best practice in stroke care. NHS England has set out key ambitions and commitments for the improvement of stroke services nationally, which are reflected in local commissioning strategies and priorities. Evaluations of centralised HASU/ASU service models have been completed, demonstrating that centralised stroke services have led to fewer patient deaths, less time spent in hospital, the provision of better care and overall good patient experiences and value for money. This section has summarised the strong evidence base and the national policy direction and priorities that support the proposed new clinical model set out in this Business Case.

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5.0 OPTIONS DEVELOPMENT AND APPRAISAL

5.1 Assurance & Governance Arrangements Whilst the development of the Pre‐Consultation Business Case has been a Commissioner‐led process overseen initially by the local Warwickshire and Coventry CCG Federation and now by the Strategic Commissioning Joint Committee (comprising CCG Clinical Chairs, Accountable Officers, Chief Financial Officers and other key members of all three local CCGs), it has extensively involved key stakeholders through a multi‐agency project governance structure as shown below:

The Senior Responsible Officer for the project is Andrea Green, Chief Officer for Warwickshire North CCG, who is responsible to the Warwickshire & Coventry CCG Federation and now to the Strategic Commissioning Joint Committee, which acts as the Project Board. Local acute and community service providers, as well as ambulance, Local Authority and patient representatives, have been represented at various levels, including via: • Stakeholder Board – comprising provider strategy and medical leads; • Clinical Review Group – comprising Medical Leads to support the development of the clinical model; • Activity and Finance Workstream. • Clinical and Operations Group – comprised of Clinical and Operational Leaders The Clinical Review Group has been a primary group in expanding the clinical model beyond the hyper‐acute and acute stroke phases to include the community and rehabilitative phases of care; helping to build the evidence and model for this.

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The Clinical and Operations Group has provided clinical and operational management expertise, oversight and challenge into the development and evaluation of; • potential scenarios for service delivery • staffing models of each aspect of the proposed service options • implementation plans There has been an extensive programme of pre‐consultation engagement with the public including, stroke survivors and carers. The project also established a Public & Patient Advisory Group which is chaired by a Stroke Association representative. A member of this group attends the Stroke Stakeholder Project Board. This group has overseen the pre‐ consultation engagement to date and has helped to broaden the voice of the patient/public, feeding into the Chair who sits on the Stakeholder Board. The pre–consultation engagement is further described in section 5.2 and in detail in appendices 5‐7.

5.2 Stakeholder Engagement The CCGs have undertaken an array of stakeholder engagement activities and co‐production with regards to improving the Stroke and TIA service provision across Coventry and Warwickshire. Throughout the engagement programme, the focus has been on ensuring that there is good visibility, clarity and understanding of the services currently being delivered and the evidence base for the proposed changes in the stroke pathway and services. The engagement process provides the platform through which patients, carers, the public, health professionals and other key stakeholder groups (i.e. Local Authorities, Councillors etc.) are able to voice their thoughts, observations and concerns. The feedback from the pre‐consultation activities has resulted in two phases of development of potential scenarios, the first to identify and build the scenarios for the provision of Hyper Acute and Acute services (sections 5.3 and 5.4) and the second phase to facilitate the inclusion of rehabilitation services and primary prevention of stroke (sections 5.5 and 5.6). Crucially the pre‐consultation engagement has supported the co‐production of the options under consideration and the non‐financial appraisal of those options. The summarised findings from the engagement processes are noted in section 5.2.2. Appendices 5 and 6 contain full details of the engagement processes.

5.2.1 Pre-consultation engagement approach and objectives A programme of pre‐consultation engagement has been undertaken in two phases:

• Phase 1 was undertaken in 2014/15 to build up the possible scenarios for the Hyper Acute and Acute pathway; and

• Phase 2 followed on from the outcome of Phase 1, in which it was identified there was the need for the inclusion of rehabilitation and prevention of stroke in patients with Atrial Fibrillation. Phase 2 focused on the option of UHCW providing the centralised specialist HASU/ASU units with localised rehabilitation at home via ESD, bedded and community rehabilitation. The engagement builds on significant work that has been undertaken in recent years to help improve stroke and stroke‐related services across the local health economy.

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5.2.2 Summary of Engagement, Themes and Responses The responses from stakeholders throughout the engagement process were varied, mainly depending on the location of those being engaged, with issues and queries being raised in relation to each scenario. It is important to note that most respondents acknowledged that ‘something’ needed to change. Depending on their personal circumstances, how that change would affect them varied across the county. The overriding theme however, appears to be an acknowledgement of the need for intensive hyper acute care at the onset of a crisis. This is offset by concerns around the longer and costlier travel journeys some patients and families will experience during the acute phase of care. The consultation material will address the key concerns and queries raised through the pre‐ engagement process. It is acknowledged that the issue of travel, transport and parking is the predominant theme and this has not only been included in an extended Integrated Impact Assessment in 2017/18, but the Coventry and Warwickshire CCGs are already engaged with the West Midlands Combined Authority to establish a long‐term transport plan for vulnerable people which includes patients and carers. Work is in train with local Councils to see if local policies might better support transport for carers and relatives not just for those who have a stroke, but others who are deemed vulnerable. Other areas of concern raised that the consultation document has addressed include: • Travel, transport and parking: including costs of travel and difficulty in parking at UHCW, the impact on both patients and family/carers/visitors and ambulance travel times; • The loss of rehabilitation beds in Rugby; • Concerns about capacity in UHCW; • Concerns about recruitment to serve the new model; • Whether the longer distance to UHCW for those patients who live further afield, negates the benefit of being taken to the HASU for assessment; • Whether the closure of acute stroke services at GEH and SWFT will result in the closure of other services; • Risk of over‐crowding on the UHCW site, and potential negative impact on beds for those that most need them; and • The need for good communication between the hospital units and Consultants and other staff. There is a perception that teams across sites do not currently communicate when patients are being transferred.

5.2.3 Health Overview and Scrutiny Committees The programme has undertaken extensive stakeholder engagement and co‐production with regards to developing and appraising the options for improving stroke service provision across Coventry and Warwickshire. A key aspect of this process has been regular engagement with Council Overview and Scrutiny Committees. Senior members of the programme have attended committee meetings to provide updates on progress and receive feedback and comments.

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Below is a summary of meetings attended: September 2015 Health Overview and Scrutiny Committees in Warwickshire and Coventry 2nd June 2016 Nuneaton and Bedworth Health Overview and Scrutiny Panel 13th October 2016 Brooke Overview and Scrutiny Committee (Rugby Borough Council) 6th July 2017 Nuneaton and Bedworth Health Overview and Scrutiny Panel 10th July 2017 Coventry Health and Wellbeing Board 13th July 2017 Brooke Overview and Scrutiny Committee meeting 22nd February 2018 Nuneaton and Bedworth Health Overview and Scrutiny Panel 27th February 2018 Warwickshire and Coventry Council Joint HOSC Members briefing session 8th October 2018 Coventry Health and Wellbeing Board 20th March 2019 Coventry and Warwickshire Joint Scrutiny Committee 18th April 2019 Nuneaton and Bedworth Health Overview and Scrutiny Panel The feedback from each meeting attended has been considered and any requirements for further engagement/consultation that came out of those meetings have been detailed below with reference to the specific meeting the request came from.

Rugby Borough Council’s Brooke Overview and Scrutiny Committee Andrea Green, Senior Responsible Officer for the project on behalf of the Coventry and Warwickshire CCGs and Chief Officer NHS Warwickshire North and NHS Coventry and Rugby CCGs and Dr Adrian Canale‐Parola, Chairman of Coventry and Rugby CCG attended Rugby Borough Council’s Brooke Overview and Scrutiny Committee meeting on 13 July 2017 to present the Improving Stroke Services In Coventry and Warwickshire engagement document and respond to questions. Key points discussed included: • the methods by which consultation materials would be publicised and stakeholder groups would be engaged • the expected impact of ESD and community stroke rehabilitation on outcomes and the number of Social Care packages required following implementation and • the rationale for the 6 beds at St Cross Hospital not being included. It was agreed that a full list of consultees would be shared with the Scrutiny Committee and explained that minimum clinical standards based on bed numbers needed to be considered in assessing the viability of units. 6 beds had been identified as too small a number to sustain a viable unit. Members were informed that outcomes of the engagement period will be considered in August/September 2017. Further bed modelling has been considered since the engagement report and more information will be available during the consultation period.

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Summary of Nuneaton and Bedworth Health Overview and Scrutiny Committee Members considered the stroke engagement document at their meeting on 6 July 2017, below is a summary of the key points raised and responses to those points: • Transport: councillors were clear that this was a very real issue for local residents both in terms of getting to UHCW and parking capacity and costs whilst there. The recent Integrated Impact Assessment completed since the engagement phase will be available to provide information at the consultation stage. • Rehabilitation: the importance of getting this right and ensuring patients are cared for close to home. Further bed modelling has taken place since the engagement phase and more information will be available at the consultation stage. • Workforce: a need to understand concerns about workforce capacity and skills. Further workforce assessment has taken place and more information will be available at the consultation stage. • Carers: the importance of supporting and listening to carers during the process and ensuring there is a sufficient community service offering to support them. Carers have been listened to during the engagement phase they will continue to be engaged during and after the consultation phase. • Nuneaton: ensure more engagement in Nuneaton during the consultation phase. Every effort will be made to engage widely and comprehensively with the people of Nuneaton.

Warwickshire and Coventry Council Joint HOSC Members briefing session Warwickshire and Coventry Council worked together to form a joint HOSC Members briefing session on 27 February 2018, to hear about the proposals after taking account of the public engagement during June and July 2017. The final proposals and actions to address the outcomes of the engagement in June and July 2017 and the latest Integrated Impact Assessment were presented.

5.3 Long-List of Scenarios - Hyper Acute and Acute Services At the onset of the project a set of underpinning principles were agreed by Commissioners for the potential scenarios for the delivery of stroke services. These were: • All scenarios must meet the requirements of the NHS Midlands and East regional Stroke Service Specification and therefore provide for: - A Hyper‐Acute Stroke Unit – to remain at UHCW; - Acute Stroke Unit(s) with one aligned to the HASU at UHCW at a minimum; - A standard Early Supported Discharge service; • Stroke rehabilitation beds will be provided locally for the post‐acute phase of care: for those patients who no longer require acute stroke care, but have ongoing care and rehabilitation needs that prevent them from returning home; • All high risk TIAs would be seen at UHCW.

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Based on the above principles, a longlist of scenarios for the provision of Hyper Acute/Acute services was developed by the Clinical and Operations Group as follows: Scenario 1 ‐ Do Nothing Scenario 2 ‐ HASU at UHCW / 1 ASU at UHCW Centralisation Scenario 4 ‐ HASU at UHCW / 3 ASUs at UHCW, SWFT & GEH Scenario 5A ‐ HASU at UHCW / 2 ASUs at UHCW & SWFT Scenario 5B ‐ HASU at UHCW / 2 ASUs at UHCW & GEH

During the work to develop the above scenarios, two additional scenarios were considered: • Scenario 3 ‐ a scenario was introduced which sought to have a HASU and an ASU for Coventry and Rugby patients up to the point of discharge, and north and south Warwickshire patients at UHCW up to day 7. The latter cohort of patients would be repatriated to a local ASU at SWFT or GEH as appropriate, if a longer acute hospital stay was needed. This scenario was later discounted following external advice sought from a senior External Clinical Advisory Panel member who cautioned against splitting a patient’s acute length of stay in an ASU; • Scenario 5 – a 2‐ASU scenario was considered, with one ASU being specified at UHCW and the other at either SWFT or GEH. It was later agreed that this scenario would be sub‐divided into Scenarios 5A –and Scenario 5B, with specific locations at SWFT and GEH identified for each.

5.4 Short-List of Scenarios - Hyper Acute and Acute Services

5.4.1 Clinical and Operational Viability Assessment of Scenarios Having developed the long‐list of scenarios, an initial assessment based on clinical viability was undertaken. The criteria against which the scenarios were assessed were developed by the Clinical Review Group. These were that each scenario must:

1. Be capable of meeting the NHS Midlands and East Stroke Service Specification;

2. Be clinically viable in terms of both activity and workforce. Using the findings of the visits to Stroke services that were demonstrating best practice, members of the Group agreed that to be clinically sustainable, a Stroke Unit would require a minimum of 10 stroke beds being operational. To support the assessment of the scenarios against criteria 2 above, capacity modelling was completed, the results of which are shown in the table overleaf.

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Shortlisting Exercise Based on Clinical Viability – Modelling Results for Total No of Beds Scenario 1 Scenario 2 Scenario 4 Scenario 5A Scenario 5B UHCW 42 beds 43 beds 40 beds 40 beds 39 beds (6 HASU / (12 HASU / (10 HASU / (12 HASU / (13 HASU / 30 ASU / 31 ASU) 30 ASU) 28 ASU) 26 ASU) 6 Stroke Rehab) SWFT 32 beds 0 beds 3 beds 2 beds 0 beds (12 ASU / (All ASU) (All ASU) (All ASU) (All ASU) 20 Stroke Rehab) GEH 19 beds 0 beds 2 beds 0 beds 3 beds (All ASU) (All ASU) (All ASU) (All ASU) (All ASU)

It can be seen that in Scenarios 4, 5A and 5B, the Acute Stroke Units at both SWFT and GEH are projected to require considerably fewer than 10 beds, which was determined as the minimum threshold for sustaining an acute stroke service. This is predominantly due to: • A shift of suspected stroke activity from SWFT and GEH to UHCW; • Reduction in overall lengths of acute hospital stay by the introduction of an ESD service and additional support in the community.

On the basis that Scenarios 4, 5A and 5B result in the Acute Stroke Units at SWFT and GEH being clinically unsustainable, these scenarios were discounted. This left two scenarios under consideration i.e. Scenario 1 – Do Nothing; and Scenario 2 – Centralisation.

Given that Scenario 1 – Do Nothing does not meet the Midlands and East Stroke Service Specification requirements and was included for comparative purposes only, the Coventry & Warwickshire Stroke project identified only one clinically viable scenario for the acute phase of the pathway: Scenario 2 ‐ Centralisation. As only one clinical viable scenario remained for the provision of hyper acute and acute services, financial modelling was not undertaken on the non‐viable options.

5.4.2 Patient and Public Engagement and Feedback In parallel, in 2014/15 the pre‐engagement phase of the project with the public was handled informally through meetings with stroke groups and groups representing the ‘nine protected characteristics’ equality strands and identified in the initial Integrated Impact Assessment. The purpose was to ascertain their thoughts and wishes for an acute stroke service. The 2015 engagement exercise then engaged on the following 4 scenarios: 1. Do nothing; 2. Maximise centralisation at UHCW (hyper acute and acute unit for ALL patients); 3. All patients go to UHCW Hyper‐Acute unit for 2 – 3 days then patients who are from the Warwickshire North area transfer to GEH and patients from South Warwickshire transfer to Warwickshire Hospital; and 4. All patients go to UHCW Hyper‐Acute unit for 2 – 3 days then North and South Warwickshire patients transfer to one other hospital, either the George Eliot Hospital or Warwick Hospital with closure of stroke facilities at the other unit.

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The feedback captured in the Engagement Report was considered by the Project Board who, in response to the feedback, decided to expand the scope of the project to include specialist stroke community rehabilitation services and action to prevent more strokes for patients with Atrial Fibrillation.

5.5 Long list of Scenarios – Rehabilitation Services The original principles for the stroke service improvements described in section 5.3 had only included the ESD aspects of out of hospital care. Following the feedback received in 2015 from the first engagement phase, a decision was made by Commissioners to expand the scope of the business case to include specialist stroke community rehabilitation and action to prevent more strokes; namely increased anticoagulation rates for those with Atrial Fibrillation. There is clear clinical best practice evidence in the Midlands and East Specification and also described from other health systems and the Coventry pilot, that improved outcomes and shorter lengths of stay are achieved by services that enable those patients suitable for ESD to receive ESD and community rehabilitation. This evidence is detailed in section 4.3. This evidence strongly suggests that ESD and an expansion of community rehabilitation in patients own homes are a prerequisite in whichever new pathway is introduced for Coventry and Warwickshire. A proposed model of care that included the expanded scope above was developed. At this stage there appeared to be only one way to secure a clinically viable, future end to end pathway. So, from 15th June to 28th July 2017 a further, comprehensive, 6 week public engagement process was undertaken on a proposal for a centralised hyper acute and acute service, bedded rehabilitation on 2 sites, ESD, community stroke rehabilitation at home and improvements in AF anticoagulation therapy. This engagement included the following activities: • More than 500 stakeholders received electronic engagement and a questionnaire via NHS and Local authority partners, Healthwatch and the voluntary sector; • Five public meetings were held; • There were nine community engagement events and meetings; • Local media advertisements, including two items on local radio throughout July 2017 and 27 articles in local newspapers. The key concerns identified by the public from this engagement related to concern for carers of those living in Coventry and Rugby, who would need to travel to access the bedded stroke rehabilitation proposed for them at George Eliot Hospital and Leamington Rehabilitation Hospital i.e. not a local provision for this cohort of individuals. This feedback was considered in the updated Integrated Impact Assessment and most of these addressed through an action plan working with Council colleagues. Alongside this, the stroke expert Clinical and Operations Group leading the clinical design of the future stroke service model, was asked to revisit the work completed to date and consider if there was another method of delivering bedded rehabilitation for the Coventry and Rugby population, that might mitigate this.

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The following longlist of scenarios was identified by the Clinical and Operations Group for the provision of rehabilitation services: Scenario 1 ESD and community rehabilitation in all areas. Bedded rehabilitation at South Warwickshire Foundation Trust (SWFT) in Leamington and George Eliot Hospital (GEH) in Nuneaton Scenario 2a ESD and community rehabilitation in all areas. Community bedded rehabilitation provision in Coventry with specialist therapy in‐reach and bedded rehabilitation at SWFT in Leamington only. Scenario 2b ESD and community rehabilitation in all areas. Community bedded rehabilitation provision in Coventry with specialist therapy in‐reach. Bedded rehabilitation at SWFT in Leamington and GEH in Nuneaton Scenario 3a ESD in all areas (no community rehabilitation). Discharge to Assess in Coventry with in‐reach. Bedded rehabilitation at SWFT in Leamington only Scenario 3b ESD in all areas (no community rehabilitation). Community bedded rehabilitation provided in Coventry with specialist in‐reach. Bedded rehabilitation at SWFT in Leamington and GEH in Nuneaton Use of rehabilitation beds at the Hospital of St Cross, Rugby was not considered clinically feasible for inclusion in the long list. Splitting the specialist rehabilitation model over three hospital bedded units would demand a workforce model that clinicians agreed could not be recruited to and sustained. The key drivers for this were: • the reduced size and patient volumes that each rehabilitation unit would be managing would present viability challenges for the size of clinical teams and retention of clinical skills in each of the units; • operating over three units would increase the additional workforce needed and the national workforce shortage in specific skill sets led to concerns regarding the ability to recruit sufficient staff to operate the services.

5.6 Short list of Scenarios – Rehabilitation Services

5.6.1 Clinical and Operational Viability Assessment of Scenarios Having developed the long‐list of scenarios, the Clinical and Operations Group reviewed each option to assess their ability to meet the following minimum essential criteria: • meet national guidance and the NHS Midlands and East Regional Stroke Service Specification • must demonstrate at least the minimum standards of quality; be safe; be sustainable and deliver better outcomes for patients

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In addition, the Clinical and Operations Group assessed the long‐list options against nine standard, health service best practice criteria: 1. Better access to services – equality; travel; car parking 2. Improved clinical quality – better health outcomes; better configuration; enabling new methods of delivering care 3. Improved environmental quality – conditions conducive to effective care; meeting patient and staff expectations; functional suitability 4. Development of services – increasing quantity 5. Improved strategic fit – meeting strategic needs of the locality or region 6. Meeting training, teaching, research needs – easier to recruit, train, retain staff; protecting accreditation standards; improve productivity 7. More effective use of resources – human; service; facilities; better value for money 8. Ease of delivery – practical delivery and implementation 9. Meeting national, regional policy initiatives

Against these nine criteria each option was scored by the Clinical and Operations Group, to facilitate a robust discussion about the relative risks, benefits and issues with each. The agreed scoring criteria used a scale of 0 to 4, with the following descriptors: Score Description 4 Excellent degree of confidence in delivery model. High certainty of delivery of model and associated outcomes 3 Comprehensive and able to fully meet requirements. High level of confidence in delivery model and associated outcomes 2 Acceptable level of confidence in delivery model. Reasonable level of confidence in delivery model and associated outcomes 1 Limited degree of confidence in delivery model. Fails to meet requirements of delivery model and associated outcomes 0 Deficient model that offers no confidence in ability to deliver the model and associated outcomes

As a result of this assessment process, 3 scenarios were rejected due to not meeting the essential criteria. Two viable options remained: Option 1 Early Supported Discharge Service (ESD) and community rehabilitation in all areas. Bedded rehabilitation at South Warwickshire Foundation Trust (SWFT) in Leamington and George Eliot Hospital (GEH) in Nuneaton Option 2b Early Supported Discharge Service (ESD) and community rehabilitation in all areas. Community bedded rehabilitation provision in Coventry with specialist therapy in‐reach. Bedded rehabilitation at SWFT in Leamington and GEH in Nuneaton.

These options were to be taken forward (as Option 1 and Option 2) for full non‐financial appraisal by all key stakeholder groups. Details of the non‐financial appraisal process are provided in section 5.7.

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5.6.2 Patient and Public Engagement and Feedback The Clinical and Operations Group shortlisting process had identified two viable options for the provision of bedded rehabilitation; both assume that ESD and community stroke rehabilitation at home will be delivered in all areas. Further engagement sessions were carried out with the Patient and Public Advisory Group and wider stakeholder groups to recap on the journey so far, gather feedback and agree the process for appraising the viable options. One of the key activities undertaken was the co‐production of the list of desirable non‐ financial criteria against which the options would be appraised. An initial meeting with the Patient and Public Advisory Group in August 2018 resulted in the development of a set of patient and public focussed criteria with which to assess the options for future stroke bedded rehabilitation services. These were shared with wider members of the public via 4 public engagement sessions in September 2018. These sessions tested and further developed the detail of the desirable criteria. Key themes already captured from previous engagement in 2017 and the Integrated Impact Assessment were also incorporated into the desirable criteria.

5.7 Options Appraisal The results of the option development work had found that there was only one option for the provision of HASU/ASU services and the establishment of ESD and community rehabilitation across Coventry and Warwickshire. The only aspect of the stroke pathway with options for consideration was therefore the bedded rehabilitation provision. A wide and representative group of stakeholders were invited to a non‐financial options appraisal event, to appraise the two viable options for the provision of bedded stroke rehabilitation. The stakeholder group included patients and carers, local councillors, voluntary sector and community support groups, community pharmacists, NHS clinical staff, NHS commissioners, social care commissioner and managers. The process of inviting stakeholders to this event involved mapping our comprehensive stakeholder lists against the nine protected characteristics within equality law and cross‐referencing these to the 2017/18 Integrated Impact Assessment to ensure that appropriate representation was achieved. The options appraised were: 1. One bedded rehabilitation unit at South Warwickshire Foundation Trust (SWFT) in Leamington Spa and one bedded rehabilitation Unit at George Eliot Hospital (GEH) in Nuneaton. 2. One bedded rehabilitation unit in the Coventry area, not on an NHS hospital site, with specialist therapists coming into the site to provide rehabilitation into the unit; one bedded rehabilitation unit at South Warwickshire Foundation Trust (SWFT) in Leamington Spa and one bedded rehabilitation Unit at George Eliot Hospital (GEH) in Nuneaton. Both options assumed that HASU/ASU care would be provided at UHCW and ESD and Community rehabilitation at home would be delivered in all areas.

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As described in section 5.6.2 above, through extensive patient and public engagement a list of non‐financial desirable criteria was co‐produced and used to appraise each of the clinically viable service delivery options. These criteria are shown in the table below.

Stakeholder coproduced desirable criteria for the non-financial options appraisal Equality, Services should be equitable, consistent and always available accessibility Availability of car parking / accessibility of public transport and Equality of access no matter where you live, who you are and what your personal consistency circumstances are of services Staff development, training, skills and information should be consistent – from ambulance teams to rehab therapists No patient or carer should feel disadvantaged by the new service Improved Service should focus on the best quality and the best possible outcomes and clinical recovery quality of Providing better long term health outcomes for patients services Addressing existing clinical problems that not all clinical services are available on all sites There needs to be the right balance of staff, in the right places with the right skills and knowledge Providing the opportunity to ensure that we have the best clinical outcomes for every stroke patient Improved Professionals who are delivering the services should understand the stroke delivery of patients’ feelings and the consequences of having a stroke services We should create an environment where experiences, knowledge and information can be shared to benefit stroke survivors and their carers All stroke services should work together with a smooth transition at all points in the stroke patients care Patients should feel that staff are working in one team for their patient, even if they work for different organisations. Holistic services need to be considered as they help people to not fall through the cracks Services should integrate and include community and voluntary Development Services should be personalised with care that is right for each individual patient of Loved ones and carers need to be supported, informed and consulted at all stages personalised Services should be modelled on the best outcome and care for patients not what services can be done with the current staff or finances Patients and loved ones should receive timely, awareness raising communications and signposting All or other health considerations should be taken into consideration when planning the patients care

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The options appraisal event used the following process: • The co‐produced desirable criteria were reviewed as a group and weightings agreed for their relative importance • Smaller table top groups were then asked to consider each of the two viable options against the desirable criteria to enable each individual present to score these • Each table then fed back their scores which were entered into a single spreadsheet. • The result was a consensus view from those attending the options appraisal event on the options for bedded rehabilitation.

The agreed weightings and resulting scores for each option are shown below:

Options were scored on a scale of 0 to 10, where 0 indicated an option completely failed to meet the criteria and 10 indicated that an option completely met the criteria. As the results above show, the preferred option from the non-financial options appraisal was option 1.

One bedded rehabilitation unit at South Warwickshire Foundation Trust (SWFT) in Leamington Spa and one bedded rehabilitation Unit at George Eliot Hospital (GEH) in Nuneaton.

Full details of the options appraisal can be seen in Appendix 8.

5.8 Risk Assessment of Options To support Commissioners in assessing the clinical and operational delivery feasibility of each of the bedded rehabilitation options and further support the decision‐making as to the preferred option, a risk assessment was undertaken by the Clinical and Operations Group.

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At the non‐financial options appraisal event stakeholders had challenged the Clinical and Operations Group assessment that it would not be possible to sustainably staff 3 hospital sites for rehabilitation. The option of providing bedded rehabilitation at the Hospital of St Cross, Rugby was therefore included in the risk assessment to enable a robust re‐assessment of this position. The options risk assessed were: ESD and community rehabilitation in all areas. Bedded rehabilitation at Option 1 SWFT in Leamington Spa and GEH in Nuneaton

ESD and community rehabilitation in all areas. Community bedded rehabilitation provision in Coventry, not on an NHS hospital site, with Option 2 specialist therapy in-reach. Bedded rehabilitation at SWFT in Leamington Spa and GEH in Nuneaton

ESD and community rehabilitation at home available in all areas. One bedded rehabilitation unit at South Warwickshire Foundation Trust Option 2 (SWFT) in Leamington Spa, one bedded rehabilitation Unit at George using Rugby Eliot Hospital (GEH) in Nuneaton and one bedded rehabilitation unit at the Hospital of St Cross, Rugby.

The Clinical and Operations Group agreed a set of criteria to reflect the range of clinical, operational delivery and healthcare system risks that any model could present. The agreed risk assessment criteria are shown in the table that follows.

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Risk Assessment Criteria

Patients are transferred to the bedded rehabilitation provider that are ready for 1 rehabilitation but have medical needs outside the capability of the rehabilitation provider Patients developing complications and/or deteriorating cannot be appropriately 2 supported in the bedded rehabilitation provider, leading to transfers to A&E Difficulty in recruiting and retaining sufficiently skilled clinical staff to cover the rotas – 3a Consultants Difficulty in recruiting and retaining sufficiently skilled clinical staff to cover the rotas – 3b Nurses Difficulty in recruiting and retaining sufficiently skilled clinical staff to cover the rotas - 3c other clinical staff Difficulty in securing a high quality, sustainable provider with on-site facilities conducive 4 to rehabilitation Limitations on the capabilities of the bedded rehabilitation reduce capacity, impacting 5 on patient flow out of UHCW Lack of consistent clinical governance arrangements across the providers reduces the 6 system ability to manage the quality of care Adverse impact on wider NHS provider sustainability in the health system, that could 7 impact on the need for changes in other local services Fragmented care and unnecessary delays in the management of patients journeys due 8 to lack of access to social workers and/or other community-based infrastructure to support patient needs assessment 9 An inability to sustain staff skill levels and competence in stroke rehabilitation

Each of the options was assessed against the risk criteria, using a NHS standard likelihood and consequence assessment matrix.

Likelihood Almost Consequences Unlikely Possible Likely Rare (1) certain (2) (3) (4) (5) Negligible (1) 1 2 3 4 5 Minor (2) 2 4 6 8 10 Moderate (3) 3 6 9 12 15 Major (4) 4 8 12 16 20 Catastrophic (5) 5 10 15 20 25

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To ensure consistency in the scoring of each option the following assumptions were agreed and applied when considering each option against the risks. 1. Beds provided at the Hospital of St Cross in Rugby would be providing the same level of service as those provided by SWFT and GEH 2. The number of beds provided at the Hospital of St Cross in Rugby would be based upon the geographically identified number of patients closest to the location 3. For all options risk assessed ESD and community stroke rehabilitation would be provided as per the Business Case 4. For all options, clear service specifications would be in place for the services commissioned 5. The beds provided for community bedded rehabilitation with in‐reach (Option 2) would all be provided from one location

The results of the risk assessment are shown below. Option 2 using Option 1 Risk Option 2 Risk Risk Rugby L C Score L C Score L C Score 1 3 2 6 4 3 12 3 2 6

2 1 1 1 4 3 12 1 1 1

3a 3 2 6 3 2 6 3 2 6

3b 3 4 12 4 4 16 4 4 16

3c 3 4 12 4 4 16 4 4 16

4 1 5 5 4 5 20 1 5 5

5 2 4 8 3 4 12 2 4 8

6 1 2 2 2 2 4 1 2 2

7 2 2 4 3 3 9 4 4 16

8 2 2 4 3 2 6 3 2 6

9 2 3 6 4 3 12 4 3 12

66 125 94 As is shown in the results above, Option 1 has a lower level of risk than Option 2, having a total risk score of 66 compared to 125. The risk assessment also supported the original assessment that developing a third rehabilitation unit in Rugby poses higher risks of an inability to recruit the required nursing and therapy staff and critically, presents a significant, red risk of having an adverse impact on wider NHS provider sustainability in the health system, that could impact on the need for changes in other local services.

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The risk assessment therefore supports the results of the non‐financial options appraisal in determining that the option with the least clinical and operational service delivery risks is Option 1. One bedded rehabilitation unit at South Warwickshire Foundation Trust (SWFT) in Leamington Spa and one bedded rehabilitation Unit at George Eliot Hospital (GEH) in Nuneaton.

The full risk assessment document can be found in appendix 9.

5.9 Integrated Impact Assessment and Equalities Integrated Impact Assessments have been carried out in 2015 and 2017/18 as proposals have developed, the purpose of these was to identify the groups most likely to be affected by stroke and provide a full analysis of the impacts of the potential scenarios on travel and access, determinants of health and equality. The scenarios considered within the 2017/18 assessment reflect the short‐list of options identified through the process described in sections 5.3, 5.4, 5.5 and 5.6: Scenario 1: Do nothing Scenario 2a: all stroke patients in Warwickshire will be treated at UHCW throughout both the hyper‐acute and acute phases. When appropriate for discharge, patients will be sent home for supported rehabilitation or, in the case of bedded rehabilitation requirements (around 30% of patients), will have the choice of either GEH or Leamington Spa Hospital (LSH) dependent on proximity to usual residence and/or bed availability. Scenario 2b: all stroke patients in Warwickshire will be treated at UHCW throughout both the hyper‐acute and acute phases. When appropriate for discharge, patients will be sent home for supported rehabilitation or, in the case of inpatient bedded rehabilitation requirements (around 30% of patients), will be transferred to either GEH or Leamington Spa Hospital (20%) with the remainder of patients in Coventry and Rugby (10%) being commissioned a suitable care home bed in Coventry, with access to a specialist in‐reach stroke rehabilitation team. The Integrated Impact Assessment (IIA) documents are appended (appendices 10 and 11). The following table summarises the potential scale of the impact for each of the elements of service changes on patient numbers and estimated numbers of those by district and in the quantifiable equality population groups. These are considered a broad estimate of the scale of impacts for consideration alongside the following impact assessments. The impact on carers and visitors can be assumed to follow a similar distribution in the absence of additional information to the contrary.

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IIA estimates of impacts for the proposed changes by district and assorted equality groups, based on 2015/16 data.

Element of the Service Estimated By Area By Equality group Description Change numbers impacted Coventry – 19 Age (over 65s) - 582

North Warwickshire – 84 BAME - 89

Nuneaton & Bedworth – 86 Males - 346 All Stroke patients not currently treated at UHCW Centralisation Stroke 726 Rugby – 32 Female - 380 for hyperacute and acute stage Stratford – 133 Deprived areas - 58

Warwick – 191 Pregnant/maternity - 13

Out-of-Area – 81 Coventry – 1 Age (over 65s) - 135

North Warwickshire – 23 BAME - 24

Nuneaton & Bedworth – 44 Males - 79

All TIA patients not currently Rugby – 3 Female - 86 165 Centralisation (TIA) treated at UHCW. Stratford – 25 Deprived areas - 9

Warwick – 41 Pregnant/maternity - 3

Out-of-Area – 28

Coventry – 245 Age (over 65s) – 683

North Warwickshire – 76 BAME - 137 All stroke patients suitable for ESD and community Nuneaton & Bedworth – 199 Males - 510 recovery and rehabilitation ESD and community post-acute stage (70%) 952 rehabilitation including those currently Rugby – 86 Female - 442

receiving ESD and community rehab Stratford – 99 Deprived areas - 131

Warwick – 123 Pregnant/maternity – 21

Out-of-Area – 123 Age (over 65s) - 323 Coventry – 105

North Warwickshire - 33 BAME - 65 All stroke patients requiring inpatient rehabilitation post- Nuneaton & Bedworth - 85 Males - 190 Complex and bedded acute stage (30%) including 408 those currently receiving Rugby - 37 Female - 218 rehabilitation inpatient rehab Stratford - 42 Deprived areas - 45

Warwick – 53 Pregnant/maternity - 5

Out-of-Area – 53

Source: The Strategy Unit.

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Summary of the impacts and potential mitigations identified in the IIA The proposed changes are designed to improve outcomes for all stroke patients regardless of their area of residence: thereby increasing the likelihood of survival, decreasing recovery time with lower risk of complications and permanent disability, enabling shorter lengths of stay in hospital with more time at home, receiving appropriate support and rehabilitation. The total number of stroke patients likely to be affected by the changes is estimated, using 2017/18 activity data, to be an additional 699 patients in the hyper and acute phase, an estimated total of 1,268 patients for the ESD and community rehabilitation and 349 patients for bedded rehabilitation. It is important to note that because many patients will receive input and care from a combination of all of these stroke services, individual patients will appear multiple times in these numbers. Three principle areas of impact were identified in the IIA: • Travel and access • Health • Equality It is recognised that there will be negative short‐term impacts felt by some of the carers of, and regular visitors to stroke patients during the inpatient stays in both the hyper/acute and rehabilitation phases, particularly those reliant on public transport. Carers and visitors in North Warwickshire, Warwick and Stratford‐upon‐ Avon district will be disadvantaged most in terms of longer and further journeys in relation to acute care in Coventry. Carers and visitors from Coventry and Rugby will be impacted most during the rehabilitation phase, should their relatives need rehabilitation in a bedded setting prior to discharge home, as the rehabilitation beds will located in Nuneaton and Leamington only. On balance the negative impacts of increased travel time and distance for some visitors and carers is offset by improved availability of specialist stroke treatment throughout the pathway, reduced lengths of stay (during both the acute and rehabilitation phases) and the potential improvement in health outcomes and reduction in disability for all stroke survivors. To support those visitors and carers who will be using public transport, information regarding existing direct and non‐direct public transport services will be made available, as will information about voluntary and subsidised transport schemes. Consideration will also be given to inpatient visiting hours, especially during winter, to reduce the amount of time visitors and carers spend traveling in the dark.

Summary of overall impacts and conclusions The technical documents included at appendix 11 of this business case provide a full account of the scores for each element of the IIA. For example, the EIA scores can be found in section 5.3 and appendix 7.10 of the technical documents and the health scores are in section 5.2 and appendix 7.9 of the technical documents. The summary scores are shown below:

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Scenario Health Travel & Equalities Access Health Health Determinants Impact Inequalities of Health Impact 1 0 0 0 0 0

2a -6.5 +20 +15 -1 +18

2b -5.5 +3 -7 +1 +22

The assessment and scoring suggest that both proposals for centralisation of all acute care and rehabilitation would have an overall positive impact on the population compared to the do‐nothing scenario, reducing the inequalities in the current/do nothing scenario. Scenario 2a offers the greatest gain in terms of the direct health benefits to patients and the most positive impact on reducing health inequalities. If the scoring is considered alongside information on the scale of the impact in terms of the volume of patients affected by the proposed changes, the impacts would be magnified further, as the clinical model for 2a is considered more effective and viable than in option 2b. Scenario 2b offers the most flexible rehabilitation pathway and appears to provide the greatest extent of positive impacts in terms of equality of access, particularly in respect of those in the population with protected characteristics. However, it should be noted that some of the equality groups would constitute a relatively small volume/scale of stroke patients (e.g. pregnant/maternal women and those from BAME groups), thus additionally their carers and visitors. Similarly, the number of strokes from areas that might be affected more by changes to travel are lower than in some of the more urban areas. Overall, the IIA demonstrates both quantitative and qualitative evidence that the proposed scenarios could have major benefits for the Warwickshire and Coventry populations including vulnerable groups. The key benefits relate to the ability of the changes to achieve: • Everyone within 72 hours of the onset of stroke to have the benefit of assessment in a Hyper Acute Stroke Unit (‘HASU’); • Increased timeliness and equitable access to hyper acute, acute and rehabilitative care for all Coventry and Warwickshire residents, removing inequalities in the current provision; • Improved workforce development opportunities, and recruitment and retention of Stroke specialist staff; • Reduced levels of mortality and morbidity for people who have suffered a Stroke; • Reduce levels of dependency for people after suffering a stroke; • Improved cognitive function for people after suffering a stroke; • Improvements in stroke prevention for all patients reducing the current inequalities. Whilst the centralisation will invariably negatively impact on patients and visitors travel and access, particularly from the North and South of Warwickshire, the expected health benefits, greater proportion of time recovering at home and a reduction in inequalities from the exemplar service provision across the area in the proposals should more than offset them.

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Headlines from the feedback from the groups identified as most affected by stroke echoed the feedback by the Stroke group engagement meetings and were as follows:

Transport Location Services

Transport is a problem if people Quality of care more important Things cannot stay as they are; have to travel further; than location;

Concern about increased travel All services should be at UHCW There is the need for consistency time to UHCW in an ambulance; where best care is delivered; in service provision;

Extra travel wouldn’t be too GEH provides better care; Concerns around capacity as much of a problem; UHCW is already busy;

Concern about cost of transport Centralisation is a good idea; Better training for carers needed; and car parking; better if they come back to their local hospital afterwards;

Parking is difficult at UHCW; Specialist unit first and then to a Best treatment and facilities are local hospital is a good idea; the most important;

Concern about increased travel Access to specialist first and then Community care needs for visitors; to a local hospital; consideration;

Public transport from Nuneaton Access to specialist stroke unit in Sharing of patient notes between to Coventry is difficult, their local area, which are better hospitals do not work; particularly for the elderly; for people especially the elderly;

Voluntary transport is variable, Specialist stroke unit in Nuneaton Poor communication between particularly at weekends; needed; hospitals, with the need to repeat yourself; and

Long‐term outcomes are more Do not change the existing Patients need to be discharged important than travel; services; only with sufficient support.

Car parking is difficult and It doesn’t make sense to bypass expensive at UHCW and the local hospital if time is Warwick; critical;

Concern about poorer outcomes Care closer to home is best, to for patients if they have to travel help local carers and relatives;

further;

Need to think about how Centralisation at UHCW may not patients travel home. be best for everyone.

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5.10 Quality Assurance In line with best practice the Coventry & Warwickshire Stroke project has undertaken the following quality assurance reviews and processes: • Health Gateway Review 0; • National Clinical Advisory Team Review; • West Midlands Strategic Clinical Network Assurance; • West Midlands Clinical Senate Review; • Achievement of the five tests for service change will be tested in the final assurance meeting with NHS England; • Two Integrated Impact Assessments (IIA) as the model has evolved; and • Privacy Impact Assessment (PIA). Each of the quality assurance reviews and processes are detailed below.

5.10.1 Health Gateway Review 0 In October 2014 the project commissioned an OGC Health Gateway 0 Review to help assure the process being undertaken. This review resulted in a rating of ‘amber’ (i.e. successful delivery appears feasible but issues that appear resolvable require management attention). Each of the 4 actions recommended by the OGC Health Gateway Team were subsequently addressed as follows: • Critical path to be clearly identified – a clearly defined critical path document was produced and monitored; • Project governance structure to be reviewed and strengthened – this resulted in clearer delineation between Commissioner and Provider roles; • Robust risk management strategy and plan to be developed – this task was completed, and a detailed risk register maintained and shared with all parties; and • Necessary resources required for successful delivery of the Business Case to be secured – the necessary support and resources were secured.

5.10.2 National Clinical Advisory Team Review The project has been supported by an External Clinical Advisory Group (ECAG) comprising the following members: • Dawn Good, Head of Stroke Services, Nottingham University Hospitals NHST; • Dr Christine Roffe, Consultant Stroke Physician, North Staffordshire Combined HCT; • Professor Tony Rudd, Consultant Stroke Physician, Guy’s & Thomas’ NHSFT and National Clinical Director for Stroke; • Matthew Ward, Head of Clinical Practice, West Midlands Ambulance Service; and • Rob Wilson, Cardiovascular Manager, West Midlands Strategic Clinical Network. The ECAG was specifically invited to review the longlist of scenarios in 2014 which resulted in a more detailed exploration and development of the post‐acute element of the care pathway. In addition to this, Professor Tony Rudd has visited each of the three local acute

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provider sites to see the Stroke wards and meet with key staff and in doing so, provide support and guidance in the development of the clinical model.

5.10.3 West Midlands Strategic Clinical Network Assurance From the outset of the project, the Associate Director for the West Midlands Strategic Clinical Network has been represented on the Stakeholder Board and as such, has had oversight of the development of local plans. Additionally, the regional Stroke lead for the Strategic Clinical Network has provided his support and input on request.

5.10.4 West Midlands Clinical Senate Review A review of the clinical model was undertaken by the West Midlands Clinical Senate in line with NHS England’s stage 2 assurance process. As a result, the Senate convened an Independent Clinical Review Panel chaired by Dr Nick Harding, Chair of Sandwell & West Birmingham CCG and comprised of a further 22 panel members including the national Clinical Director for Stroke, Professor Tony Rudd. Following a review of submitted information, the Panel convened a 3‐day review in January and February 2016, of which the first two days were spent with members of the Coventry and Warwickshire Stroke programme. Members of the programme met with the Panel on day 2 and included the Senior Responsible Officer; the Clinical, Finance and Project Management leads; and Stroke medical/clinical leads from the current four provider organisations. Following the review and the updated clinical case for change document, the Clinical Senate submitted their report in May 2016 which concluded that the case for change “contains strong and compelling national and international evidence for improved stroke care and that its final iteration should result in an enhanced patient care pathway and is likely to improve patient outcomes”. The Senate approved the clinical model and case for change, whilst identifying 11 recommendations to be addressed. Project leaders met with the Senate to review completion of the 11 recommendations in July 2018. The Senate concluded that adequate work had been done to meet the recommendations. A copy of the letter from the Clinical Senate Chair is attached (Appendix 12).

5.10.5 “Five Tests” for Reconfiguration Support from GP Commissioners Through the governance of the project, GP clinical commissioners have been engaged with and provided support to the Clinical Review Group. The CCG Federation convened as the stroke Project Board acting as the oversight and decision‐making body for the project. The CCG Federation is chaired by the clinical chair of one of the CCGs and attended by the other two clinical chairs. The CCGs evolved the Federation into a Joint Strategic Commissioning Committee in 2017. The CCG federation reviewed and approved the Pre‐Consultation Business Case and proposed model on 13th February 2019.

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Strengthened Public and Patient Engagement As evidenced in section 5.2, there has been wide and deep engagement across the whole community with stroke survivors and their carers. A Patient and Public Advisory Group chaired by the Stroke Association has met regularly as part of our assurance process and advised on the process for our engagement and the appraisal of options. On‐going engagement will be carried out to support the implementation of the commissioned pathway and public views will be fed into these plans.

Clarity on the Clinical Evidence Base The clinical model which the CCGs seek to commission is based on national evidence used in developing the Midlands and East Stroke Services Specification, is in line with stroke service developments nationally and is supported by Professor Tony Rudd – the National stroke lead. Local services have been audited and assessed against best practice and local clinical engagement has supported the shaping of the model. Evidence from other areas stroke service improvements have also been used to test the design of the proposed clinical model. Sections 3.6, 3.7, 4.1, 4.3 and 4.5 of this document draw together clinical evidence base that underpinned the development of the proposed model.

Consistency with Current and Prospective Customer Choice The CCGs as commissioners are committed to the provision of patient choice and to ensuring that patients service options are of both adequate quality and accessible. With the current configuration and range of services, patients experiencing a stroke in South and North Warwickshire that are outside the 4‐hour window from onset of symptoms but within 72 hours, do not have the choice of a HASU assessment, from which they could benefit. Also, some patients in North and South Warwickshire don’t have a choice of the right specialist rehabilitation service. The proposed future pathway increases patient choice of the right quality and volume of services. Alongside this the outcomes of the engagement with patients and the public, has shaped the model to ensure that all patients will get access to specialist services when they need them, but are returned to their own home, or into a facility close to home where they require further medical or nursing care, as soon as they are medically able.

The 5th Test From 1 April 2017 NHS England introduced a new test for proposed service changes. This test requires that in any proposal that includes plans to significantly reduce hospital bed numbers, commissioners are expected to be able to evidence that they can meet one of the following three conditions: i. Demonstrate that sufficient alternative provision, such as increased GP or community services, is being put in place alongside or ahead of bed closures, and that the new workforce will be there to deliver it; and/or

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ii. Show that specific new treatments or therapies, such as new anti‐coagulation drugs used to treat strokes, will reduce specific categories of admissions; or iii. Where a hospital has been using beds less efficiently than the national average, that it has a credible plan to improve performance without affecting patient care (for example in line with the Getting it Right First Time programme). The proposed service model does not reduce the overall number of hospital beds; it realigns the use of some beds based on robust modelling of the proposed improvements in patient pathways and a significant expansion of community services.

5.10.6 Data Protection Impact Assessment A Data Projection Impact Assessment (Appendix 13) has been undertaken based on the services being delivered by existing providers and the proposed new model. All providers are currently subject to an existing Information Sharing Agreement. The assessment has been reviewed by the CCG Information Governance Advisory Group. The Group concluded that no immediate further actions are needed and that once the model has been agreed and as implementation arrangements develop, the assessment should be revisited.

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5.11 Conclusion Whilst the development of the Pre‐Consultation Business Case has been a Commissioner‐led process, it has extensively involved key stakeholders through a multi‐agency project governance structure. There is an existing, well‐established evidence base for the most effective clinical models for providing stroke care, which the programme has drawn on in establishing the elements of the pathway that need to be in place for Coventry and Warwickshire. Clinical and operational leaders alongside members of the public, including stroke survivors and carers, have played a key role in the development and evaluation of the potential scenarios for service delivery. Crucially, public engagement has also supported the co‐ production of the process for the non‐financial appraisal of the options. To develop the proposed model a range of options have been considered. Initial development work focused on the acute stroke pathway only (HASU/ASU, supported by ESD). Following an assessment of the clinical viability of the options on the long‐list, it is evident that there is only one clinically viable scenario for acute care: centralisation of HASU/ASU services at UHCW. ESD and community stroke rehabilitation are key services required for a high quality stroke pathway. Both need to be provided in patients homes and community settings across Coventry and Warwickshire and require some investment and development; they are not optional parts of the care model. Development work for these services has focussed on modelling the workforce implications to develop the optimal service delivery model affordable within Commissioners planned investments in stroke care. There were a number of potential ways in which bedded rehabilitation could be provided. A long list of potential scenarios was developed and clinically assessed for viability, with two viable options remaining. A full non‐financial appraisal of these options by all key stakeholder groups, identified the preferred option as the provision of bedded rehabilitation at two sites, Leamington and Nuneaton. A clinical and operational risk assessment of the different models and a financial appraisal of indicative costs supported the outcome of the non‐financial appraisal. Our work to identify and evaluate the options for provision of the future clinical model for stroke care has therefore identified the preferred option for Coventry and Warwickshire as: • Centralised HASU/ASU at UHCW • ESD and community rehabilitation in all areas. • Bedded rehabilitation at SWFT in Leamington and GEH in Nuneaton.

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6.0 FUTURE CLINICAL MODEL A significant amount of work has been undertaken by clinicians from across the health economy to design a new model for stroke services in Coventry and Warwickshire that will meet the clinical best practice outlined in the Stroke Services Specification developed by NHS Midlands and East and more recent updates to national clinical guidelines. This section sets out the future clinical model and vision.

6.1 Future Clinical Model & Pathway Patients will be seen more promptly and in the right place by specialist, skilled professionals, where they will receive the highest quality care. Once the acute episode is complete, patients will either transfer to an inpatient community rehabilitation bed or return home or to their usual place of residence with the appropriate level of community support from both health and social care services. The three CCGs are working in partnership with their partners in local authorities and the third sector to develop seamless services that support people to be as independent as possible and receive appropriate support when they need this. At a high level, the future pathway will be as follows:

The future pathway has the following key features: • Provision of a single centralised hyper acute stroke unit (HASU) and an acute stroke unit (ASU) at UHCW, with the necessary infrastructure, support and workforce to assess and diagnose all patients suspected of having had a stroke from across Coventry and Warwickshire, within 72 hours of onset; • An Early Supported Discharge service; • Community stroke rehabilitation services, and • Bedded stroke rehabilitation services for those patients that require more intensive support after discharge from the ASU.

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• All patients suspected as having a stroke will be admitted to the HASU/ASU for assessment and treatment, patients will then follow one of 3 routes depending on their clinically assessed need: • Discharged home with community stroke rehabilitation support, or potentially requiring no further support. Analysis of historic activity identifies this route applies to 30% of patients • Discharged home with Early Supported Discharge. Analysis of historic activity identifies this route applies to 40% of patients; 30% of these patients will need further rehabilitation and therapy input to reach their goals and increase their independence and will go on to receive community stroke rehabilitation support • Discharged to a bedded Stroke Rehabilitation Unit. Analysis of historic activity identifies this route applies to 30% of patients. 90% of patients within this cohort will, on discharge from bedded rehabilitation, go on to receive community stroke rehabilitation to achieve their optimal rehabilitation. It is proposed that the HASU length of stay will be up to 72 hours in line with the NHS Midlands and East Stroke Services Specification. ASU length of stay will be eight days, after which patients will transfer to a bedded rehabilitation facility if they are not ready to return home. Components of the new pathway are outlined through the rest of this section, all of which are explicitly in line with the NHS Midlands and East Stroke Services Specification.

6.1.1 Early prevention and Atrial Fibrillation Each CCG has plans in place to improve primary and secondary prevention of stroke, including: • Identification of patients with Atrial Fibrillation (AF) in primary care; and • Increased anticoagulation rates for those diagnosed with Atrial Fibrillation. During August and September 2017, primary and secondary care professionals involved with the AF and anticoagulation pathway started regular meetings to discuss, plan and agree collaborative working practices to deliver an integrated anticoagulation pathway. The CCGs are already commissioning primary prevention improvements where there are opportunities for the better management of AF, hypertension and diabetes. Opportunistic screening for AF is underway to increase the identification of patients to bring prevalence up to the expected 2%. Contracts are in place with General Practice to initiate Direct‐acting Oral Anticoagulants (DOACs) in primary care across Warwickshire. Coventry and Rugby CCG work to agree contracts is progressing. In addition, a full programme of work across the diabetes pathway is underway, with an emphasis on stroke. From April 2018 the national programme for prevention of diabetes has been rolled out.

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6.1.2 Pre-Hospital Care All patients identified as having a stroke within the first 72 hours of onset will be transferred by emergency ambulance for a hyper acute assessment at UHCW. Ambulances will need to collect patients from wherever they have their stroke, as well as from Warwick and George Eliot Hospitals as some patients may self‐present at their local A&E Department.

6.1.3 Hyper Acute Stroke Unit For all patients suspected of having a stroke, the HASU will provide expert specialist clinical assessment, clinical imaging and the ability to offer intravenous thrombolysis for those who need it 24 hours a day, 7 days a week, typically for no longer than 72 hours after admission. At least 600 cases per year are typically required to provide sufficient patient volumes to make a hyper acute stroke service clinically sustainable, to maintain staff expertise and to ensure good clinical outcomes. As is shown in the activity modelling in section 7, the proposed HASU patient flow will easily meet this target.

6.1.4 Acute Stroke Unit Acute stroke care will immediately follow the hyper acute phase, mostly after the first 72 hours of admission. The ASU will provide: • Continuing specialist day and night care; • Daily multi‐disciplinary care; • Continued access to Stroke Specialist Consultant care; • Access to physiological monitoring; and • Access to urgent imaging as required. In‐hospital rehabilitation should be assessed immediately after the person has had a stroke and commence as soon as possible.

6.1.5 Early Supported Discharge ESD will enable appropriate stroke survivors to leave hospital ‘early’ through the provision of intense rehabilitation in the community at a similar level to the therapy care provided in hospital. The ESD service will operate 7 days a week, able to deliver immediate response to all hospital discharges and patients at risk. The service is therapy led, with medical support provided by the Stroke Consultant where required. The team will provide intense rehabilitation at home for up to six weeks, thereby reducing the risk of re‐admission for stroke related problems, increasing independence and quality of life, with support to the carer(s) and their family. Based on analysis of 3 years of activity data and the Coventry ESD service outcomes it is assumed that 40% of patients will be appropriate to receive ESD services. Local CCGs will commission ESD using a standard ESD specification across Coventry and Warwickshire, thus ensuring equity of access, service quality and performance standards.

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6.1.6 Community Bedded Stroke Rehabilitation Community bedded stroke rehabilitation is recommended for stroke patients who are medically stable enough to not require daily medical care from stroke physicians, but have ongoing care and rehabilitation needs that prevent them from returning home. The point prevalence audits, bed audits on the UHCW stroke unit and clinical discussions have concluded that this cohort equates to 30% of the patients in an acute stroke unit at any point in time. Local CCGs will commission community bedded stroke rehabilitation using a standard specification across Coventry and Warwickshire, thus ensuring equity of access, service quality and performance standards. The provision of this service will be predicated on ‘pulling’ appropriate patients from the acute stroke unit, providing goal focused rehabilitation and facilitating an onward discharge either home or into an onward residential or care setting, should that be required. Based on local activity analysis, 90% of the patients admitted to bedded stroke rehabilitation will be discharged with community stroke rehabilitation to achieve their optimal rehabilitation. The facility will require the wider health and care system to support onward flow and thus ensure capacity to continuously improve patient flow from the acute stroke service. The criterion for the bedded rehabilitation facility has been determined as follows: • Nurse led care provision, with multidisciplinary therapy interventions; • Initial admission for up to six weeks of care and stroke rehabilitation; • Maximum extension of a further four weeks reviewed on an individual case basis; • Minimum of a weekly review of progress and identification of onward care and therapy needs; • In‐reach support from the ESD service to identify and facilitate the onward pathway of care, including access to the ESD/Community Neuro‐Rehabilitation service; and • Support from Social Care to support onward discharge to home, residential/nursing home placement, ensuring that the maximum period of a 10 week admission is not breached.

6.1.7 Community Stroke Rehabilitation Stroke survivors’ rehabilitation will continue out in the community after time spent in a bedded rehabilitation unit, or after their acute inpatient stay on an ASU. These services enable stroke survivors to develop a greater quality of life and independence following a stroke. Patients will access community stroke rehabilitation services following standard discharge from a stroke unit or following ESD. The service will ensure regular review of rehabilitation goals with stroke patients, their carer(s) and families and regular review of whether the full rehabilitation potential has been achieved, so that patients can be suitably discharged from the service.

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Local CCGs will commission community stroke rehabilitation using a standard specification across Coventry and Warwickshire, thus ensuring equity of access, service quality and performance standards.

6.1.8 Long-term Recovery Stroke survivors and their carer(s) should be enabled to live a full life in the community in the medium and long‐term (i.e. greater than three months). The ESD and community stroke rehabilitation teams will review all stroke patients at 6 months post stroke and offer long term access to rehabilitation for patients with a stroke‐based need for multi‐disciplinary team intervention. Support will be required from local services to ensure that stroke survivors receive tailored support to assist in their re‐integration into the community and maximise the quality of life experienced by stroke survivors, their carer(s) and families.

6.2 Workforce An important part of mobilising and implementing the proposed model is creating the workforce that will be required by providers to deliver the pathway. Workforce modelling has been completed with providers as part of the development of the options for service delivery and the subsequent financial appraisal of those options. Staffing levels and skill mix have been based on the NHS Midlands and East Stroke Service Specification, which gives clear guidance on the minimum staffing levels for the various core specialist skills required for high quality stroke care. For those staff groups not prescribed in the Midlands and East Stroke Service Specification, workforce requirements were agreed based on published national guidelines for stroke services and local clinical experience. With regard to ESD and community stroke rehabilitation, local clinical experience of patient complexity, the impact of rurality and recruitment challenges have been used to adapt the proposed skill mix. The workforce model was reviewed with West Midlands CVD Network and their recommendations were used to further shape the proposed model. The rehabilitation services (community and bedded) have been modelled to provide a 7 day service, in particular it should be noted that therapy services will operate 7 days a week, including providing immediate response to all hospital discharges and patients at risk. The capacity for specific elements of rehabilitation services will vary across the 7 days and has been modelled to match the known profile of demand. This will facilitate the flow from acute and rehabilitation beds over the weekend into the community whilst offering priority visits and intervention to these groups of patients at weekends. It is acknowledged that as a result of local tailoring, the proposed skill mix for ESD and community stroke rehabilitation includes some deviations from the NHS Midlands and East Stroke Specification. Where the proposed workforce model is not fully aligned to the Specification the adjustments are based on responding to the clinical expertise and experience of the local clinicians.

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There are strong rationales underpinning the decisions to change the skill mix profile which include: • The proposed model has been designed to mirror that of the successful Coventry pilot described in section 4.3; a key factor in this decision is the successful outcomes the team is delivering. The most recent SNNAP results (July‐Dec 18) measuring modified Rankin scores, shows that the team delivers input to a much higher percentage of moderate and severely impaired patients as compared to national levels. • The ESD and CSR teams do not currently include nursing posts as nursing vacancies are currently high in the acute pathway, rehabilitation and community nursing both locally and nationally. Band 4 Assistant Practitioner and Band 3 Rehabilitation Technician Posts have been created within the model and their roles will include traditional nursing activities such as tissue viability and continence management. • The model includes senior therapist posts; reasons for this include: o Having experienced clinical specialists on the ground and available to risk assess, manage arising daily concerns and support less experienced and unregistered staff is an essential foundation for any future plans to develop services further to provide enhanced ESD o Providing banding progression through all therapy disciplines was felt to be a clear and sure way of attracting, recruiting and retaining the high numbers of therapy disciplines required. o Band 8b psychology posts have been sustained in the model to provide governance and guidance to Band 8as as this support is not available within the existing structures outside of the stroke teams.

The tables that follow show the current stroke workforce in place in each of the providers and the proposed workforce developed to meet the needs of the future service model.

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The current stroke workforce is as follows: Role Band UHCW SWFT GEH CWPT

Consultant 4 1 1.8 0

SpR 2 2.34 1 0

Stroke Speciality Doctor 2 0 0 0

SHO 4 0 1 0

Locum Doctor 0 0 0 0 Dietetics 7 0 0.65 0.9 0 Dietetics 6 1 0 0 0.37 Speech & Language Therapist 7 0.8 0.8 0.95 1.45 Speech & Language Therapist 6 1 1.2 1.5 0.67 Speech & Language Therapist 5 0.6 0.6 0 0 Speech & Language Therapist 4 1 0 0.4 0 Physiotherapy 7 0.8 2 0 0.8 Physiotherapy 6 3 2.5 2 2.88 Physiotherapy 5 3 2 1 1 Physiotherapy 2 0 1.5 0 0 Occupational Therapy 7 1 1.28 0 1.64 Occupational Therapy 6 2.8 2.35 0.75 1.81 Occupational Therapy 5 2 1.5 0.4 1 Occupational Therapy 2 0 1.2 0 0 Therapy assistants/MTO 4 0 0 0 2.9 Therapy assistants 3 2.79 4.3 2 4 Therapy assistants 2 2 0 0 0 Psychology 8 0.5 1 0.5 1.64 Psychology assistant 5 0.5 0 0 0 Pharmacy 8 0.5 0 0 0 Stroke co-ordinator/Clinical Lead 8 1 0 0 0 .83 Stroke CNS 7 1.4 3 2 0 TIA support worker 3 1.02 0 0 0 Stroke secretary 4 2 0 0 0 Stroke data officer 3 1 0 0 1 Stroke data officer 2 1 2.02 0 0 Nursing 7 2.4 2 1 0 Nursing 6 2.8 4 4 0 Nursing 5 28.42 25.81 11.11 0 Nursing 4 0 0 0 0 HCA 3 3.18 2.6 1.93 0 HCA 2 16.33 23.2 10.49 0 Ancillary 2 0 1.46 0 0

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The proposed workforce model is as follows: HASU/ Bedded Community Role Band ESD ASU Rehab Rehab Consultant Physician (thrombolysis trained) 8 SpR 3 2 0 0 Stroke Specialty doctor (Fast Bleep/TIA clinics) 2 0 0 0 SHO 4 0 0 0 Dietician 6 1 1 0.4 0.5 Dietician 5 0.5 1.63 0 0 Dietician 3 0 0.5 0 0 Speech & Language Therapist 7 0.8 2 1.6 1.05 Speech & Language Therapist 6 2 2 1 1.87 Speech & Language Therapist 5 1 2 0 0 Speech & Language Therapist 4 1 0 0 0 Speech & Language Therapist 3 0 0.5 0 0 Physiotherapist 7 1.8 2 1.8 2 Physiotherapist 6 4 4 1.8 7.1 Physiotherapist 5 3 2 4 3 Occupational Therapy 7 1 2 1.8 1.84 Occupational Therapy 6 3.8 4 2.3 5.8 Occupational Therapy 5 2 2 3.8 3 Assistant Practitioner 4 0 0 0 6.85 Rehab Assistant 3 5.8 6 10.6 6 Rehab Assistant 2 2 0 0 0 Psychologist 8b 0 0 0 1.84 Psychologist 8a 1 1.2 1.4 1.2 Psychology Asst 5 0.5 0 0 0 Stroke Services Team Leader 8a 1 0 0.9 0.9 Stroke Clinical Nurse Specialist 7 1 0 0 0 Medical Sec 4 2 0 0 0 Data Clerk/Admin 3 1 2 0 0 Admin 2 1 1 0 0 Ward Sister 7 1.2 2 0 0 Fast Bleep Holders (nursing) – ward 6 6 0 0 0 Ward nurse 6 5 2 0 0 Ward nurse 5 38 29.5 0 0 HCA – ward 3 8.2 3.2 0 0 HCA - ward 2 21 19.2 0 0 Orthotics 0 0.24 0 0 Pharmacist 8a 1 0 0 0

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6.3 Conclusion To deliver the NHS Midlands and East Stroke pathway and to achieve the step change improvement that has been achieved by other health economies in areas of best performance, we need to change the way that stroke services are collectively provided across Coventry and Warwickshire. The new networked stroke pathway proposed has been designed based on the best practice evidence available, incorporating HASU, ASU, bedded rehabilitation, ESD and community rehabilitation support services. It will ensure that all stroke survivors can access the right standard of stroke specialist ESD and community stroke rehabilitation, providing evidenced based care to reduce the level of disability of those who survive a stroke. The proposed future service model for stroke care described in this Business Case will meet the projected population demands and support providers to achieve the best practice standards for anyone on the stroke pathway. The new networked workforce model and pathway when commissioned will place the local providers in the best position to overcome the current recruitment challenge and gap between the number of stroke specialist staff we need and those employed. The NHS Long Term Plan and National Stroke Programme set out national ambitions for improvements and new developments in stroke services such as mechanical thrombectomy, to further increase stroke survival and rehabilitation outcomes. Crucially, the proposed new clinical model for stroke in Coventry and Warwickshire will establish a service structure and pathway that gives the foundations for these improvements in stroke care to be delivered.

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7.0 FINANCIAL AND ACTIVITY IMPACT Finance and activity modelling have been undertaken to estimate the likely impact on patient flows, costs and potential savings from the potential new models. The results of this work provide evidence to demonstrate that the proposed new model is affordable.

7.1 Financial Appraisal of Remaining Options Following an assessment of the clinical viability of the potential options for a new model of stroke services, it was evident that: • there is only one clinically viable scenario for acute care: centralisation of HASU/ASU services at UHCW • ESD and community stroke rehabilitation are key services required for a high quality stroke pathway. Both require some investment and development across Coventry and Warwickshire; they are not optional parts of the care model. • There is more than one possible way to provide bedded stroke rehabilitation. Based on the options development and appraisal the financial case has been prepared on the basis of a do‐nothing comparison to a centralised model for HASU/ASU. Modelling for ESD and community stroke rehabilitation has been based on a clinical assessment of the workforce needed to provide these services. A smaller financial options appraisal was undertaken to develop indicative costs for the following options for bedded rehabilitation: Option 1 ‐ Bedded rehabilitation at SWFT in Leamington Spa and GEH in Nuneaton. Option 2a ‐ Bedded rehabilitation provision in the Coventry area, not on an NHS hospital site, with specialist therapy in‐reach; one bedded rehabilitation unit at SWFT in Leamington Spa and one bedded rehabilitation unit at GEH in Nuneaton. A lack of clarity on how clinical and operational risks could be mitigated and market availability of beds have made this option difficult to quantify. Pathway costs are subject to significant variation dependent on the location, spread of patients and the exact service support put in. Best estimates of the costs range from this option saving £135k on Option 1 to incurring an additional £200k per annum, assuming that therapy support needs doubling and with medical support going into the facilities. Given the risks identified in section 5.8, the actual pathway required to deliver this option could be beyond this cost base. Option 2b ‐ One bedded rehabilitation unit at SWFT in Leamington Spa, one bedded rehabilitation unit at GEH in Nuneaton and one bedded rehabilitation unit at the Hospital of St Cross in Rugby. This pathway when costed was £788k per annum more than Option 1. The results of the risk assessment (section 5.8) provide a strong steer from the clinical and operational leaders of stroke services that: • Option 2a has significantly higher levels of clinical and operational risk than Option 1. • Option 2b poses higher risks of an inability to recruit and a significant risk of having an adverse impact on wider NHS provider sustainability in the health system, than both Option 1 and Option 2a

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The above financial appraisal provides a high level, indicative financial test only. Option 1, as the clinically most viable option and preferred option from the non‐financial options appraisal, has been used as the basis for the financial case that follows.

7.2 Bed Modelling Bed capacity modelling has been undertaken to establish the number of beds that should be required to manage demand through the current service model (do nothing state) and for the proposed future clinical model. Modelling for the proposed new clinical model has also been tested to ensure achievement of SSNAP measures. Activity for 2017/18 was used to form the baseline for modelling, with growth of 1.07% assumed annually. Appendix 14 details the assumptions applied to the activity to complete the modelling and their source/evidence base. Cross boundary activity involving Coventry and Warwickshire’s bordering providers (University Hospitals of Leicester, Worcestershire Acute Hospital and Birmingham Heartlands Hospitals) was also analysed to identify any potential impacts. The resulting cross‐boundary flow of activity was found to be minimal. The results of the activity modelling on the required bed numbers are shown in the table below: Bed and Service Provision: Current vs Future State Bed/Service Current Future Difference (Beds) provision

Hyper Acute Stroke 6 beds at UHCW 12 beds at UHCW + 6 beds beds

30 ASU beds at UHCW

12 ASU beds at SWFT

Acute Stroke beds 18 ASU beds plus 1 31 ASU beds at UHCW - 30 beds assessment bed at GEH

(Total 61 beds)

6 inpatient rehabilitation

beds at Rugby site, 17 for C&R CCG

UHCW for Rugby (preferred option 9 in patients aged 65+ + 13 beds Community Stroke SWFT/8 in GEH) (N.B. different 20 inpatient Rehabilitation beds 12 beds in SW (SWFT) specification of rehabilitation beds at 10 beds in NW (GEH) beds) Leamington site, SWFT

for SW patients only (Total 39 beds)

(Total 26 beds)

Total bed numbers 93 beds 82 beds - 11 beds

In establishing the future bed base, the following assumptions about the patient flow through the proposed future clinical model were made: • HASU length of stay would continue to be up to 3 days; • Acute length of stay is expected to reduce from the current 18 days (spell average) to 11 days at day 1 of introduction of the full pathway, reducing further to 7 days from

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year 2 of the new pathway being implemented. The implementation plan for the proposed new model introduces and embeds the new community rehabilitation services in phase 1, to make the necessary changes to patient flow to reduce length of acute stay in advance of centralising the HASU and ASU services. • Following their stay on the ASU, patients will be discharged as follows: o 40% of patients will be discharged with a standard ESD package o 30% of patients will transfer to bedded rehabilitation provision o 30% of patients will be discharged with community stroke rehabilitation. • Community stroke rehabilitation will also support 30% of the patients completing ESD and 90% of the patients discharged from bedded rehabilitation. • Bed occupancy rates have been agreed with clinical input from providers to enable the pathway to manage peaks in demand and to deliver the patient flow necessary to sustain the existing HASU/ASU bed ringfencing policy. The occupancy rates applied are as follows: o HASU – modelled assuming 85% occupancy o All other Stroke related beds – modelled assuming 90% occupancy The proposed new clinical model results in a redistribution of the current stroke bed capacity and an overall reduction of 11 beds in the total number of stroke beds required. These beds will be reallocated to other hospital specialisms, recognising the demand pressures for other acute hospital beds in the system from demand growth and given the need to ensure that patient flow is maintained.

7.3 Activity Impact A detailed model of patient flow through the system was constructed with clinical engagement and using points prevalence audits to test and refine assumptions (Appendices 14‐16) . The tables below show a comparison of activity flows through the Coventry and Warwickshire acute hospitals through the current versus the proposed future pathway, for each of the acute provider organisations. This illustrates the potential impact that the centralisation of HASU/ASU is likely to have on both patients and providers.

Activity Impact UHCW GEH SWFT Current Future Current Future Current Future Suspected stroke patients – arriving by 2,077 3,091 437 ‐ 577 - ambulance No of patients assessed in A&E 2,336 3,345 659 224 820 246 Patients transferred to UHCW HASU - - - 120 - 109 No of patients Treated in HASU/ASU 1,053 1,752 281 ‐ 418 - No of patients to receive bedded rehab - 170 - 179

Early supported discharge and Community Stroke Rehabilitation Coventry and Warwickshire

No of patients to receive ESD 465 No of patients to receive CSR 803

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Due to the likely increase in patient journeys identified within the proposed new model we have directly engaged with NHS West Midlands Ambulance Service (WMAS) to enable them to model patient journeys under the proposed future model. This modelling completed by WMAS has identified that implementation of the proposed new model will result in an additional 2.78 ambulance journeys per day. WMAS have confirmed that this increase could be planned into their annual workload. The WMAS modelling report can be found in Appendix 15. Specific review and agreement of the proposed model was sought from NHS England Specialised Commissioning to ensure that the changes proposed would not impact on the services commissioned by them. A letter of support in principle from Specialised Commissioning has been received.

7.4 Financial Modelling The financial implications of the proposed new model have been assessed through joint work between commissioners and providers. The results have been discussed at STP level and the following principles have been agreed by both commissioners and providers: • The bedded part of the stroke pathway (i.e. HASU/ASU and bedded rehabilitation) will continue to be covered by tariff under the current tariff cost envelope. • The three CCGs will invest the required amounts in the additional ambulance transfers, elements of prevention and the community stroke rehabilitation pathway. The agreement that tariff will cover the bedded elements of the proposed new pathway has been used to set an overall financial envelope. This will be recast for the latest tariff at the time of implementation. The three local acute providers have agreed to operate the model within this envelope and to jointly mitigate and manage any risks associated with this element of the pathway, having assessed the costs of delivery and scope for efficiencies. It is important to note that there will be no savings to Commissioners from the planned stroke bed base realignment outlined above. Tariff will continue to be paid on the nationally set basis. The level of investment required from CCGs into the community elements of the pathway has been calculated based on the activity modelling and costing of the proposed workforce models and associated service delivery costs. Further details on the commissioner investments are provided in section 7.4.2 In line with the agreements and assumptions identified above, estimates have been produced by Commissioners and Providers of the impact on income, activity and costs under the current model and the future model options, both at system and individual provider level. These estimates have been based on 2017/18 planned activity and prices to enable a consistent approach to be taken. The table that follows compares the costs for both CCGs and providers of the current and preferred option.

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Change Historic from Investment Revised Historic by CCGs Model Investment UHCW GEH SWFT CWPT Other £000s £000s £000s £000s £000s £000s £000s £000s Acute HRGs 8,476 9,312 836 9,312 Rehabilitation 2,338 3,980 1,642 1,990 1,990 Bedded facilities 0 Acute Outpatients 620 642 22 642 Acute elements 11,434 13,934 2,500 9,954 1,990 1,990 0 0 Community - ESD and Rehab 1,663 4,775 3,112 2,669 2,106 Ambulance extra journeys 171 171 171 AF Net investment 128 128 128 Community elements 1,663 5,074 3,411 0 0 2,669 2,106 299 Total cost of pathway/model 13,097 19,008 5,911 9,954 1,990 4,659 2,106 299 Notes: • Community costings – taken from Provider costings • Stroke tariff based on 19/20 plan and as such within Provider and CCG baselines

7.4.1 Inpatient Bedded Care Costs The cost of hospital bedded care will remain the same for CCGs with the three acute providers agreeing to deliver within the current funding. All three acute provider Boards have confirmed in writing their sign up to this agreement and to jointly managing and mitigating any risks arising. The financial impact of the proposed model was assessed through joint work with providers to agree the likely impact. The table that follows shows the position from the acute provider perspective:

Cost of Proposed Model £000s Acute Inpatient 9,312 Rehabilitation 3,980 Acute Outpatients 642 Acute elements 13,934

Funding Envelope £000s HRG Tariff 10,440 Rehabilitation 2,478 Acute Outpatients 642 Funding by CCGs 13,560

Difference 374

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Please note that the following assumptions have been made in this analysis: • Total acute costs for UHCW, GEH and SWFT are paid on a cost and volume basis at national tariff. • Staffing has been costed on updated pay levels. • A risk share arrangement is in place for under/over activity based on length of stay. • The Trust income changes (and therefore the CCG costs) have been calculated based on the effects of the change to Atrial Fibrillation anticoagulation therapy only. Evidence indicates that there is the potential to avert 230 strokes over three years across the three CCGs (NHS England Atrial Fibrillation QIPP Report 2012/13). NICE estimates the average cost of acute and community care for one stroke at between £12,228 and £40,000 per year. However, there are additional costs associated with delivering this part of the pathway in terms of prescribing and patient identification, which make this a small net cost overall. Further assumptions have been included relating to length of stay as described in the following section.

Length of Stay Assumptions The centralised service model improves Commissioner and Provider financial sustainability. The baseline activity data used for modelling reflects a current average length of stay per spell of 18 days. Given the current limitations on availability of stroke rehabilitation beds, the current acute spell length is believed to include some rehabilitation level bed days, which is therefore inflating the reported average acute stay. The proposed new model of care sets a target of 11 days for the average acute length of stay (i.e. HASU/ASU total stay). This is based on a prudent expectation of the acute length of stay reduction that will be achieved through establishing comprehensive ESD and community stroke rehabilitation. The reduction in length of stay helps to lower the bed requirement for acute stroke from the existing bedded quantum at the three sites to the equivalent of 12 additional beds at UHCW. For Commissioners, the provision of alternative rehabilitation options will reduce the average length of stay needed within an acute setting by creating services which actively ‘pull’ patients who are medically stable and in need of rehabilitation into non‐acute settings which are more appropriate and closer to home. The 11 day average acute length of stay is noted as being a prudent estimate when compared with other similar models in England evidencing a 7 day average length of stay. As discussed in section 4.3, evidence from the evaluation of other systems in England that have already centralised stroke admissions supports the assumption that investment in community services will deliver a reduction in length of stay. Further, local evidence from the implementation of the ESD and community stroke rehabilitation in Coventry has already demonstrated a significant reduction in acute length of stay for Coventry patients. The three local acute providers report current average acute stroke lengths of stay of between 12 and 14 days. It is therefore recognised that a proportion of the overall reduction in length of stay required has already occurred and gives credence to the deliverability of the business case.

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The development of this Business Case coincides with the release of 11 decant beds at UHCW, which were created to enable fire stopping works at the Trust. These beds will accommodate the bed requirement transfer to UHCW. The prudent assumptions on the expected length of stay further mitigate the capacity risk at UHCW. To transact this, commissioners have agreed an unbundling methodology with UHCW. It is important to note that there will not be any overall bed closures for the system; beds not required for stroke care will be transferred to other specialties as required by demand.

7.4.2 Commissioner Costs As stated above, it has been agreed by all three Commissioners that they will fund the additional costs required in the community elements of the pathway. As with the acute costs, joint work with providers has been undertaken to calculate the cost of these changes, based on activity modelling and costing of the consequent workforce model and associated service delivery costs. The resultant total investment and split between each of the three CCGs has been agreed and signed off by CCG Governing Boards as follows: • NHS Warwickshire North CCG 17th July 2019 • NHS Coventry and Rugby CCG 17th July 2019 • NHS South Warwickshire CCG 17thJuly 2019 The table below compares the costs for both CCGs and community providers of the current and proposed model.

Current Investment Cost of by CCGs Proposed Model £000s £000s Community - ESD and Rehab 1663 4,775 Ambulance additional journeys 171 AF Community investment 128 Community elements 1,663 5,074

Additional cost of community model 3,411 Additional cost of Acute model 374 Less savings on CHC packages -700 Net additional CCG investment required 3,085

Agreed split by CCG: CRCCG 300 1,283 SWCCG 440 547 WNCCG 1,008 1,254 1,748 3,085

This analysis indicates that the CCGs will be required to invest a further £3.1m in the community pathway. The agreed split of investment between the CCGs is as shown in the table above. Proposed investment levels are within CCG financial plans for 2019/20 (on a

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part year basis) and 2020/21 (on a full year basis). The five-year financial plan being developed will also include the impact of this service provision. The source of funding for stroke prevention (Atrial Fibrillation anticoagulation therapy) is savings delivered from elsewhere within CCG budgets. The estimate of costs has been based on the following assumptions: • It is based on a current cost breakdown received from providers. Current staffing levels will be altered in line with business case assumptions. It has been assumed that income will cover costs under the proposed model. • ESD: up to 40% of all Coventry and Warwickshire patients would receive this service. This is consistent with what is known about the numbers of patients receiving the current Coventry service and take-up rates. Further details of the modelling used to predict ESD demand can be found in Appendix 16. • Community stroke rehabilitation: costs have been included for the provision of a service throughout Coventry and Warwickshire which meets the Midlands and East Service Specification. • Ambulance service: additional funding will be required as a centralised model will increase the number of emergency transports into the specialist centre following a 999 call and also the number of non-emergency journeys as a result of repatriation for rehabilitation. The estimated activity impact of this and associated costs have been worked up by WMAS. In line with the Implementation Plan for the proposed new model, the cost of the community pathway has been assumed to start at an earlier stage than the bedded pathway, to enable the pull of patients through the system to be created and embedded before implementation of the acute centralisation.

7.4.3 Impact on Social Care Costs The financial impact of improved stroke management on Social Care costs has not been included in the costings due to there being: • no increase in the number of stroke patients that social care will be supporting; the new model will change the flow of patients through the system, not the volume and should reduce patients’ level of dependency through the enhanced rehabilitation. Therefore, there are not expected to be any additional costs incurred by the Local Authorities • there being net anticipated savings to the Council from improved patient outcomes that are not necessarily attributable to the CCGs. It should be noted that similar stroke models piloted in other parts of the country have observed significant reductions in post-stroke Social Care packages. In Essex, a shift took place from 8.9% of strokes requiring a Social Care package before implementation of the new stroke pathway to 2.7% after implementation. It is estimated that this could save around £2m across all 3 CCGs if this percentage reduction is applied to the projected strokes in this business case.

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7.4.4 Financial Risks and Sensitivity Analysis A number of financial risks have been identified which are described in the table below.

Value Risk estimate Provider Commissioner Number Risk Description (£m) (£m) (£m) Recurrent? Level of Risk Basis Mitigating actions

Agreement has been reached that Providers will take the risk on the The proposal is that tariff bedded part of the Stroke pathway. Work with Clinical leads is risk shared for acute Currently above 11 undertaken with expectation that pathway can deliver better than 11 1 Risk Share 1.4 1.2 0.3 R High length of stay at under 11 days as a system day length of stay. Contract approach and clauses should mitigate. days. Acute Length of stay will reduce with introduction of bedded rehab, which accounts for a substantial part of current Acute length of stay.

The movement of bed ESD already in place for CRCCG, 6-9 months implementation is usage may not result in Bed Trust Estimate on anticipated at most. Clear communication of issues during an income neutral implementation phase with recovery actions. Contract approach will 3 Opportunity 0.4 0.4 NR High possible income equivalent service being be to pay for reasonable levels of transition with limits on reasonable Cost loss re-provided within the adjustment set. Delay on implementation of the next phase would Trusts. be the ultimate mitigation. Sensitivity analysis shows Assumption based that there is a risk of Provider on additional 5 Peak times will be managed through overflow and through occupancy 5 additional beds in both 1.2 1.2 R Medium being allowed to be greater than 85%. Sustained period of peak flow Efficiency days LOS, 6 beds at HASU/ASU needed for unlikely. £200k per bed. peak times Based on NICE CCG CHC Community package guidance, but Prudent assessment of impact of AF already in place. Community 9 Community investment and AF 0.7 0.7 R Medium without certainty package impact will be taken out of budgets as part of investment Savings Prevalence assumptions as to where plan, but prudent assessment of valuation taken. savings occur. Tariff has been based on Tariff changes each 2019/20 tariff levels and year. Could these will change Tariff change as contract 11 impacting on 0.0 R Medium Zero impact confirmed for Health Economy Changes basis may change. commissioners/providers. Not financially As an STP this should only valued. move the deficit. TOTAL 3.7 2.8 1.0

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As described in section 7.2 above, bed capacity has been modelled on the basis of running the proposed new model with bed occupancy of 85% in HASU and 90% in all other beds, in line with accepted best practice. Sensitivity analysis has been undertaken to test the resilience of the resultant bed numbers, modelling the impact of an increase in acute length of stay and variations in the total volume of strokes through the model. In terms of acute length of stay it has already been shown that the creation of dedicated rehabilitation beds alone should reduce the required number of beds to the level for 11.5 length of stay. An increase in the overall total number of strokes is a more likely risk to the model. Planning bed capacity based on the occupancy rates used means that occupancy should be low enough to offset the sensitivity around this in the short to medium term. Increased numbers should only be needed for very high peak times as outlined within the risk table. The health economy will need further conversation if this does peak in a sustained way above this level.

The results of the sensitivity modelling are shown in Appendix 17. This has been included within the risks.

7.5 Conclusion The financial analysis indicates that the CCGs would be required to invest £3.1m to deliver the proposed model of care. The three CCG Governing Boards have agreed to invest this level of funding and included their respective proposed investments in financial plans for 2019/20 (on a part year basis) and 2020/21 (on a full year basis). Working together, the three acute providers have agreed to deliver the hospital bedded elements of the pathway within the national tariff and a joint risk share arrangement is in place for under/over activity based on length of stay. Some modest financial savings will accrue to the CCGs as a result of the new model (£0.7m from the impact of improved anticoagulation therapy for AF and reduction in long term NHS funded packages of care through the improved rehabilitation offer). This is considered an appropriate investment to make to increase quality, improve outcomes and access and address the key issues outlined in this business case. After the consultation process and as part of mobilisation, further work will be undertaken on the timing of the required investments.

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8.0 IMPLEMENTATION This section outlines the next steps for the CCGs to proceed to implementation of the proposed future clinical model for Stroke services.

8.1.1 The Process Following Consultation Once the final pathway has been identified following public consultation, the project will move into the contracting and implementation phase. As Commissioners commence the contract process, they will focus on the governance arrangements with accountability routed through the Strategic Commissioning Joint Committee (SCJC) formed from the three CCGs of Coventry and Warwickshire. Implementation will be overseen by the formation of an Implementation Board, chaired by a Chief Executive of one of the provider organisations (to be nominated), with membership comprising at least one Executive from each of the provider and commissioner organisations. It is expected that the governance structure for the implementation process will be as set out in the diagram below.

Governance Structure – Implementation Phase

Strategic Commissioning Joint Committee (SCJC)

Implementation Board

Decisions Gateway Approvals Mobilisation Plans Assurance Reports Risks and Issues

GEH Stroke Lead SWFT Stroke Lead UHCW Stroke Lead

WMAS Representative CWPT Stroke Lead LA representative/s

Implementation Team

Workforce Task and Finish Communications and Engagement Task Contracting and Data Task and Group and Finish Group Finish Group

Staff consultation Public Consultation Performance Management Recruitment Strategy Staff engagement and Metrics

The Implementation Board will meet every two months. Providers will agree arrangements for project management support and leadership at the start of the implementation phase. The Implementation Board will have responsibility and accountability for signing off progression through the implementation gateways defined. It is proposed that the already established Stroke Clinical and Operations Group will reconfigure to become the Implementation Team, with day to day responsibility and

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accountability for managing the delivery of the new networked clinical model. The C&W Stroke Implementation Team membership will comprise a minimum of a Stroke project lead from each provider organisation and representation from West Midlands Ambulance Service, both Coventry and Warwickshire Local Authorities and any other key stakeholders identified as critical to the delivery of the future pathway. In line with best practice project management, the Implementation Team will be responsible for ensuring that mobilisation plans (including timelines) are provided and adhered to, providing formal assurance reports and escalating any risks and issues to the Implementation Board and SCJC as appropriate. They will also be responsible for the regular performance review of patient flow through the system, outcome data, effectiveness of the staffing skill mix and ensuring that defined gateways are achieved before transitioning to the next phase of implementation. This is a complex programme of implementation, delivered in phases with defined “go/no go” gateways. On the basis of the performance and progress review, the Implementation Team will make recommendations to the Implementation Board for approval regarding progress and/or suggested amendments to the implementation plans. Individual providers will be responsible for establishing their own internal governance structure and mobilisation plans for their specific elements of the model.

8.1.2 Commissioning of Future Stroke Pathway The Commissioners have undertaken an options appraisal of the available contractual mechanisms and procurement routes in order to recommend the most effective way of commissioning the integrated stroke pathway. In assessing the contract mechanisms and procurement routes the commissioners considered the following factors: • Local needs and profiles; • Sustainability; • Continuity; • Value for money • Affordability; • Stability • Deliverability, and • Procurement Law and Guidance. After assessing the options the Commissioners intention is to move to a Lead Provider arrangement with mandated sub‐contractors as this should give the best opportunity for an integrated model of care and an integrated workforce across the future pathway CCG Commissioners recognise that there is further work required to underpin the future contracts with robust outcome measures, performance indicators and clinical protocols in order to support the principle of integrated care, continuous improvement and ensure patients flow seamlessly through the pathway. These will be developed in collaboration with providers.

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8.1.3 Implementation Implementing the proposed new clinical model represents a significant change to current services and as such will be a complex process. We are currently in the early stages of implementation planning as the focus to date has been on comprehensively engaging with all key stakeholders to design the most appropriate service delivery model. Therefore, and, acknowledging that greater detail will be provided during and following consultation, the present outline implementation timeline is provided below. A high‐level project plan Gantt chart illustrating the key tasks and project gateway decision points is attached at Appendix 18. Business Case Business case complete June 2019 NHS England Assurance process commences June 2019 Consultation period August 2019 – October 2019 Governing Bodies consider consultation results and decision made (BC updated November 2019 with consultation outcomes) Contract signed Late Feb 2020 Proposed Mobilisation and Implementation should pathway be agreed Community pathway mobilisation/ implementation Recruitment commences to ESD and CSR posts Jan 2020 Mobilisation of ESD and CSR May 2020 ESD and CSR fully implemented Jan 2021 Acute pathway mobilisation/ implementation Recruitment commences to acute posts Dec 2019 Adequate acute staffing in post. Go/No gateway decision Dec 2020 UHCW: additional HASU/ASU beds implemented SWFT: ASU beds closed / SWFT CSRB implemented April 2021 GEH: ASU beds closed / GEH CSRB implemented Complete pathway implemented April 2021

8.1.4 Workforce The workforce model for the proposed new clinical model is based on ensuring that the system has the right skills to manage patients complex and varying needs, in the right setting. It has also been developed based on understanding the current local and national recruitment pressures, to seek to optimise where we are targeting workforce expansion. For example, recognising that we currently have high levels of nursing vacancies in the acute stroke pathway, Band 4 Assistant Practitioner and Band 3 Rehabilitation Technician posts in the ESD and community stroke rehabilitation services will include traditional nursing activities such as tissue viability and continence management, so that our nursing recruitment can be focussed on enhancing the acute team. The workforce required for the future clinical model represents a significant increase in the numbers of staff in the stroke services workforce in Coventry and Warwickshire. It is recognised that this will present a significant challenge given the current difficulties faced in recruitment and is therefore identified as a key implementation risk, with mitigation plans agreed. Critically, the implementation plan has been designed to include key clear gateway criteria for progression with the implementation of aspects of the proposed new clinical model, many of which are based on levels of recruitment to new posts achieved.

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A Workforce Group has already been established as part of the STP‐wide Workforce action to manage recruitment. This group will take the following actions to manage the recruitment process and deliver our workforce plans: 1. Assess the current skill mix and competencies of the workforce against the recognised national competency frameworks, to give a clear indication of where new skills should be recruited and which new posts should be prioritised. Further to this the effectiveness of the workforce skill mix will be regularly reviewed as part of the routine review of the achievement of expected outcomes and benefits and responding to any staff turnover.

2. With regard to nursing recruitment challenges, we will recruit more experienced nurses from within the existing workforce. We will use targeted recruitment processes and work closely with local universities to highlight opportunities within stroke services. We will give opportunities for the development of existing staff who would like to progress into more specialist band 6 and 7 roles within the nursing team. We will put a development plan in place to offer newly qualified and less experienced nursing staff opportunities to gain experience within the specialist wards as part of a rotational training process. We will offer targeted training to ensure that the necessary competencies are readily available in both the acute and community nursing workforce. We will rotate band 5 nurses through ASU, bedded rehabilitation and community services to give them a broad understanding of the pathway and develop the skills required to deliver care in a seamless way. We will offer rotational opportunities at band 6 and 7 for nurses to enhance the ability to retain this important workforce.

3. Within therapy services, nationally there is no current shortage of staff at band 5, there are however challenges in retaining staff at this level and a consequential high turnover, due to limited progression opportunities, particularly noted in some fixed community posts. The presence of clinical specialism within the therapy offer can act as a draw and a clear range of skills and specialists to learn and develop from. Consideration will be given to providing rotational opportunities between services once the model is embedded and this should increase competency, neuro skill and retention at a band 5 level, at least in some posts. We will need local specific actions to recruit experienced band 6 and higher posts. We will run an internal STP wide development programme around the stroke pathway to attract and retain experienced workforce. The band 6/7 physiotherapy and occupational therapy posts in the new structure will be clearly differentiated, to allow current post holders to be clearly slotted into the roles and to attract new employees. We anticipate a shift of band 6/7 experience and clinical experts from acute services into community services as the rehabilitation offer increases in the community, this will allow flow through for lower banded staff to move into their first Band 6 or 7 position in an environment of increased governance and support in bedded units and we would expect this trend to continue and allow a sustainable workforce from OT and PT perspective.

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4. For medical recruitment, the role of Consultant Stroke Physician is recognised nationally as being a shortage specialty and recruitment to the proposed establishment will be a challenge. Promoting a new “stroke pathway of excellence” for the area with a minimum 1:6 on-call rotation should make the posts more attractive to new consultants in particular. The opportunity to have varied input across the whole pathway will also be attractive. Recognising the challenge in recruiting, despite our attractive service model, this has been identified as a key risk to implementation. We have designed our implementation plans to mitigate the risks to delays in implementing the future clinical model, through phased implementation of the model. We will work with HEE and the local Deanery to agree additional training placements locally at F1, STR and SPR level.

5. We will include new and extended roles in the pathway in the medium term. We will seek to develop extended scope practitioners, including extended scope nursing roles, therapy roles, physician’s associates and extended scope pharmacists. Having the HASU/ASU on a single site will make the mentoring and support of these roles less complicated and will offer opportunities to develop skills based, rather than qualification-based job roles. This approach could also be applied to more junior roles with the introduction of nursing associates and assistant practitioners, both within nursing and therapies, to extend the scope of skills delivery. Additionally, we will use apprenticeships to develop HCA and therapy assistant roles.

6. We will put in place retention and reward strategies across the health economy to help retain the workforce. This approach will help to secure additional short-term staffing, whilst the new pathways are established, and staff gain confidence in the delivery model.

Timescales for recruitment Subject to the consideration of the outcome of public consultation and assuming that CCG Boards approve the implementation of the proposed model in November 2019, recruitment to the new workforce model would start in December 2019. The high‐level project Gantt chart attached at Appendix 18 sets out the timescale for recruitment for the key workforce groups. It is important to note that whilst the implementation of the proposed new model will be phased, with ESD and community stroke rehabilitation introduced first and centralisation of HASU/ASU occurring after these rehabilitation services are fully mobilised, recruitment to key posts within the new HASU/ASU model will start immediately after CCG Board approval, i.e. in December 2019. This is a key requirement for mitigating the risk of delays in recruitment given the national shortages of specialist staff in specific key areas such as Stroke Consultants. Recruitment to the ESD and community stroke rehabilitation teams would start early in the new year of 2020. A whole health economy wide induction process for those people joining the pathway, both for existing staff and for those new to the team, will be required. This will have the dual benefits of enabling everyone to have a common understanding of the pathway and where

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they fit within the services and support the development of an integrated networked approach across the team that is not dependent on the employing organisation, but on the delivery of the pathway.

8.1.5 Risk Analysis This is a complex service reconfiguration and as such work has already taken place to identify the potential risks to delivery of the proposed new clinical model and to develop appropriate mitigation plans. The key risks identified are as follows: Workforce: The inability to recruit the necessary staff and reconfigure existing staff as required by the new clinical model. In mitigation implementation will be phased with clear thresholds for gateway progression to ensure that the service is safely mobilised and embedded. The establishment of a clinical network workforce model is seen as a key benefit for recruitment as well as quality of care and whilst initially being applied to Consultants, the principle will be reviewed with respect to its value for other major staff groups such as nurses and AHP staff. Mobilisation of the rehabilitation services will be front‐loaded enabling extra time to complete Consultant recruitment before the centralisation of the HASU/ASU services. Whilst the intention is to recruit to a networked model of Stroke Consultants, recognising the recruitment challenge, alternative mitigating workforce strategies have been outlined by the providers to enable progression to centralisation should only 50% of the new consultants required be recruited. Core to these is the separation of the rehabilitation beds Consultant cover from the HASU/ASU. Establishment of a Workforce Workstream is underway to oversee the workforce challenges and proposals, also acting as the link with the West Midlands Deanery and West Midlands Health Education. The specific situation at the time of each gateway review will be considered by the Implementation Board and the relevant mitigation plan will be enacted should recruitment not be progressing as planned. Capacity: Whether sufficient capacity at UHCW can be developed and sustained to be able to manage any peaks in demand for the HASU and ASU services and any delays in patient flow. In mitigation, capacity planning has been completed using the latest available data and clinically agreed assumptions on the impact of the new model on patient flow. Bed occupancy of 85% for the HASU and 90% for the ASU has been assumed and sensitivity analysis completed which demonstrate that the system is resilient to expected peaks in activity. In addition, implementation will see rehabilitation services implemented first to enable the impacts on acute length of stay to embed prior to the centralisation of the HASU/ASU service. Review and oversight of the implementation of the new service model will be managed by an Implementation Board that includes all providers within the networked model, to ensure alignment and joint ownership of any issues and actions.

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9.0 CONCLUSION This document has described how stroke services are currently provided across Coventry and Warwickshire, the current gaps and inadequacies with these and our proposal for change. It is clear from the analysis of current services that there is considerable unwarranted variation in the range and quality of service provision for patients across each CCG footprint in Coventry and Warwickshire. For example, access significantly differs to inpatient rehabilitation beds, specialist community rehabilitation and ESD dependent on where patients live within the STP footprint. Current services do not meet the Midlands and East Stroke Specification and fail to deliver against a range of key service performance indicators. National and local skill shortages have a significant impact on workforce availability and the ability to recruit and retain sufficient staff to operate high quality services across three sites. Given this range of current, significant access, quality and workforce issues, work is clearly required to improve local stroke care across Coventry and Warwickshire so that more patients can survive their stroke and achieve their optimum level of recovery. Considerable collaborative work has been undertaken over the last 4 years with all stakeholders to design, develop and appraise new clinical models for future stroke services. We recognise that stroke services across Coventry and Warwickshire can be better delivered to provide improved health outcomes for patients, by being set up in line with established best practice guidance. The Business Case has identified the preferred option which is: • A centralised HASU/ASU at UHCW which will receive all stroke patient presentations • One bedded rehabilitation unit at South Warwickshire Foundation Trust (SWFT) in Leamington Spa; • One bedded rehabilitation Unit at George Eliot Hospital (GEH) in Nuneaton; • ESD and community stroke rehabilitation at home areas available across all of Coventry and Warwickshire; In addition, actions have been agreed to improve the identification of people with Atrial Fibrillation and further improve their anticoagulation therapy for people to reduce the occurrence of stroke. The proposed new clinical model will create a pathway of excellence for stroke services, improving the quality of services and removing the current inequities in service provision and access for our population. We believe that through delivery of this business case we will create services that contribute to a higher quality, more effective health and care system, and allow the further development of the NHS long term plan Integrated Stroke Delivery Network and mechanical thrombectomy.

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Consultation on Improving Stroke Services in Coventry & Warwickshire Communications, Engagement and Consultation Plan

Authors Andrea Clark – Head of Engagement Communications and Marketing

Date July 5th 2019 Version 8.0 Public consultation dates

Consultation on Improving Stroke Services in Coventry & Warwickshire

1. Introduction Stroke is a serious, life-threatening medical condition that occurs when the blood supply to part of the brain is cut off, due to a bleed or a blood vessel being blocked.

In 2015-16 just over 1200 people in Coventry and Warwickshire had a stroke and were taken to one of our three local hospitals. Just under 800 of these were diagnosed as having suffered a stroke.

There were over 15,000 stroke survivors on local GPs’ stroke registers.

Over 700 people were diagnosed with a ‘transient ischaemic attack’ (TIA) sometimes called a ‘mini-stroke’.

Strokes are medical emergencies and urgent treatment in the first 72 hours is essential because the sooner a person receives an effective diagnosis and treatment for a stroke, the less damage is likely to occur.

Current stroke services in Coventry and Warwickshire have developed over time as a result of localised planning. While improvements in care have been made, further work is required to improve stroke care so that more patients survive their stroke and stroke survivors can achieve their best level of recovery.

The three local CCGs are working together to strengthen the local good practice for those people who have suffered a stroke or a mini-stroke. The review has looked at both the hospital and community services where people receive stroke care.

This consultation is being run by three CCGs: NHS Coventry and Rugby CCG, NHS South Warwickshire CCG and NHS Warwickshire North CCG. The key partners in this consultation are: • University Hospitals Coventry and Warwickshire NHS Trust • South Warwickshire NHS Foundation Trust • George Eliot Hospital NHS Trust • Coventry and Warwickshire Partnership NHS Trust • West Midlands Ambulance Service NHS Trust • Warwickshire County Council • Coventry City Council • The Stroke Association

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2. Consultation & Engagement Outcomes

• All stakeholders have had the opportunity to take part in the consultation and have their say.

• Appropriate targeted engagement and consultation has taken place with relevant and seldom heard groups, to include those who experience health inequalities e.g. those living in low socio economic areas, and those who are at risk of stroke due to lifestyle or existing health conditions.

• An informed and aware patient and public body that understand the reasons for change and the solution(s) proposed and has input to the final decision.

• An involved local population including views obtained from those with protected characteristics.

• An engaged workforce who are aware of the need for change and are comfortable with the process taking place to achieve change.

• A well-run consultation which meets statutory guidelines and obtains views from a wide variety of publics.

3. Key messages

• The NHS is committed to ensuring a high quality, equitable stroke service for the people of Coventry and Warwickshire.

• Clinicians and patients have been involved throughout the development of the consultation and are at the heart of change.

• Public and stakeholder involvement will make a difference to the care of future stroke patients and the quality of life of stroke survivors.

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4. Stakeholder mapping and database

For the pre-consultation engagement process, stakeholder mapping took place and identified a wide variety of stakeholders and the best way to engage and consult with them. Information gathered during the pre-consultation engagement process provided a rich source of data. This has been coupled with a further stakeholder mapping process by Arden and GEM CSU which has informed the creation of an even more comprehensive stakeholder database including all statutory stakeholders, partners and many organisations who are able to cascade to large numbers, as well as smaller groups and individuals.

It is this comprehensive stakeholder database that supports the activity outlined in the communications and engagement plan. Face-to-face engagement will be scheduled with seldom heard and patient groups before the consultation begins. The scope of the consultation across the three CCGs has meant that geography as well as demography has been of uppermost consideration in the design of the communications and engagement plan. We have also specified activity with out of area CCGs. This is because it is imperative that stakeholders, patients, carers and as many members of the public as possible from all areas are given the opportunity to feed into the consultation process. Existing engagement mechanisms across all CCGs will be included in the consultation process.

Patient and Public Advisory Group (PPAG) stakeholder group

The PPAG has been part of the pre-consultation engagement process and will continue to be part of the consultation process. Regular meetings for this group will be scheduled and arranged before the consultation begins.

Patients who have experienced a stroke and their carers

These patients were a vital group in the pre-consultation engagement and all groups involved previously will be invited to complete the consultation questionnaire. Disease specific groups at risk of stroke such as diabetes, cardiovascular disease, alcohol related groups, smokers and those seeking help with being overweight or obese will also be included in the consultation plan as more scoping continues in preparation for the start of the consultation.

Health inequalities

Engagement will also be planned and conducted in low socio economic geographical areas across Coventry and Warwickshire.

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5. Consultation methodology

• Face to face briefings • Attendance/presentations at meetings e.g. stroke groups; community groups; voluntary sector groups; disease specific groups • Public meetings • Drop in sessions • Press releases • Newsletter articles • Web (intranet and internet) content • Social media • Staff briefings • Consultation documents including questionnaire • Online questionnaire • Media coverage (Print/Radio/TV) • Individual MP meetings • GP briefings

Opportunities for consulting via already existing channels are being scoped and included in the plan below. This includes providing information on the consultation via GP surgeries, PPG forums, practice manager forums, health champions, public health, and the voluntary sector and locality meetings. All meetings and opportunities of this kind across all three CCGs need to be accessed as an opportunity to keep clinicians and health care staff up to date and to encourage cascade to the widest patient and public community possible. These opportunities will be confirmed, speakers sourced and then added as the consultation plan is further developed.

The geographical distribution range will cover all three CCGs and their bordering areas. We know that areas of high social deprivation have high incidences of ill health and that people living in rural areas may have different concerns about changes to service provision than those living in urban areas, therefore geographical and demographic considerations have been taken into account in the development of the consultation plan.

The consultation document will be supported by information and additional materials on websites, in presentations and other communication materials, outlining the proposed options. It will also provide information about how to respond to the consultation and how feedback will be examined and outcomes communicated. It will include a questionnaire which can be returned to a Freepost address. The consultation questionnaire will be available interactively online.

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To reach as wide an audience as possible, people will have the option to request the information in other languages and in formats including audio, in hard copy and on websites, supported by extensive and regularly updated Questions and Answers and presentations. Hard copies will be put on display at numerous sites across the organisations involved and at appropriate meetings, supported by posters. For internal audiences, articles will appear in staff newsletters, briefings etc.

At meetings and presentations during the consultation period, all questions and verbal feedback will be recorded so they can be fed into the consultation analysis. Key stakeholder organisations’ formal responses will be requested in writing, either by way of their meeting minutes or separate letter/email.

A formal log of all consultation activities will be kept. The Stroke Patient and Public Advisory Group (PPAG) will be used to sense check our plans and highlight any opportunities for further engagement.

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6. Consultation Engagement Plan All dates to be confirmed following NHSE panel and governing body meeting(s).

Governance process and involvement of statutory bodies

Task Action 1 Action owner Date Status NHS England assurance Liaise with NHS England CCG TBC meeting to sign off business case, final consultation document and process Keep PPAG updated on CSU TBC consultation dates once business case approved by NHSE HOSC meetings Arrange attendance to update CCG TBC Attendance at HOSC HOSCs once NHSE have signed meetings off business case

CCG governing body Prepare template introduction to CSU As required meetings Governing Body papers for the throughout the three CCGs. consultation period Prepare updates as required on process/presentation/ Snapshot analysis To be confirmed with CCGs Joint governing body Prepare documents as required CSU As required meetings e.g. updates on throughout the process/presentation consultation period To be confirmed with CCG

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7. Pre-consultation planning and preparation

Task Action Action owner Date Status Consultation document Consultation document final draft CSU March 6 2019 preparation and prepared for sign off production Final Sign off at three CCGs CCG July 2019 governing Bodies Design, prepare for printing CCG All prepared and Print documents CSU signed off prior to Draft text for website CSU consultation Create online questionnaire CSU Create Easy-read version of CSU materials Create audio version of materials CSU for website

Stakeholder mapping Final check stakeholder mapping CSU All prepared prior and distribution and identify any gaps to consultation preparation Check engagement and CSU consultation document distribution list and identify any gaps

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Task Action Action owner Status Seldom heard Identify meetings and request CSU engagement preparation attendance at community groups and voluntary sector meetings to reach the nine protected characteristics, low socio economic and CVD groups

Clinical engagement Scope locality meetings and who CSU In preparation for preparation will attend to update consultation start

Scope any scheduled meetings, CSU e.g. Practice Managers Forum, PPG meetings, etc

Attend STP comms meeting to CSU discuss consultation including staff, patient and public engagement

Communications Draft briefing for HOSC if CSU As required before, materials preparation required (CCG may choose to do during and after this) consultation

Staff briefing draft CSU All prepared and Staff briefing signed off CCG signed off prior to start of consultation

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Action Action owner Status Draft stakeholder, patient and CSU public briefings CCG Briefing signed off Develop public presentation CSU Presentation signed off CCG Draft text and design poster to CSU promote consultation Poster signed off CCG Draft Q&As CSU Signed off CCG Draft proactive press release CSU Prior to start of Sign off CCG consultation Draft social media and schedule CSU Sign off CCG Spokespeople identified and CCG briefed

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8. Consultation launch and logging

Task Action Action owner Date Status Launch consultation Briefing sent to staff and CSU 48 hrs prior to stakeholders one to two days consultation launch day before the launch of the consultation Consultation document including CSU First day of questionnaire live on the website consultation

Email briefing sent out to all CCG

stakeholders and public

Press release issued/social media CSU commenced CSU As required following Media interviews arranged consultation launch Distribution of consultation Distribute hard copes via CSU In time for document mechanisms identified in consultation start distribution list eg to libraries, GP surgeries, community venues etc Continue distribution throughout CSU As required consultation as required Logging of responses Logging of hard copy, phone and CSU Throughout the12 electronic responses week consultation Logging of electronic questionnaire CSU Throughout the 12 responses week consultation Logging of feedback from public CSU Throughout the 12 meetings week consultation Logging of stakeholder interactions Throughout the 12 week consultation

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9. Consultation communications and engagement activity - staff

Clinical engagement Task/group Action Action owner Date Status Locality meetings Confirm dates and CCG attendee CSU will organise During 12 week consultation Member engagement Confirm dates and CCG attendee CSU will organise During 12 week meeting consultation Practice Managers Confirm dates CCG and attendee CSU will organise During 12 week Forum consultation Protected Learning Time Confirm dates and CCG attendee CSU will organise During 12 week consultation Staff briefings at acute Confirm dates and speakers CSU will organise During 12 week hospitals consultation Staff briefings at Confirm dates and speakers CSU will organise During 12 week community hospitals consultation

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10. Consultation communications and engagement activity – Patient and Public engagement

Patient and Public engagement Task/group/area Action Action owner Date Status North Warwickshire 2 patient and public engagement CSU will organise During 12 week drop-in sessions Commissioner and consultation 1 daytime event Clinical lead to 1 evening event attend South Warwickshire 2 patient and public engagement CSU will organise During 12 week drop-in sessions Commissioner and consultation 1 daytime event Clinical lead to 1 evening event attend Coventry 2 patient and public engagement CSU will organise During 12 week drop-in sessions Commissioner and consultation 1 daytime event Clinical lead to 1 evening event attend Rugby 2 patient and public engagement CSU will organise During 12 week drop-in sessions Commissioner and consultation 1 daytime event Clinical lead to 1 evening event attend Seldom Heard As scheduled during scoping CSU During 12 week Engagement period consultation Libraries across the As scheduled during scoping CSU to attend During 12 week region period consultation Community groups to As scheduled during scoping CSU to attend During 12 week engage with the 9 period consultation protective characteristics

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Patient and Public engagement Task/group/area Action Action owner Date Status Attend Community CSU to attend CSU During 12 week groups in areas of high consultation socio economic deprivation Visit CSU to attend CSU During 12 week outpatients/hospitals to consultation talk to patients Engage with PPG CCG/CSU to attend CSU During 12 week forum/s consultation Attend voluntary sector CSU to attend CSU During 12 week meetings consultation

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3. Gap analysis and evaluation

Task Action Action owner Date Status Gap analysis Snap analysis of age, postcode, CSU As required by CCG option chosen. During 12 week Further targeting of any gaps as consultation required Final analysis and report Analyse responses and prepare CSU Following close of development consultation report consultation Send completed consultation CSU One week before report to CCGs Governing Body meeting Decision making Consideration of consultation CCG At Governing Body report at CCG Governing Bodies Outcome announcement Feedback and evaluation to key CSU Following decision stakeholders Publication of consultation report CSU Following decision on websites Press release announcing CSU outcome Implementation Confirmation of approach and CCG/CSU Following decision responsibilities re: implementation comms and engagement

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A consultation log of all engagement and activity will be kept during the consultation process

A distribution log will be kept and updated of all communications including documents that are sent out during the consultation

All face to face engagement during the consultation will be recorded, saved and included in the consultation analysis

All letters, emails received during the consultation will be recorded, saved and included in the consultation analysis

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Developing a pathway of excellence for stroke services in Coventry and Warwickshire Public Consultation Developing a pathway of excellence for stroke in Coventry and Warwickshire

Contents

Foreword ...... 2

About us ...... 3

About stroke ...... 4

Why we are developing proposals to change current stroke services ...... 4

Our assessment of existing stroke services ...... 7

How we have developed our proposals ...... 8

Patient and Public involvement in developing proposals for the future ...... 9

How we developed possible scenarios for hospital care when people first have a stroke ...... 7

Outcome of the clinically led scenario assessment process for the acute phase of the stroke pathway ...... 12

Other concerns fed back during patient and public engagement and how we have addressed them ...... 14

Capacity at University Hospitals Coventry and Warwickshire ...... 16

The non-financial options appraisal process for community rehabilitation beds ...... 17

The preferred option for consultation ...... 18

The questions ...... 20

1 Developing a pathway of excellence for stroke in Coventry and Warwickshire

Foreword

Dear reader,

Welcome to our public consultation on developing a pathway of excellence for stroke in Coventry and Warwickshire.

The consultation document details why we need to change the way stroke services in Coventry and Warwickshire are delivered, how the proposals for change have been developed and our preferred proposals for an improved stroke service.

We started by considering changes to hospital services but, it became clear that we needed to review the whole patient pathway; including rehabilitation services and stroke prevention in order to make the biggest difference to the health outcomes of stroke patients.

From the work we have done it is evident that services across our area differed from place to place and also did not meet some of the principles of good care set out in national guidance.

It was also clear from public feedback, that high quality, specialist stroke services were valued by people but there was also a desire for localised rehabilitation services where possible.

We have listened to all feedback from the extensive public engagement over the last four years and taken it into account in the final proposals we are bringing to you for public consultation. We are clear from what people have said through the engagement so far, that should the proposals be approved, the home-based rehabilitation services must be in place before any changes to hospital services are made.

Once again, we are looking for your views as we need your assistance to help us gain feedback on our final proposals. Our objectives are about developing a pathway of excellence for stroke care which results in real improvements in health outcomes for local people.

Our proposals will need more investment in specialist rehabilitation services, medicines and more ambulance transfers than the services available now. But we feel that it is important to make this investment in order to reduce the chances of having a stroke and the disability resulting from a stroke.

Thank you for taking the time to read this document. Please complete the questionnaire at the end of this document or attend one of our consultation events. Your contributions and opinions really do count and will be used by us, the NHS, in making the decisions about future stroke services in the area.

Dr David Spraggett Chair, South Warwickshire Clinical Commissioning Group Dr Inayath Ullah Clinical Lead, NHS Warwickshire North Clinical Commissioning Group Dr Sarah Raistrick Chair, NHS Coventry and Rugby Clinical Commissioning Group

2 Developing a pathway of excellence for stroke in Coventry and Warwickshire

About us

We are three NHS Clinical Commissioning Groups (CCGs): NHS Coventry and Rugby, NHS South Warwickshire and NHS Warwickshire North. The CCGs plan and buy the majority of NHS healthcare services across the area and are overseen by NHS England.

The key partners in this consultation are: • University Hospitals Coventry and Warwickshire NHS Trust (UHCW) • South Warwickshire NHS Foundation Trust • George Eliot Hospital NHS Trust • Coventry and Warwickshire Partnership NHS Trust • Warwickshire County Council • Coventry City Council • West Midlands Ambulance NHS Foundation Trust

These organisations support acute stroke services from three hospitals across our area. Rehabilitation services provided from a hospital bed or at home are to support stroke survivors to regain their health following a stroke. Rehabilitation may include a package of care such as physiotherapy, speech therapy and emotional support at home. Acknowledgements:

Photograph of Clinical and ops group to be inserted

Photograph of PPAG to be inserted

This public consultation is the culmination of a long journey to develop a pathway of excellence for stroke services in Coventry and Warwickshire. We have been through a process of co-production of proposals that includes pre-consultation engagement and planning work with the help of our local clinicians, patients, carers, community groups and our dedicated Stroke Patient and Public Advisory Group. This work has led to the proposed options for the future of this important service. The input we have received has made a real difference in the production of our plans and we would like to thank everyone that has contributed.

3 Developing a pathway of excellence for stroke in Coventry and Warwickshire

About stroke

Stroke, a preventable disease, is the fourth single leading cause of death in the UK and the single largest cause of complex disability (source - Stroke Association (2018) State of the nation: Stroke statistics).

A stroke is a rapid loss of brain function that occurs when the blood supply to part of the brain is cut off, leading to brain cells either being damaged or destroyed. Whilst largely preventable, stroke is one of the main causes of deaths in the UK and is also the leading cause of adult disability. Strokes are medical emergencies and urgent treatment in the first 72 hours is essential because the sooner a person receives an effective diagnosis and treatment for a stroke, the less damage is likely to occur.

There are two types of stroke:

• An ischaemic stroke resulting from a blockage in one of the blood vessels leading to the brain.

• A haemorrhagic stroke resulting from a bleed in the brain.

In addition, a transient ischaemic attack (TIA) or ‘mini-stroke’ is a sign that a person is at risk going on to have a full stroke.

Although people often assume that only older people have strokes, in fact young and middle-aged people also experience strokes. A stroke can have a huge impact on the quality of someone’s life, irrespective of age.

Why we are developing proposals to change current stroke services

There is strong and growing evidence, that prompt specialist assessment and treatment significantly improves a person’s chance of surviving with the least complications and disabilities following a stroke. When we reviewed our services we discovered that we have some gaps against these specifications. We want to change these services so that patients get the best outcomes.

We also want to ensure that we are in the best position to develop the Integrated Stroke Delivery Networks described in the new NHS Long Term Plan published in January 2019. These networks will, over the next five years ensure our services meet the NHS seven-day standards and National Clinical Guidelines for Stroke and higher intensity models of stroke rehabilitation. We will also be prepared for adoption of the latest medical advances such as mechanical removal of a blood clot in the brain.

The expansion of the latter (from 1% to 10% in the future) is predicted to mean that 1,600 more people a year, would be independent after their stroke. (source NHS Long Term Plan - stroke care).

4 Developing a pathway of excellence for stroke in Coventry and Warwickshire

This is a list and link to the key clinical evidence we have used in developing our plans:

1 The National Stroke Strategy www.strokecovwarks.nhs.uk identified key changes in stroke care and has contributed to a reduction in the numbers of patients dying within 10 years of having a stroke. That reduction is largely due to improved co-ordination and speed of getting people to the right specialists in stroke care; more patients who need it receiving clot-removing drugs, and more patients receiving brain scans within 24 hours of admission to hospital. This will ensure that the optimum treatment and care can start as soon as possible.

2 Evidence that hyper-acute interventions such as brain scanning and thrombolysis are best delivered as part of a networked 24/7 service. https://doi.org/10.1371/journal.pone.0070420

3 Areas that have centralised hyper-acute stroke care into a smaller number of well-equipped and staffed hospitals have seen the greatest improvements. (https://doi.org/10.1136/bmj.g4757)

4 The NHS Long Term Plan, https://www.longtermplan.nhs.uk

5 The Midlands and East Regional Stroke Services Specification sets out expected standards to achieve the best outcomes for patients. For full details please visit www.strokecovwarks.nhs.uk/Documents/Documents

In particular:

• Pre-hospital care

• All patients suffering from a stroke receive appropriate hyper acute care within the first 72 hours

• There is comprehensive access to Early Supported Discharge services and specialist community stroke rehabilitation

• Greater focus on primary prevention

• Long term care.

5 Developing a pathway of excellence for stroke in Coventry and Warwickshire

The Midlands and East stroke specification is summarised in the diagram below

The Midlands and East specification has already been put in place in Nottingham, Birmingham and Worcestershire and they have already seen improved outcomes as a result.

Please see further information in the business case at www.strokecovwarks.nhs.uk/Documents/Documents

6 Developing a pathway of excellence for stroke in Coventry and Warwickshire

Our assessment of existing stroke services

Current stroke services in Coventry and Warwickshire are providing a good standard of care but they are not meeting the latest national and regional guidance and evidence.

We also have inequity of access that we want to address through the proposed improvements.

The main gaps we have identified from working with the professionals and patients, carers and the Stroke Association are:

• Not everyone who could benefit (ie within the first 72 hours of having a stroke) is being taken to the hyper acute unit at University Hospital Coventry and Warwickshire.

• Although we have tested out a model of the best practice specialist rehabilitation services in one area, we don’t have these available for everyone after their stroke.

• We have struggled over many years to recruit stroke specialist doctors and we are aware there is growing evidence of not enough specialist stroke nurses. Our stroke doctors, nurses and therapists are not organised in a way to deliver an integrated, seamless service due to not having the best model of service, in addition to gaps in services. Introducing a better integrated and networked stroke service will help us to recruit, develop and retain the right number of stroke specialists.

• Evidence suggests that although we are identifying most, we are not identifying everyone who has atrial fibrillation who could reduce their risk of stroke by optimising their drug therapy. Early intervention could save around 100 local people a year from having strokes.

• People want more local co-ordinated action and information on how to prevent strokes, so that they can easily find out how to help themselves and loved ones.

• Having looked at our services, we are also clear that we are not in the best place to develop services in line with the ambitions in The NHS Long Term Plan which are nationally set.

By 2020 we will begin improved post-hospital stroke rehabilitation models with full roll out over the period of the Long Term Plan.

By 2022 we will deliver a ten-fold increase in the proportion of patients who receive thrombectomy after a stroke, so that each year 1,600 more people will be independent after their stroke.

By 2025 we will have amongst the best performance in Europe for delivering thrombolysis to all patients who could benefit.

In summary we have considered the evidence, what local people and professionals have told us and taken advice from experts, to come to a conclusion that we need to make improvements that will require change now.

7 Developing a pathway of excellence for stroke in Coventry and Warwickshire

How we have developed our proposals

Clinical involvement in developing proposals for the future

We have looked at national and regional evidence and best practice for delivering stroke services and have taken advice from a range of experts at different stages of the development, this included Professor Tony Rudd, National Clinical Director for Stroke.

We have worked with local doctors, specialist nurses and therapists - including GPs and stroke consultants, nursing and therapy specialists and tested our proposals with a panel of national experts in stroke care, as part of the review led by the NHS West Midlands Clinical Senate. This work led us to understand what the best clinical model is for stroke patients in Coventry and Warwickshire.

Dr Gavin Farrell, Consultant Clinical Neuropsychologist, Head of Neuropsychology Services Central England Rehabilitation Unit, and Chair of the Stroke Clinical and Operations Group explains:

The whole redesign of the stroke pathway came about when NHS East and Midlands published the new stroke specification, and we have been working over the last few years as a senior group of people, senior doctors, nurses, therapists and commissioners across Coventry and Warwickshire to implement the recommendations of the specification. Really, the specification was designed to increase the level of provision for stroke and increase the ability for people with stroke to get to the acute hospitals as quickly as possible and to get the specialised interventions they need, and in addition to providing that level of stroke intervention in order to help survival, it was also specified how to increase the level of rehabilitation after leaving hospital. So, back home in the community to give people the level of rehabilitation they need for as long as they need it.

Claire Quarterman Clinical Lead for the Early Supported DischargeTeam and Community Rehabilitation Team, and a member of the clinical and operations group says:

I have been part of a clinical and operational working party discussing stroke services currently, the provision that we offer currently to patients, trying to really think about how can we improve and make service equitable, accessible for patients across the region, and that everybody no matter where they live in the region, when they have a stroke get access to the best possible acute care and then following on from that the rehabilitation that they require, so live as best a life as they can.

Throughout the development of proposals clinical involvement has been continuous. The clinical and operations group of local stroke service providers has provided clinical expertise into the development and evaluation advising on:

• Potential scenarios for improved service delivery. • Staffing models of each aspect of the proposed options. • Ability to implement scenarios and more latterly proposals.

8 Developing a pathway of excellence for stroke in Coventry and Warwickshire

Patient and Public involvement in developing proposals for the future

At the same time as getting information from clinical experts over the last five years, we have held an extensive programme of pre-consultation engagement with the public including stroke survivors and Carers. Just as we created a local group of clinical experts, we also created a group of stroke patient and carer experts. This group known as the Patient and Public Advisory Group (PPAG) is chaired by a representative from the Stroke Association and includes people who have experienced a stroke, Carers and family members of those who have experienced a stroke and Healthwatch representation.

Initially, we asked local stroke survivors and carers about how we could improve hospital stroke services and through this work tested out some scenarios. A clear outcome of this work was a message that they wanted us not only to plan improvements in hospital services, those involved wanted us to look at preventing more strokes and rehabilitation after the stroke.

It was at this stage that we established the Patient and Public Advisory Group to act as a critical friend to guide and validate the engagement process. We also went back with the patient and public feedback, to look at how we might design an end to end pathway that included preventing more strokes, providing the right type of hospital care and then more specialist rehabilitation for those who have had a stroke.

9 Public Consultation Developing a pathway of excellence for stroke in Coventry and Warwickshire

How we developed possible scenarios for hospital care when people first have a stroke - known as hyper acute (first assessment and 72 hours) and acute care

In 2014/15 we began talking with local stroke survivors and carer groups, as well as other members of the public who could be affected by a change to gather their views on how we could improve stroke services sharing with them reasons why change was necessary - such as the national shortage of expert stroke doctors and the new evidence about timeliness and organisation of care that improves the chances of recovery.

After the discussions we asked people whether:

• We should do nothing and leave services as they are.

• We should centralise the hyper acute and acute service at University Hospitals Coventry and Warwickshire. All patients across the city and county would go to the Hyper- Acute and Acute unit rather than as currently, some go to their local hospital – George Eliot Hospital or South Warwickshire Foundation Trust.

• All patients go to University Hospitals Coventry and Warwickshire Hyper- Acute unit for 2-3 days. After this, people from the Warwickshire North area transfer to George Eliot Hospital and people from South Warwickshire area transfer to South Warwickshire Foundation Trust.

• All patients go to University Hospitals Coventry and Warwickshire Hyper- Acute unit for 2-3 days then north and South Warwickshire patients transfer to one other hospital, either George Eliot Hospital or South Warwickshire Foundation Trust, with the closure of stroke facilities at the other hospital.

At that time, we were only looking at the hospital services and we collated the feedback from engagement we did with them on this. However the groups asked that we also look at stroke rehabilitation and how people can prevent a stroke. Along with other views, they were clear that travelling to a specialist centre when you first have a stroke was acceptable if your rehabilitation could be closer to home.

Areas of concern included:

• Transport and travel • Travel time by ambulance • Capacity at University Hospitals Coventry and Warwick • Parking at University Hospitals Coventry and Warwick

Commissioners considered all feedback and worked with clinicians, senior managers and local authority colleagues to address the concerns.

10 Developing a pathway of excellence for stroke in Coventry and Warwickshire

In parallel to this phase of patient and public engagement, the commissioners reviewed the available evidence and commissioning guidance, then developed a set of underpinning principles for the potential scenarios for hospital services which were that:

• All scenarios must meet the requirements of the NHS Midlands and East regional Stroke Service Specification, and therefore provide:

A hyper-acute stroke unit (HASU) – should remain at University Hospitals Coventry and Warwickshire as the specialist hospital and trauma centre;

Acute Stroke Unit(s),(ASU) care: one to be aligned to the Hyper Acute Stroke Unit at University Hospitals Coventry and Warwickshire at a minimum;

An Early Supported Discharge (ESD) service should be available for everyone who needs it after their stroke.

• Stroke rehabilitation beds will be provided locally for the post-acute phase of care: for those patients who no longer require acute stroke care, but have ongoing care and rehabilitation needs that prevent them from returning home. All high risk TIAs (mini stroke) would be seen at UHCW as adjacency to the HASU is critical.

Based on these principles, a list of scenarios for the provision of Hyper Acute and Acute services was developed by the clinical leads as follows:

• Hyper Acute Stroke Unit at University Hospitals Coventry and Warwickshire / 1 Acute Stroke Unit at University Hospitals Coventry and Warwickshire Centralisation

• Hyper Acute Stroke Unit at University Hospitals Coventry and Warwickshire / 3 Acute Stroke Units at University Hospitals Coventry and Warwickshire, South Warwickshire Foundation Trust & George Eliot Hospital

• Hyper Acute Stroke Unit at University Hospitals Coventry and Warwickshire / 2 Acute Stroke Units at University Hospitals Coventry and Warwickshire and South Warwickshire Foundation Trust

• Hyper Acute Stroke Unit at University Hospitals Coventry and Warwickshire / 2 Acute Stroke Units at University Hospitals Coventry and Warwickshire & George Eliot Hospital

These scenarios were then assessed for clinical viability: The criteria used were: 1. Scenarios are capable of meeting the NHS Midlands and East Stroke Service Specification. 2. Scenarios must be clinically viable in terms of both workforce and number of patients treated; the latter is critical for staff to maintain their stroke specialist knowledge and skills. 3. Scenarios must be no less than 10 bedded units, as the findings from the visits to stroke units already identified as providing the best practice was that this was the minimum for the service to be clinically sustainable.

More detail is available in the business case at www.strokecovwarks.nhs.uk/Documents/ Documents

11 Developing a pathway of excellence for stroke in Coventry and Warwickshire

Outcome of the clinically led scenario assessment process for the acute phase of the stroke pathway

It was clinically agreed that the only clinically viable option for the acute phase of the stroke patient pathway is to centralise hyper acute and acute services at University Hospitals Coventry and Warwickshire with additional provision for Early Supported Discharge at home.

Feedback from public engagement in 2014/15 led to the extension of the stroke patient pathway to include stroke community rehabilitation and proposals to improve stroke prevention. During 2016 the clinical group developed specialist stroke home based community rehabilitation and a proposal for how to prevent more strokes. A second stage of formal engagement was undertaken to understand the views of the proposals:

• 5000 questionnaires were circulated across Coventry and Warwickshire • 23 public meetings took place • 27 newspaper articles were published • 3 radio interviews were undertaken • Social media reached 800,000 people • Over 300 people completed questionnaires to feedback their views.

People were asked if they agreed with the proposal to prevent more strokes by:

• Optimising treatment for those appropriate • Centralising the service for everyone who suffers a TIA and is at high risk of a stroke.

173 respondents agreed with the proposals to prevent more strokes, 70 disagreed. People were also asked what they thought about the proposal for a stroke rehabilitation service. The proposal includes Early Supported Discharge where people will receive rehabilitation at home. For those not well enough for Early Supported Discharge, community based beds will be available in hospital at South Warwickshire Foundation Trust (SWFT) in Leamington Spa and the George Eliot Hospital (GEH) in Nuneaton.

• 160 people agreed with the developed proposal for stroke rehabilitation • 133 people disagreed with the developed proposal for stroke rehabilitation.

Key concerns were raised during the engagement relating to travel and the requirement for Coventry and Rugby residents to travel to the George Eliot Hospital in Nuneaton or South Warwickshire Foundation Trust to receive bedded stroke rehabilitation.

In response, the Clinical and Operational Group considered alternative scenarios for delivering bedded rehabilitation for the population of Coventry and Warwickshire (for more information please see the business case at): www.strokecovwarks.nhs.uk/Documents/Documents

12 Developing a pathway of excellence for stroke in Coventry and Warwickshire

This further work identified that there were a number of potential scenarios for providing the bedded rehabilitation aspect of the pathway. A long list of potential scenarios was developed by the Clinical and Operational Group. These scenarios were assessed against their ability to:

• Meet national guidance and the requirements of the NHS Midlands and East Regional Stroke Service Specification

• Demonstrate at least the minimum levels of delivery of: quality; being safe; being sustainable and better outcomes for patients.

Following these clinical assessments two viable stroke rehabilitation options remained:

Option 1

Early Supported Discharge Service (ESD) and community rehabilitation in all areas. Bedded rehabilitation at South Warwickshire Foundation Trust (SWFT) in Leamington and George Eliot Hospital (GEH) in Nuneaton

Option 2

ESD and community rehabilitation in all areas. Community bedded rehabilitation provision in Coventry with specialist therapy in-reach. Bedded rehabilitation at SWFT in Leamington and GEH in Nuneaton

These options were then taken forward for full non-financial appraisal by all key stakeholder groups.

Details of the options appraisal are provided in the Redesigning Stroke Services in Coventry and Warwickshire Engagement Report August to November 2018 and in the business case at: www.strokecovwarks.nhs.uk/Documents/Documents and under the heading non-financial options appraisal later in this document.

13 Developing a pathway of excellence for stroke in Coventry and Warwickshire

Other concerns fed back during patient and public engagement and how we have addressed them

Patient and public engagement has informed the development of proposals for an improved stroke service since 2014 to the present (please see the infographic below).

Summary of our engagement journey with patients, carers and stakeholders

Work begun with Dedicated stroke patient and public Stroke Association Plans developed to NHS Warwickshire North Clinical advisory group formed, chaired by the locally to visit all discuss possible Commissioning Group’s patient and Stroke Association and including support groups in options or scenarios public advisory discuss initial ideas membership of stroke survivors, carers Four possible scenarios the area. in line with national 2015 2014 relating to applying national and and Healthwatch. The Coventry and to improve local stroke and regional stroke regional guidance on stroke services Warwickshire stroke patient and public services in the future guidance. to local services in Coventry and advisory group has met regularly from assessed and discussed Warwickshire. then until now. with stroke patients and stakeholders.

Initial concerns raised by Different options Visits to EVERY Stroke Association The Project team was asked to groups visited and Coventry assessed with patients in North and South public support group in Coventry expand the scope to include specialist and Warwickshire stroke Warwickshire Public Health’s Impact Warwickshire, and Warwickshire, reaching over rehabilitation and action to prevent patient and public advisory Assessment identified the groups at risk Coventry and Rugby. stoke survivors, their carers strokes. The 3 CCGs agreed to relook group on equality of specialist 150 that needed to be included in and families. at the Project and expand the scope stroke rehabilitation services, engagement. Feedback from additional to develop an end to end pathway transport links and prevention groups identified as at risk of stroke in the of excellence for improvement of of strokes. future included discussions with alcohol services. and substance support groups, Age UK Stroke patient and public Lorem ipsum and diabetes support groups. advisory group support stronger clinical scenario to clinical experts The findings were presented back to 25 centralised hyper-acute Stroke patient case the Stroke patient and public advisory assess possible future and acute stroke services. studies developed Work is undertaken on implementing group, local clinical leads, commissioning model for local stroke The group help to on how the proposed the 11 recommendations from the managers and NHS England on the service. Their feedback communicate this option new service could Clinical Senate. An Integrated 2016 possible scenarios for how an end to end is incorporated patient through coproduction of have helped their Impact Assessment is commissioned pathway of excellence might be achieved. engagement document. future public outcomes. of the emerging pathway of excellence as an alternative to the ‘Do Nothing’ option.

Almost 5000 questionnaires distributed Prevention of stroke and development of Concerns raised over acute stroke across Coventry and Warwickshire to rehabilitation services beds, transport routes, bedded gather views.23 public meetings, 27 are tested in a further rehabilitation for patients located in newspaper articles, 3 radio interviews six week engagement 2018 Rugby or Coventry, transport links took place and social media reached exercise. 2017 and staffing addressed following almost 800,000 people. engagement.

Proposals presented to Plans for a public consultation developed, incorporating Case study video created by NHS England for their feedback and advice from the 2017 engagement. two members of the patient review and then to the We worked with the patient and public The advisory group endorsed action being taken to: seek advisory group talking about Clinical Senate, to assess advisory group to develop draft criteria to Results of the integrated advice from the Clinical group on the provision of bedded their involvement in the impact assessment the delivery of actions assess any proposals; these were shared rehabilitation more locally to Rugby and Coventry; to give development and decision to address the 11 more widely with public groups in Coventry, considered by CCGs confidence to the public about delivering future making process, as well as alongside the outcomes recommendations from Rugby, North Warwickshire and South rehabilitation services ahead of any changes to acute how possible future services their review in 2016. Warwickshire to gain feedback prior to an from the engagement services; to see how carers could be supported to travel to could have helped them. work. options appraisal by a group of specialists bedded rehab services and also how parking for carers at including, patients and carers, Healthwatch UHCW might be improved. and the Stroke Association.

14 Developing a pathway of excellence for stroke in Coventry and Warwickshire

Consistent areas of concern included:

• Transport and travel including travel time by ambulance • Capacity at University Hospitals Coventry and Warwickshire • Parking

Commissioners considered all feedback and worked with clinicians, senior managers and local authority colleagues to address the concerns.

We have constantly considered patient and public feedback in the development of proposals for an improved stroke service. Commissioners throughout the development of the new model have listened and responded to concerns expressed by patients and the public, these have included the following:

Travel

People are worried that there won’t be enough ambulances to take additional patients if the hyper acute unit and acute unit are centralised at University Hospitals Coventry and Warwickshire.

More funding for you - The detailed modelling we have done means that we know that we will need more investment into ambulance services. Extra funding has been identified to commission adequate ambulance service provision.

People are concerned about how they will travel to visit family and friends.

The right information at the right time - we have reviewed and refreshed the information pack, currently being piloted, to provide stroke patients with information on public transport, patient and voluntary transport and private transport. It will include useful information from bus timetables to the local area, how stroke survivors aged 50 plus and/or their carers can attend NHS related appointments all the way through to social and wellbeing activities for low cost.

We’re changing bus routes - the number 65 hourly bus service, operated by Arriva, is now extended to service Tamworth Hospital to George Eliot Hospital, Nuneaton. This gives a new direct service from several North Warwickshire communities.

Keeping information accurate - transport planners regularly send the latest public transport timetables to named representatives on stroke wards to make sure information is up to date.

Getting more from bus transport - bus operators have agreed the principles of a bus pass plus across Coventry and Warwickshire, costs are to be agreed.

Posters detailing voluntary car schemes in Warwickshire advertise in local hospitals and are available on stroke units.

For information on travel and transport please visit: warwickshire.gov.uk/activetravel

15 Developing a pathway of excellence for stroke in Coventry and Warwickshire

Capacity at University Hospitals Coventry and Warwickshire

People are concerned about beds, they worry that moving the acute stroke services at George Eliot Hospital and South Warwickshire Foundation Trust will mean there will not be enough beds for stroke patients in hospitals.

Faster discharge where appropriate - the new model offers Early Supported Discharge and community rehabilitation. This means that patients can continue their recovery at home and in the community. The new model has taken into account population growth and busiest times.

Our review of established services show that because of shorter stays in hospital for the majority of stroke patients (70%), fewer acute beds will be needed. Community stroke rehabilitation beds have been allocated for patients who are not fit enough for Early Supported Discharge and community rehabilitation. Please see ‘staffing tables by Provider’ detailed in the business case at: www.strokecovwarks.nhs.uk/Documents/Documents

People are aware and concerned about national shortages in specialist stroke consultants and difficulties in recruitment

Bringing the workforce together - a more centralised model for the acute stroke service will optimise the specialist workforce available and improve recruitment, retention, education and training and workforce sustainability (for further detailed information please visit the business case at): www.strokecovwarks.nhs.uk/Documents/Documents

People are concerned about busy times at A & E and delay in reaching the Hyper Acute Stroke Unit of the Acute Stroke Unit.

Getting you to where you need to be - clinicians have developed a protocol to ensure patients are handed over quickly to the hyper acute stroke unit and do not get delayed in the Emergency Department. To inform the protocol, clinicians looked at peak and surge demand times (busiest times) and developed plans to make sure patients will reach the right service even at these times.

People are worried about the difficulty in parking at UHCW

A new car park will provide an additional 1,600 car parking spaces (awaiting planning decision).

16 Developing a pathway of excellence for stroke in Coventry and Warwickshire

The non-financial options appraisal process for community rehabilitation beds

At a meeting in August 2018, the Stroke Patient and Public Advisory Group worked to co-produce a set of desirable criteria and the process to be used to assess the options for bedded rehabilitation. The group also confirmed their support for the preferred option for acute and hyper acute stroke services to be centralised at University Hospital, Coventry.

The assessment criteria coproduced by the Patient and Public Advisory Group and subsequently tested at further public engagement events in Autumn 2018 were:

• Services should be equitable, consistent and always available • Services should focus on the best possible outcomes and recovery • Services should be personalised with a package of care that is right for each individual patient • We should create an environment where experiences, knowledge and information can be shared to benefit stroke survivors and their carers • Professional who are delivering services should understand the stroke patients’ feelings and the consequences of having a stroke • All stroke services should work together with a smooth transition at all points in the stroke patients’ care.

At the patient and public engagement events in autumn 2018 the preferred option for stroke hyper acute and acute services was also revisited, as well as discussing the options for stroke rehabilitation. The findings from these engagement events then fed into a formal public and stakeholder non- financial options appraisal event for bedded stroke rehabilitation services.

To ensure a mix of people offering a range of perspectives attended the meeting, invitations were mapped against the recognised nine protected characteristics and the Integrated Impact Assessment. More than 40 people attended, including staff members who will be involved in delivering a future improved service. They were asked to consider the relative importance of each of the criteria and score each option out of 10 for how well they met (or did not meet) each of the desirable criteria. There was overwhelming support for the option of one bedded rehabilitation unit at Leamington Spa Hospital and one at George Eliot Hospital (to view the full report on the non-financial options appraisal please visit): www.strokecovwarks.nhs.uk/Documents/Documents

The Clinical and Operational Group then completed a financial option appraisal (for more detail please see the business case.

17 Developing a pathway of excellence for stroke in Coventry and Warwickshire

The preferred option for consultation

The considerable collaborative work undertaken over the last four years with clinicians, stakeholders, patients and the public has led to a proposed new clinical model for stroke services. The new model will provide a pathway of excellence for stroke services, removing the current inequities in service provision and access for the population of Coventry and Warwickshire (for more detail please see the business case at www.strokecovwarks.nhs.uk/Documents/Documents. The preferred option for delivering an improved stroke service is therefore:

Acute stroke services Acute stroke services to be centralised at University Hospital Walsgrave, Coventry with stroke rehabilitation provided closer to home. All patients across the city and county would go to the Hyper Acute and Acute Stroke Unit at University Hospital in Coventry. Patients would be diagnosed and treated there until they are ready for rehabilitation closer to home, either in a bedded rehabilitation unit or in their own home with clinical support. The Acute Stroke Units at Warwick Hospital and the George Eliot Hospital, Nuneaton, would no longer operate as all patients would be treated in one specialist centre.

Rehabilitation Stroke Service There will be an Early Supported Discharge Service and community stroke rehabilitation in all areas. Patients who need in-patient rehabilitation will receive the care and treatment they need at South Warwickshire Foundation Trust in Leamington Spa and the George Eliot Hospital in Nuneaton.

Your feedback is important. Please let us know your views on the proposed options for the new stroke service by completing the questionnaire

18 Developing a pathway of excellence for stroke in Coventry and Warwickshire

The option

Acute stroke services

Acute stroke services to be centralised at University Hospital Walsgrave, Coventry with stroke rehabilitation provided closer to home.

• All patients across the city and county would go to the Hyper Acute and Acute Stroke Unit at University Hospital in Coventry.

• Patients would be diagnosed and treated there until they are ready for rehabilitation closer to home, either in a bedded rehabilitation unit or in their own home with clinical support.

• The Acute Stroke Units at Warwick Hospital and the George Eliot Hospital, Nuneaton, would no longer operate as all patients would be treated in one specialist centre.

Rehabilitation Stroke Service

• There will be an Early Supported Discharge Service (ESD) and community rehabilitation in all areas.

• Patients who need in-patient rehabilitation will receive the care and treatment they need at South Warwickshire Foundation Trust in Leamington and the George Eliot Hospital in Nuneaton.

Your views are very important to us. Please tell us what you think about the option outlined above by answering the questions on the next pages.

Thank you for your time.

19 Developing a pathway of excellence for stroke in Coventry and Warwickshire

The questions

Q1: Have you or do you care for someone who has experienced a stroke or transient ischemic attack (TIA)?

Yes I have experienced a stroke or TIA Yes I do or have cared for someone who has experienced a stroke or a TIA No Prefer not to say

Q2: To what extent do you agree or disagree with the option to centralise acute stroke services in Coventry and Warwickshire:

Strongly Agree Agree Neither agree / disagree Disagree Strongly disagree Prefer not to say

Please tell us the reason for your answer ......

Q3: Please indicate the impact the option to centralise stroke services will have on you:

No impact Postive Negative Prefer not to say

Please tell us the reason for your answer ......

20 Developing a pathway of excellence for stroke in Coventry and Warwickshire

Q4: Please indicate the impact the option to centralise stroke services will have on family/ friends/carer:

No impact Postive Negative Prefer not to say

Please tell us the reason for your answer ......

Q5: To what extent do you agree with early supported discharge rehabilitation services in all areas?

Strongly Agree Agree Neither agree / disagree Disagree Strongly disagree Prefer not to say

Please tell us the reason for your answer ......

Q6: Please indicate the impact Early Supported Discharge services in all areas will have on you:

No impact Postive Negative Prefer not to say

Please tell us the reason for your answer ......

21 Developing a pathway of excellence for stroke in Coventry and Warwickshire

Q7: Please indicate the impact Early Supported Discharge services will have on friends/ family/carer:

No impact Postive Negative Prefer not to say

Please tell us the reason for your answer ......

Q8: To what extent do you agree or disagree to in-patient rehabilitation at South Warwickshire Foundation Trust in Leamington and the George Eliot Hospital in Nuneaton:

Strongly Agree Agree Neither agree / disagree Disagree Strongly disagree Prefer not to say

Please tell us the reason for your answer ......

Q9: Please indicate the impact in-patient rehabilitation in South Warwickshire Foundation Trust in Leamington and the George Eliot Hospital in Nuneaton will have on you:

No impact Postive Negative Prefer not to say

Please tell us the reason for your answer ......

22 Developing a pathway of excellence for stroke in Coventry and Warwickshire

Q10: Please indicate the impact in-patient rehabilitation at South Warwickshire Foundation Trust in Leamington and the George Eliot Hospital in Nuneaton would have on family/friends/carers:

No impact Postive Negative Prefer not to say

Please tell us the reason for your answer ......

Equalities monitoring

We recognise and actively promote the benefits of diversity and we are committed to treating everyone with dignity and respect regardless of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation. To ensure that our services are designed for the population we serve, we would like you to complete the short monitoring section below. The information provided will only be used for the purpose it has been collected for and will not be passed on to any third parties.

Q11: Please state which area of Coventry or Warwickshire you live in......

Q12: Please state your postcode below Please use all capital letters eg CV34 4DE ......

Q13: What is your gender?

Male Female Transgender Prefer not to say

Q14: If female, are you currently pregnant or have you given birth within the last 12 months?

Yes No Prefer not to say

23 Developing a pathway of excellence for stroke in Coventry and Warwickshire

Q15: What is your age?

Under 16 16-24 25-34 35-59 60-74 75+ Prefer not to say

Q16: What is your ethnic group?

English/Welsh/Scottish/Northern Irish / British Irish Gypsy or Irish Traveller Any other White background, please describe ......

Mixed/Multiple ethnic groups White and Black Caribbean White and Black African White and Asian Any other Mixed/Multiple ethnic background, please describe ......

Asian/Asian British Indian Pakistani Bangladesh Chinese Any other Asian background, please describe ......

Black/African/Caribbean/Black British African Caribbean Any other Black/African/Caribbean background, please describe ......

Other ethnic group Arab Any other ethnic group, please describe:

......

24 Developing a pathway of excellence for stroke in Coventry and Warwickshire

Q17: Do you look after, or give any help or support to family members, friends, neighbours or others because of either:

Long-term physical or mental-ill- health/disability Problems related to old age No Prefer not to say Other, please describe ......

Q18: Are your day-to-day activities limited because of a health condition or illness which has lasted, or is expected to last, at least 12 months? (Please select all that apply)

Vision (such as due to blindness or partial sight)

Hearing (such as due to deafness or partial hearing)

Mobility (such as difficulty walking short distances, climbing stairs)

Dexterity (such as lifting and carrying objects, using a keyboard)

Ability to concentrate, learn or understand (Learning Disability/Difficulty)

Memory

Mental ill-health

Stamina or breathing difficulty or fatigue

Social or behavioural issues (for example, due to neuro diverse conditions such as Autism, Attention Deficit Disorder or Aspergers’ Syndrome)

No

Prefer not to say

Any other conditions or illness, please describe ......

25 Developing a pathway of excellence for stroke in Coventry and Warwickshire

Q19: What is your sexual orientation?

Bisexual Heterosexual / straight Gay Lesbian Prefer not to say Other, please state ......

Q20: Are you?

Single - never married or partnered Married/civil partnership Co-habiting Married (but not living with husband/wife/civil partner) Separated (still married or in a civil partnership) Divorced/dissolved civil partnership Widowed/surviving partner/civil partner Prefer not to say Other, please describe: ......

Q21: What is your religion and belief

No religion Baha’i Buddhist Christian (including Church of England, Catholic, Protestant and all other Christian denominations) Hindu Jain Jewish Muslim Sikh Prefer not to say Other, please describe ......

26 Coventry and Warwickshire Stroke Review c/o NHS Warwickshire North CCG Second Floor Heron House Newdegate Street Nuneaton CV11 4EL http://www.strokecovwarks.nhs.uk/ NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc J

Report To: Governing Body Meetings in Common

Report Title: Quality, Safety and Performance Report

Report From: Steve Jarman-Davies – Director of Intelligence, Planning and Performance Jo Galloway – Chief Nursing Officer

Date: 17th July 2019

Previously Considered by: Commissioning, Finance and Performance Committee – 04/07/19 Clinical Quality and Governance Committee – 27/06/19

Action Required

Decision: Assurance:  Information:  Confidential

Purpose of the Report: To provide assurance to the Governing Body of the performance of services commissioned by Coventry and Rugby and Warwickshire North CCGs for the month of April (unless otherwise specified). The report also provides an update on quality concerns within commissioned services that are either being investigated or are being monitored against improvement plans.

Key Points: Performance

85.9% of CRCCG patients had been waiting less than 18 weeks from their GP referral date to be seen or treated by a hospital specialist against a target of 92%. The figure for WNCCG was 84.4%. There were no WNCCG or CRCCG patients waiting over 52 weeks. Both CCGs achieved against the diagnostic test waiting times target with 99.7% of CRCCG and 99.5% of WNCCG patients receiving diagnostic tests within 6 weeks of referral. The CCGs remains fully focused on working to improve the proportion of patients who are not waiting for inpatient treatment who are treated within 18 weeks, whilst there is an improvement in RTT based on under-performance of elective activity against contract being recovered.

A & E 4 hour waits A & E 4 hour waits performance improved at UHCW, rising to 82.9%. GEH deteriorated with 80.9% of patients seen within 4 hours. Focus for the system remains on mobilisation of demand management transformation schemes, in particular CHES2, flow through Discharge to Assessment, working with the Local Authority to free capacity, the clinical triage of patients in 111, avoidance of ambulance conveyance by WMAS, and focus on reducing levels of HIUs attending A&E.

Cancer waiting times CRCCG achieved all cancer waits targets in April. WNCCG underachieved against the 62 day wait from urgent GP referral to first definitive treatment at 77.3% and against the 62 day wait from referral from an NHS screening service as a result of one patient being on a complex diagnostic pathway. WNCCG marginally underachieved against the Cancer 31 day wait from first definitive treatment at 95.7%. Across the fourth quarter 31 patients at UHCW and 7 at GEH had waited more than 104 days from referral to treatment. Factors impacting performance include continued issues with provision of Robot Assisted Surgical Techniques with UHCW. The Cancer action plan is being worked through and elements of the action plan have been implemented already.

Page 1 of 4 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc J

Mixed Sex Accommodation There were no breaches for WNCCG but one CRCCG patient breached. There were no breaches at UHCW or GEH.

Cancelled Operations There were 21 patients in the fourth quarter who had operations cancelled at UHCW, on or after the day of admission for non-clinical reasons and weren’t offered another binding date within 28 days. The figure for GEH was 19, which is significantly higher than in previous months. The main reason for the breaches was capacity and the need to schedule urgent/cancer patients further reduced the capacity available

Care Programme Approach In the fourth quarter 100% of CRCCG and WNCCG patients on CPA were followed up within 7 days after discharge from psychiatric inpatient care against the 95% target.

Dementia Diagnosis Performance against the 67% dementia diagnosis target has improved significantly for CRCCG, rising to 63.7%. WNCCG also saw an improvement with the estimated percentage of dementia cases being diagnosed rising to 60.4%. The Functional Cognitive Assessment Scheme has been extended until 30th November 2019. Following feedback from some practices, the CCGs have arranged for a peer-led session to share some practical feedback and good practice with each other in order to support practices further.

Early Intervention in Psychosis (EIP) There were no WNCCG patients referred for EIP in April. CRCCG marginally breached the 56% target with five out of ten patients experiencing First Episode Psychosis treated with a NICE-recommended package of care receiving treatment within two weeks of referral. Following the Intensive Support Team visit the CCG is reviewing the recommendations from their report to determine a system plan to provide greater assurance on meeting the access targets on a sustained basis.

Improving Access to Psychological Therapies (IAPT) WNCCG and CRCCG both achieved against the IAPT access figure in March at 21.6% and 21.3% respectively against the 2018/19 target of 19%. However CRCCG marginally underachieved for the fourth quarter. The target for 2019/20 requires CCGs to reach 22% by quarter 4. Commissioners have met with NHSE/I leads for IAPT to learn from other areas that have seen improvements in access rates, which will inform the action plan.

Clinical Assessment Placement Team CRCCG marginally underachieved against the target for the number of Fast Tracks assessed in less than 48 hours, but achieved against the other two targets. WNCCG achieved against all three measures.

Wheelchair Access In the third quarter of 18/19 54.5% of WNCCG children requiring wheelchairs received the equipment within 18 weeks against a target of 92%. The figure for CRCCG had risen to 98.8%. Provisional figures suggest significant improvement in the first quarter of 2019 with both CCGs at 100%. The CCG and SWFT have been reviewing all patients who have breached and looking at how they can remain compliant throughout 2019/20.

Page 2 of 4

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc J

Quality

Coventry and Warwickshire Partnership Trust (CWPT) Since the previous report, one concern has been deescalated to level one on the Quality Assurance Framework (QAF).

There are no reported concerns at level three.

There are six areas of concern at level two on the QAF: • Adult Neurodevelopmental service (ANDS) waits • Child and Adolescent ASD and ADHD Service Waiting Times • Children and Adolescent Mental Health Service (CAMHS) Follow Up Times • Children's Therapy, Coventry • Looked after Children (LAC) Health Assessments • Safe Staffing

George Eliot Hospital (GEH) Since the previous report, no additional concerns have been added to the QAF.

There is one concern at level three on the QAF: • Mortality

There are four areas of concern at level two on the QAF: • Care Quality Commission (CQC) inspection • Emergency Department • PREVENT WRAP Training • Serious Incidents – Recognition of the Deteriorating Patient

University Hospitals Coventry and Warwickshire NHS Trust (UHCW) Since the previous report, one concern has been deescalated to level one on the QAF: • Mortality

There are two concerns at level three on the QAF: • Children and Young People in Crisis (system wide issue) • Emergency Department

There are five concerns at level two on the QAF: • Clinic Letters within seven days • CQC Inspection • Gynaecology • Maternity • Partial Booking System – Ophthalmology

Primary Care Coventry and Rugby CCG and Warwickshire North CCG All GP practices are now rated overall as either ‘Good’ or ‘Outstanding’.

Care Homes Four Seasons It has been reported in the press that Four Seasons Healthcare has entered an administration process as an organisation. The CCGs are working closely with Coventry City Council regarding the care homes that are within this group within our locality.

Page 3 of 4

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc J

Coventry There are 86 nursing and residential homes across Coventry with a total of 2017 beds. There are two nursing homes and one residential learning disability home that are on escalation and working to improvement plans.

Warwickshire North and Rugby There are 98 nursing and residential homes across Warwickshire North and Rugby with a total of 2,496 beds. There are currently three nursing homes and one residential home on escalation and working to an improvement plan.

Recommendation: The Governing Body are requested to receive the contents of the report for INFORMATION and ASSURANCE.

Implications

Objective(s) / Plans supported by this 1,2,3 & 4 report: Conflicts of Interest: None identified Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Performance: The CCG is required to meet the national NHS Constitution targets The report outlines quality and safety issues in relation to commissioned services Quality and Safety: against the Clinical Governance Framework The report provides information relating to patients with protected characteristics where care is provided by commissioned services Equality and Diversity: Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable The following areas are identified on the CCG risk register: • A&E performance UHCW • RTT Performance • CHC Complaints Risk and Assurance: • Lack of Assurance regarding CHC Service Performance • Timely CHC assessments • CHC Transition

Page 4 of 4

July 2019 Quality, Safety and Performance Report

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Contents

Section 1. CCG Performance Overview Introduction ...... 4 NHS Constitution, Supporting & Mental Health Measures – CRCCG ...... 8 Indicators achieved/underachieved by CRCCG in the latest period ...... 10 NHS Constitution, Supporting & Mental Health Measures – WNCCG ………………………..12 Indicators achieved/underachieved by WNCCG in the latest period ……………………… ... 14

Section 2. CCG Quality Overview 1. Introduction ...... 17 2. Items on Escalation ...... 17 3. Other Providers ...... 22 4. Primary Care Update ...... 22 5. Care Homes ...... 22

Section 3. Provider Level Performance and Quality UHCW Performance Dashboard ...... 24 UHCW Quality Dashboard ...... 25 GEH Performance Dashboard ...... 27 GEH Quality Dashboard ...... 38 CWPT Mental Health and Learning Disabilities Dashboard ...... 30 CWPT Quality Dashboard ...... 32 West Midlands Ambulance Services Dashboard ...... 33 South Warwickshire Foundation Trust Community Services ...... 36 Clinical Assessment Team Tracker ...... 37

Section 4. Activity Tracker Weekly Urgent Care Trackers ...... 40 Appendix 1. Contract Performance Notices ...... 43 Appendix 2. Quality Assessment Framework ...... 44 Appendix 3. Abbreviations Used in the Report ...... 45

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1 - CCG Performance Overview

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Introduction This report focuses on the month of April unless stated otherwise.

Exception reporting, mitigating actions and, where required, Remedial Action Plans, are presented and reviewed through the Commissioning, Finance and Performance Committee and Clinical Quality and Governance Committee as formal committees to the Governing Body. These are therefore not included in this report.

Separate Provider Dashboards are included in section 3.

Referral to Treatment Times (RTT)

85.9% of CRCCG patients had been waiting less than 18 weeks from their GP referral date to be seen or treated by a hospital specialist against a target of 92%. The figure for WNCCG was 84.4%.

There were no WNCCG or CRCCG patients waiting over 52 weeks.

Both CCGs achieved against the diagnostic test waiting times target with 99.7% of CRCCG and 99.5% of WNCCG patients receiving diagnostic tests within 6 weeks of referral.

Actions to Improve RTT Performance

GEH

Trauma & Orthopaedic additional weekend sessions focused on Daycases with some Inpatients, covering 3 out of 4 weekends each month. Due to the observed reduction in referrals the trust is switching 1st OP /FU OP sessions to Daycase sessions across a number of specialties

25 patients agreed to transfer to be treated at SWFT (after the Trust offering this to 90+ patients)

In Gynaecology there are additional cystoscopy sessions, and movement of Daycases to an Outpatient with procedure setting. In General Surgery there is an additional locum doing additional sessions.

The CCG remains fully focused on working to improve the proportion of patients who are not waiting for inpatient treatment who are treated within 18 weeks, whilst there is an improvement in RTT based on under-performance of elective activity against contract being recovered.

UHCW

The Trust expects to maintain RTT at circa 86% through the year at UHCW, any improvement would arise from patients moving to other providers and being seen more quickly than at UHCW helping the CCGs overall position which is generally 1-2% better than UHCWs position due to these flows to other providers. These flows however, would be outside the financial agreement with UHCW which blocks elective costs in 2019/20 and could represent a financial risk to the CCG, and are therefore being closely monitored. April’s new clock starts at UHCW accounted for 80% of all new clock starts which is in line with the normal trend we have experienced through the whole of last year. Focus is on demand management activities to restrict GP referrals in line with GP referral guidance especially for LPPs/PLCV, Single point of access for MSK, rollout of consultant connect, all coordinated through the Rugby Place Forum which has oversight of these actions across Coventry and Rugby.

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A & E 4 hour waits

A & E 4 hour waits performance improved at UHCW, rising to 82.9%. GEH deteriorated with 80.9% of patients seen within 4 hours.

Actions to Improve A & E 4 hour waits performance

The trusts’ focus remains on managing minors to protect this stream and to deliver 100% of minors seen within 4 hours, utilisation of community alternatives, and increasing ambulatory pathways, a renewed focus on flow through the Trust through daily management of delayed transfers of care, focus on super stranded patients, as well as increasing simple discharge before midday.

Focus for the system remains on mobilisation of demand management transformation schemes, in particular CHES2, flow through Discharge to Assessment, working with the Local Authority to free capacity, the clinical triage of patients in 111, avoidance of ambulance conveyance by WMAS, and focus on reducing levels of HIUs attending A&E.

For 12 hour breach reduction: the following actions are in place:

• Reviewed and implemented PDSA cycle for bed management and site management. • Stranded patient reviews with wards three times a week. • System review of discharge process • Frailty service, which was implemented in winter, is being maintained. • Escalation and DTA policy review and monitoring of application.

Cancer waiting times

CRCCG achieved all cancer waits targets in April. WNCCG underachieved against the 62 day wait from urgent GP referral to first definitive treatment at 77.3% and against the 62 day wait from referral from an NHS screening service as a result of one patient being on a complex diagnostic pathway. WNCCG marginally underachieved against the Cancer 31 day wait from first definitive treatment at 95.7%.

Across the fourth quarter 31 patients at UHCW and 7 at GEH had waited more than 104 days from referral to treatment.

Actions to Improve Cancer Waiting Times Performance

GEH

Issues impacting performance include; • Continued issues with provision of Robot Assisted Surgical Techniques with UHCW. • Pathology turnaround delays. • Other known internal factors that will be worked through as part of the cancer action plan and through the Cancer Board.

The following processes are in place: • The Cancer action plan is being worked through and elements of the action plan have been implemented already. • Further parts of the action plan are in hand subject to organisational re-structuring at GEH. • The Trust is in the process of working with external providers on issues impacting performance, this is being picked up at an executive level.

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UHCW

The target in Urology is not being achieved primarily due to long waits for prostate biopsies (TRUS) and robot assisted prostatectomies. A TRUS action plan is in place to reduce the backlog.

The Trust has looked at their internal performance management and in particular process issues which could improve performance

Mixed Sex Accommodation

There were no breaches for WNCCG but one CRCCG patient breached. There were no breaches at UHCW or GEH.

Cancelled Operations

There were 21 patients in the fourth quarter who had operations cancelled at UHCW, on or after the day of admission for non-clinical reasons and weren’t offered another binding date within 28 days. The figure for GEH was 19, which is significantly higher than in previous months.

Actions to Improve Cancelled Operations performance

The main reason for the breaches was capacity and the need to schedule urgent/cancer patients further reduced the capacity available. Capacity is an issue in general for the Trust to address the specific issue of 28 day cancellations being offered a binding date. The CCG will be enacting the sanctions relevant to the Trust failing to achieve this indicator and have requested the information required from the Trust finance team to enable this to take place.

Care Programme Approach

In the fourth quarter 100% of CRCCG and WNCCG patients on CPA were followed up within 7 days after discharge from psychiatric inpatient care against the 95% target.

Dementia Diagnosis

Performance against the 67% dementia diagnosis target has improved significantly for CRCCG, rising to 63.7%. WNCCG also saw an improvement with the estimated percentage of dementia cases being diagnosed rising to 60.4%.

Actions to Improve Dementia Diagnosis performance

The Functional Cognitive Assessment Scheme has been extended until 30th November 2019. Following feedback from some practices, the CCGs have arranged for a peer-led session to thank practices for their involvement and also to share some practical feedback and good practice with each other in order to support practices further.

The task and finish group are monitoring weekly to determine the impact this scheme is having ensuring all practices who have signed up and doing what they are required. Several communications have gone out to practices and targeted conversations are being arranged with

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practices involved in the scheme to support them in maximising impact. A number of additional actions are being investigated including POD/ District Nurses/ Age UK undertaking mini COGs.

The impact of these actions is being realised, with both CRCCG and WNCCG now ahead of the forecasted trajectories.

Early Intervention in Psychosis (EIP)

There were no WNCCG patients referred for EIP in April. CRCCG marginally breached the 56% target with five out of ten patients experiencing First Episode Psychosis treated with a NICE- recommended package of care receiving treatment within two weeks of referral.

Actions to Improve EIP performance

The recruitment process is complete. Following the Intensive Support Team visit the CCG is reviewing the recommendations from their report to determine a system plan to provide greater assurance on meeting the access targets on a sustained basis.

Improving Access to Psychological Therapies (IAPT)

WNCCG and CRCCG both achieved against the IAPT access figure in March at 21.6% and 21.3% respectively against the 2018/19 target of 19%. However CRCCG marginally underachieved for the fourth quarter. The target for 2019/20 requires CCGs to reach 22% by quarter 4.

Actions to Improve IAPT performance The CCG is meeting with GPs and Estates to request support in improving availability of space for IAPT therapists to deliver sessions from. The IAPT service is working hard to raise awareness of the service, with ongoing promotion to businesses, colleges and GP surgeries, who have been targeted with visits and promotional literature and the locality teams have attended local events to advertise the service.

The CCG and CWPT are working on a joint action plan aimed at improving access and considering methods of delivering IAPT including group interventions and digital solutions.

Commissioners have met with NHSE/I leads for IAPT to learn from other areas that have seen improvements in access rates, which will inform the action plan.

Clinical Assessment Placement Team

CRCCG marginally underachieved against the target for the number of Fast Tracks assessed in less than 48 hours, but achieved against the other two targets. WNCCG achieved against all three measures.

Wheelchair Access

In the third quarter of 18/19 54.5% of WNCCG children requiring wheelchairs received the equipment within 18 weeks against a target of 92%. The figure for CRCCG had risen to 98.8%. Provisional figures suggest significant improvement in in the first quarter 2019 with both CCGs at 100%.

Actions to Improve wheelchair access The CCG and SWFT have been reviewing all patients who have breached and looking at how they can be compliant for 2019/20.

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12

13

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CCG Quality Overview

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1. Introduction The Clinical Quality and Governance Committee in Common for Coventry and Rugby CCG (CRCCG) and Warwickshire North CCG (WNCCG) receive reports on the quality and safety of commissioned services. Reports are based on a wide range of data and soft intelligence, including contractual quality indicators, patient experience reports and learning and the impact on practice. This includes acute and community services; small providers, both NHS and independent; nursing homes; residential homes; and primary care. The committee also receives updates on safeguarding, infection prevention and control and Transforming Care.

This report provides a summary of escalated quality issues for the attention of Governing Body. The following quality dashboards are provided to Governing Body for information in the Provider Dashboard section of the report:

• Quality Indicators Dashboards for Coventry and Warwickshire Partnership Trust (CWPT) • Quality Indicators Dashboards for George Eliot Hospitals NHS Trust (GEH) • Quality Indicators Dashboards for University Hospitals Coventry and Warwickshire NHS Trust (UHCW)

2. Items on Escalation An overview of the Quality Assurance Framework (QAF) and escalation levels is included as Appendix two.

Coventry and Warwickshire Partnership Trust

Since the previous report, one concern has been deescalated to level one on the QAF:

• Care Quality Commission (CQC) rating and report

There are no reported concerns at level three.

There are six areas of concern at level two on the QAF: • Adult Neurodevelopmental service (ANDS) waits • Child and Adolescent ASD and ADHD Service Waiting Times • Children and Adolescent Mental Health Service (CAMHS) Follow Up Times • Children's Therapy, Coventry • Looked after Children (LAC) Health Assessments • Safe Staffing

Items on Level 2 of the QAF:

Adult Neurodevelopmental (AND) Service Diagnostic Waits The CCGs have met with CWPT to re-scope the pathway and activity in order to manage demand and provide complementary alternative support to patients whilst they are waiting for a diagnosis. The CCGs are proposing revised referral criteria to be implemented once jointly agreed with the CCGs and CWPT clinical leads and contracting. A health needs assessment is being undertaken by Public Health at Warwickshire County Council to accurately assess the number of patients requiring this service and to produce recommendations for service delivery.

Child and Adolescent ASD and ADHD Service Waiting Times At the end of quarter four 2018-2019, waits for children and young people for an ASD/ADHD assessment was typically 75 weeks for CRCCG and 36 weeks for WNCCG. CWPT has procured an external provider to increase the number of assessment slots available. Quarter one 2019-2020 data will be available on 20th July 2019 and will be reviewed to assess the impact on performance. Vulnerable children are prioritised and any changes in presentation are relayed to the service. There are telephone clinics available for people on the waiting list and it is anticipated that the introduction of e-referrals will speed up the process. The CCGs have commissioned Coventry and

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Warwickshire Mind to deliver support to children and young people who are diagnosed with ASD or on the waiting list for assessment, via Transforming Care funding. There are “walk and talk” workshops taking place with Grapevine, a service user and patient involvement organisation for Learning Disability and ASD, to further understand where support is required.

Child and Adolescent Mental Health Service (CAMHS) Follow up Times CWPT continues to make progress in reducing the numbers of patients waiting the longest for follow up appointments. The CAMHS 12-week wait target is being revised to ensure that this KPI is realistic and achievable, whilst being ambitious enough to drive continued improvements in performance. The proposed implementation is Quarter two 19/20. CWPT has reported that performance for follow up appointments in 12 weeks (April 2019), the current local key performance indicator for Coventry residents, is below the 95% target at 52.3%. CWPT has provided assurance that children and families are offered a range of alternative support and patients are regularly reviewed to ensure prioritisation based on clinical need. The national referral to treatment (RTT) KPI for CAMHS is 18 weeks. CWPT achieves this for all new referrals.

Children’s Therapy, Coventry The waiting list for therapies continues to increase due to the demand for statutory assessments under the Special Educational Needs and Disability Code of Practice. The CCG has worked with the Trust to develop an options appraisal. The options appraisal was presented to the Clinical Executive Group and further clarification has been requested to support decision making. The service specifications for Occupational Therapy (OT) and Physiotherapy will be included in the Community Service Development Improvement Plan (SDIP) for 2019 – 2020.

Looked after Children (LAC) Health Assessments CWPT is contracted by CRCCG to provide statutory health assessments for Looked after Children from Coventry, those placed both in and outside of Coventry and children from out of area who are placed in Coventry. The assessments include initial, review and leaving care assessments. There have been identified performance issues in relation to CWPT as a commissioned provider of healthcare assessments. These have impacted on the numbers of children who have a health assessment, or a review of their health care plan, or a leaving care health summary within statutory timescales. The CCGs have served a contract performance notice which is being managed through the contracting and performance route. This has led to an improvement in performance associated with a recovery plan and recovery trajectory to ensure that more assessments are completed within statutory timescales. Compliance is expected to be achieved and the backlog addressed by the end of August 2019. The CCG Quality Team and Contracting and Performance teams are working together with the provider and the local authority to identify and review any wider system issues which may also be having an impact.

Safe Staffing CWPT reported a Trust total vacancy rate of 13.16% in March 2019. CWPT continues to focus on recruitment and retention of staff. The recruitment fayre held in March 2019 for medical staff successfully recruited seven consultants. The recruitment fayre held in May 2019 for nursing staff successfully recruited 14 nurses. CWPT has successfully trained and recruited eight nursing associates. A further 16 are currently being trained. The CCGs have requested vacancy information is reported by department and professional group. Safe staffing levels are monitored through the Clinical Quality Review Meeting (CQRM) process and triangulated with a range of information sources.

George Eliot Hospital

Since the previous report, no additional concerns have been added to the QAF.

There is one concern at level three on the QAF: • Mortality

There are four areas of concern at level two on the QAF:

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• Care Quality Commission (CQC) inspection • Emergency Department • PREVENT WRAP Training • Serious Incidents – Recognition of the Deteriorating Patient

Item on Level three of the Quality Assurance Framework:

Mortality Mortality escalated to level three following three consecutive data reporting periods of within the ‘higher than expected range’ for Hospital Standardised Mortality Ratio (HSMR) and two consecutive data reporting periods for Summary Hospital–Level Mortality (SHMI). The HSMR is above the expected range at 118.7 for the period of February 2018 – January 2019.The reported SHMI for the period January 2018 – December 2018 is 116 and remains above the expected range.

GEH has developed a Mortality and Deteriorating Patients Improvement plan which was shared at the April 2019 CQRM. This is also being monitored at the monthly Mortality and Deteriorating Patients Group. Outcomes and findings from the Structured Judgement Reviews (SJRs) are reported to the GEH Mortality and Deteriorating Patients group. GEH continues to attend the UHCW SMHI group and has contacted the CCG to request a joint local SHMI meeting with GPs to review and focus on local pathways and to share best practice. For the SHMI time period January 2018 – December 2018, GEH reported 31 % (333) of deaths occur within thirty days of discharge compared to 69% (760) of deaths in-hospital. GEH shared the findings of the latest SHMI data analysis at the May 2019 WNCCG GP Protected Learning Time (PLT) session.

The CCGs are represented within the membership of the GEH Mortality and Deteriorating Patients Group. The Trust’s Medical Director has been invited to attending the Clinical Quality Governance Committees in Common thematic meeting in September to provide assurance regarding mortality.

Items on Level 2 of the Quality Assurance Framework:

CQC Inspection and Rating GEH was rated as overall requires improvement following the CQC’s latest inspection which was published in February 2019. GEH achieved overall ‘good’ for the caring domain and overall ‘requires improvement’ for the four domains of ‘safe, effective, responsive and well-led’. Children and young people’s services, surgery, maternity and end of life were rated as ‘good’. Urgent and emergency services and medical care, including older people’s care, were rated as ‘requires improvement’. There were no immediate risks identified.

The CCGs have requested the GEH’s CQC ‘must do’ action plan which is expected following ratification by CQC.

Emergency Department (ED) GEH reported another operationally challenging month in April 2019 with the 4 hour standard wait remaining below the 95% national target at 80.88%, previously 84.15% in March 2019. GEH reported fifteen 12 hour breaches due to hospital flow issues in April 2019, compared to three in March 2019. GEH has undertaken a detailed root cause analysis review of all 12 hour trolley breaches, no patient harm has been reported to date. GEH continues to work with mental health partners to improve the mental health patient experience by reducing length of stays in ED whilst waiting for an out of hours or weekend mental health assessment by AMHAT. GEH has submitted the ED ‘must do’ action plan to the CQC for ratification. Once ratified, this will be presented at a future CQRM.

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Prevent and Workshop to Raise Awareness of Prevent (WRAP) Training The latest available training figures for May 2019 show that GEH has achieved both targets. Basic Prevent Awareness Training (BPAT) performance has exceeded the target of 85% and is reported at 94%. The Workshop to Raise Awareness of Prevent (WRAP) training has achieved the 85% target.

Serious Incidents – Recognition of the Deteriorating Patient Triangulation of GEH clinically reported data identified concerns relating to completion of falls risk assessments, completion of post falls bundles and not consistently undertaking timely baseline observations. The national standard is 3.9 falls per 1000 bed days.GEH reported 6.1 falls per 1000 bed days in January 2019, 3.72 falls per 1000 bed days in February, 3.19 falls per 1000 bed days in March 2019 and 4.43 falls per 1000 bed days in in April 2019. Falls reduction is one of GEH’s quality commitments and they are undertaking an improvement collaborative to support falls reduction. This includes appointment of a falls champion, introduction of falls safety huddles on the wards, continued monitoring through the Stop the Falls Group, roll out of bespoke falls training and an equipment purchase programme. The implementation of the Falls Prevention Strategy is monitored via CQRM and triangulated with a range of information.

University Hospitals Coventry and Warwickshire NHS Trust

Since the previous report, one concern has been deescalated to level one on the QAF:

• Mortality

There are two concerns at level three on the QAF: • Children and Young People in Crisis (system wide issue) • Emergency Department

There are five concerns at level two on the QAF: • Clinic Letters within seven days • CQC Inspection • Gynaecology • Maternity • Partial Booking System – Ophthalmology

Items on level three of the QAF:

Children and Young People in Crisis (system wide issue)

In August 2018, a System Children and Young People in Crisis Clinical Risk Meeting was initiated in response to a reported increase in recent months regarding the number and severity of behaviours of children and young people presenting in crisis at UHCW Accident and Emergency Department and requiring admission. This was later extended to include South Warwickshire NHS Foundation Trust (SWFT) and GEH in response to system-wide pressures.

A system-wide operational group was also set up and a multi-agency action plan developed to manage and mitigate the identified risk. Both groups include representation from health and social care partners across Coventry and Warwickshire. A multi-agency protocol, pathway and escalation process for responding to children and young people in crises has been implemented, alongside other actions.

The Mental Health Network completed an independent review of the UHCW pathway in quarter three 2018/19 and this work was later extended to include a review of the emotional wellbeing and mental health pathway across the Coventry and Warwickshire system. Whilst the work undertaken to date has not had an impact on reducing the numbers of children presenting in crisis at our

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emergency departments, it has streamlined multi-agency working with resultant impact on length of stay in acute hospital paediatric beds for children and young people in crisis.

The CAMHS three plus service is due to be fully operational in July 2019 and will ensure a more robust CAMHS urgent care pathway to reduce the need for CAMHS Tier 4 admissions and assist the pressure on acute hospitals and CAMHS liaison admissions.

The System Children and Young People in Crisis Clinical Risk Meeting will have a final meeting in September 2019 and work will transition across into the CAMHS Transformation Board. The risk level will be reviewed once the CAMHS three plus service is fully operational.

Emergency Department The CCGs identified an increase in reported Emergency Department (ED) Serious Incidents for sub-optimal care and sepsis in the year 2018-2019 compared to the two previous financial years. The CCGs and UHCW have undertaken a table top review in February 2019 of 2018-2019 Serious Incident trends year to date; including themes, lessons learnt and actions taken. The CCGs are assured that planned sepsis monitoring improvements continue to be embedded within the department.

Items on level two of the QAF:

Clinic Letters within seven days UHCW reported a decline in performance from 84.0% in March 2019 to 82.1% in April 2019; against an overall target of 100%. UHCW is developing a tool to identify and prevent letter duplication. UHCW has undertaken an internal investigation to identify the issues affecting the decline in performance against the agreed trajectory. A joint audit date will be agreed within the next three months following receipt of the internal investigation report.

CQC Inspection UHCW was rated overall as ‘requires improvement’ from the latest published report in August 2018.The Hospital of St Cross was rated as overall good and University Hospital Coventry as overall ‘requires improvement’. UHCW reported to the June 2019 CQRM that the ‘must do’ actions are nearing completion. UHCW and the CQC Relationship Manager, continue to hold six weekly meetings to enable UHCW to showcase service delivery improvements and progress against the CQC action plan.

Gynaecology UHCW reported an under performance against the gynecology targets for the two week referral, 62 and 104 day cancer waits. UHCW has appointed a Consultant Gynecologist who commenced in February 2019 and two Clinical Fellows who commenced in January 2019. UHCW has reported an improving position for two week waits and 62 day waits for quarter four 2018/19. No patient harm has been reported to date. This will continue to be monitored through CQRM and triangulated with a range of information sources.

Maternity The CCGs’ Quality and Contracting teams received the maternity dashboard and saving babies’ lives improvement plan to the June 2019 CQRM. UHCW reported a decline in the Midwife to birth ratio in March 2019 to 1:30 and advised that the recruitment program is due to achieve full establishment by October 2019 which will improve the midwife to birth ratio.

Partial Booking System – Ophthalmology The CCGs formally raised concerns with UHCW regarding its internal management systems for ophthalmology patient follow up appointments. This was in response to reported serious incidents and further analysis identified a cohort of ophthalmology patients affected. UHCW has not reported any patient harm to date. This concern was de-escalated to level two on the QAF in April 2019

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following reported progress against the action plan and assurance from UHCW that no further incidents have been identified.

3. Other Providers

There are no quality concerns on the QAF relating to other providers.

4. Primary Care Update

Coventry and Rugby CCG and Warwickshire North CCG All GP practices are now rated overall as either ‘Good’ or ‘Outstanding’.

5. Care Homes

Four Seasons It has been reported in the press that Four Seasons Healthcare has entered an administration process as an organisation. The CCGs are working closely with Coventry City Council regarding the care homes that are within this group within our locality.

Coventry There are 86 nursing and residential homes across Coventry with a total of 2017 beds. There are two nursing homes and one residential learning disability home that are on escalation and working to improvement plans.

Warwickshire North and Rugby There are 98 nursing and residential homes across Warwickshire North and Rugby with a total of 2,496 beds. There are currently three nursing homes and one residential home on escalation and working to an improvement plan.

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1

3 - Provider Level Performance and Quality

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WMAS– Ambulance Response Programme

Category 1-4 Response

Category 1 Apr’19 May’19 Jun’19 Jul’19 Aug’19 Sep’19 Oct’19 Mean 7:00 90th 15:00 Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th 411 6:37 11:22 Cov & Rug CCG 168 7:20 13:14 Warks North CCG 189 8:47 15:32 South Warks CCG 5,412 6:43 11:38 West Mids

Apr’19 May’19 Jun’19 Jul’19 Aug’19 Sep’19 Oct’19 Category 2 Mean 18:00 90th 40:00 Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th 3,105 12:15 21:59 Cov & Rug CCG 1,329 12:26 21:52 Warks North CCG 1,412 14:58 26:24 South Warks CCG 43,273 12:14 22:22 West Mids

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Category 3 Apr’19 May’19 Jun’19 Jul’19 Aug’19 Sep’19 Oct’19 90th 120:00 Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th 2,411 33:46 75:23 Cov & Rug CCG 1,111 32:09 72:11 Warks North CCG 1,310 31:40 64:56 South Warks CCG 31,929 35:07 78:55 West Mids

Category 4 Apr’19 May’19 Jun’19 Jul’19 Aug’19 Sep’19 Oct’19 90th 180:00

Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th 115 54:39 112:15 Cov & Rug CCG 58 46:59 85:16 Warks North CCG 61 51:53 127:52 South Warks CCG 1,484 48:21 115:46 West Mids

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Handover Delays

Ambulance Handovers Apr’19 May’19 Jun’19 Jul’19 Aug’19 Sep’19 Oct’19 Nov’19 Dec’19 Where handover recorded 60+ mins No. £ No. £ No. £ No. £ No. £ No. £ No. £ No. £ No. £

Cov & Rug CCG 19 £4,677 Warks North CCG 20 £4,924 South Warks CCG 17 £4,185 West Mids 1,131 £278,430

Note single payment commenced April 2019 for 60mins+ handovers, refer to finance costs not illustrative costs from WMAS Hospital Activity Report

Impact by Hospital

Apr’19 May’19 Jun’19 Jul’19 Aug’19 Sep’19 Oct’19 Nov’19 Dec’19 Impact by Avg Avg Avg Avg Avg Avg Avg Avg Avg Hospital Lost hrs Lost hrs Lost hrs Lost hrs Lost hrs Lost hrs Lost hrs Lost hrs Lost hrs min min min min min min min min min George 116:08:04 33 Eliot University 261:44:23 29 Hospital

Warwick 115:20:43 31

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Clinical Assessment Team Tracker

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1. The % of Decision Support Tools (DST’s) that are undertaken in hospital setting The setting in which the DST takes place is important. Assessments carried out in an acute setting at a time when patients may not have benefited from a period of recovery can impact on the outcome. There is strong evidence that delays in hospital discharge can lead to a high risk of deconditioning and so best practice is to move patients into a discharge pathway in the community before undertaking assessment about long term needs. Best practice is that no more than 15% of DST’s are undertaken in a hospital setting.

2. The % of referrals completed within 28 days Completion of a new referral-to-decision for patients is required to be completed within 28 days. The assessment requires a multidisciplinary approach including social care and the involvement of the family and therefore requires effective processes and planning. The national target is 80% of DST’s are completed within 28 days;

3. Fast track referral conversion Patients who are in the last days or weeks of life should be transferred to their preferred place of care within 48 hours. There is no requirement for a CHC assessment prior to putting in place arrangements and funding. Patients who are fast tracked into services should be reviewed at 12 weeks (if not RIP) and a DST completed if appropriate.

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Section 4 – Activity Tracker

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Appendices

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Appendix 1 – Provider contract performance notices and sanctions applied

Contract Performance Date Issued Milestones Expected Recovery Date Notice George Eliot Hospital NHS Trust (GEH) Reference Number 1 Identification of 2019-20 GEH Contract capacity to treat Failed Ophthalmology patients Pathway First outpatient appointment dates at treating providers 24th April 2019 End August 2019 Clinical summit with STP acute providers Formalisation of agreed patient treatment pathways

Contract Date Issued Milestones Expected Recovery Performance Date Notice Coventry and Warwickshire Partnership NHS Trust Looked After 21st December The Provider has issued an TBC Children – Health 2018 update against the recovery Assessments action plan and trajectory which is being closely monitored through the contractual process. Recovery trajectory on plan for August 2019.

Contract Date Issued Milestones Expected Recovery Performance Date Notice University Hospital Coventry and Warwickshire NHS Trust

No Performance Notices To Date

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Appendix 2

Quality Escalation Matrix

Escalation Criteria Level of risk Actions for consideration Reports to level

Level Zero All KPIs are being Negligible • Monitor KPIs CCG Quality meeting achieved/within trajectory

Level One Minor concern/s Minor Level Zero, plus: Quality meeting • Risk assess Informal CQRM • Share at informal CQRM Level Two Moderate concern/s Moderate Level One, plus: CQRM • Consider quality assurance visit/deep dive CQGC • Request action plan Governing Body • Agree trajectory for improvement Risk Register • Escalate to CQRM • Exception report to CPPM

Level Three Major concern/s High Level Two, plus: CQRM • Undertake quality assurance visit / deep dive CQGC • Raise contract query Governing Body • Escalate to joint quality contracting meeting QSG • Consider performance notice Risk Register • Consider inviting executive team to CQGC to provide assurance Level Four Extreme concern/s Catastrophic Level Three, plus: CQRM • Independent review/Appreciative enquiry CQGC • Consider Risk Summit Governing Body • Inform CQC and other regulatory bodies QSG • Invite provider executive team to CQGC to provide Risk Register assurance

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Appendix 3- Abbreviations used in this report – alphabetical list

A&E Accident and Emergency Department

AMHs Adult Mental Health Services

AMU Acute Medical Unit

BCF Better Care Fund

CAMHs Children and Adolescents Mental Health Services

CCG Clinical Commissioning Group

CPA Care Programme Approach

CT Computed Tomography scan (CT)

C&RCCG Coventry and Rugby Clinical Commissioning Group

CWPT Coventry and Warwickshire Partnership NHS Trust

EMAS East Midlands Ambulance Service NHS Trust

ENT Ear Nose and Throat

GEH George Eliot Hospital NHS Trust

GP General Practitioner

HEFT Heart of England NHS Foundation Trust

IAPT Improving Access to Psychological Therapies

KPI Key Performance Indicator

NHS National Health Service

POD Point of Delivery

PSA Prostate-specific antigen

RAP Remedial Action Plan

ROH The Royal Orthopaedic Hospital NHS Foundation Trust

RTT Referral to Treatment

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SDIP Service Development and Improvement Plan

STF Sustainability and Transformation Fund

SUS Secondary Uses Service

SWCCG South Warwickshire Clinical Commissioning Group

SWFT South Warwickshire NHS Foundation Trust

TRUS Transrectal ultrasound guided biopsy

UHCW University Hospitals Coventry and Warwickshire NHS Trust

WMAS West Midlands Ambulance Service NHS Foundation Trust

WNCCG Warwickshire North Clinical Commissioning Group

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NHS Coventry and Rugby Clinical Commissioning Group Enc K

Report To: Governing Body Meetings in Common

Report Title: Health of Looked after Children Annual Report 2018/19

Report From: Jo Galloway, Chief Nursing Officer Anita Morgan - Designated Doctor Looked after Children. Lyn Parsons – Designated Looked After Children’s Nurse and Associate Child Protection

Date: 17th July 2019

Previously Considered by: Clinical Quality & Governance Committee – 27th June 2019

Action Required (delete as appropriate)

Decision:  Assurance:  Information:  Confidential

Purpose of the Report: This 2018/19 Looked after Children (LAC) Annual Report outlines to the Governing Body of NHS Coventry and Rugby Clinical Commissioning Group (CRCCG) how the statutory responsibilities to promote the health and wellbeing of children in care originating from Coventry in the health economy have been discharged under Section 11 of the Children Act 2004; the NICE quality standard on the health and wellbeing of looked after children and young people (National Institute for Health and Care Excellence, 2013, updated 2015); Promoting the Health and wellbeing of Looked after children (Department of Health, Department for Education, 2015); Children and Social Work Act 2017 (Care Leavers); Safeguarding Children and Young People: Roles and Competences for Healthcare Staff (Fourth edition: January 2019); Looked after children: Knowledge, skills and competences of health care staff. Intercollegiate role framework. March 2015 and Care Quality Commission Essential Standards of Quality and Safety National Guidance.

Rugby LAC will be included within the Warwickshire Health of Looked after Children Annual Report 2018/19.

Key Points: Health outcomes for Coventry’s Looked after Children have consistently been on a par or better than the England average. There has been a steady trend in improvement in outcomes for the last 5 years.

Areas of success: • Embedding of quality assurance systems for Looked after Children’s health assessments, including the establishment of peer review mechanisms within the health provider CWPT. This has resulted in significant improvement in the quality of LAC health assessments. • Improvement in Strengths and Difficulties Questionnaire (SDQ) scores that demonstrates an improvement in the mental health outcomes for our LAC population • Recognition of the increased risk of obesity in the LAC population as demonstrated in research and evident in our own population with a multi-agency focus to address the needs of Coventry’s Looked after Children. • Strengthening the relationships between Children’s Residential Care Homes and the Named Safeguarding Professionals (NSP’s) to improve access and engagement with primary care. • Engagement with foster carers and Looked after Young people through Corporate Parenting Board; attendance at Foster Carer Meetings and to the Coventry Foster Carers Newsletter. • Partnership working with originating CCG’s in relation to the relocation of 32 Looked After young people from a large private residential home and school in Coventry to new accommodation at various localities across England and Wales.

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NHS Coventry and Rugby Clinical Commissioning Group Enc K

Areas of challenge: • Performance relating to the provision of health assessments within statutory timescales and the completion of Care Leavers Health summaries for 16 and 17 year olds leaving care has reduced. This performance issue has resulted in a contract notice served to CWPT in December 2018, and a recovery plan and trajectory is in place to address the backlog managed through CRCCG contracting. In addition, work with CRCCG, Coventry and Warwickshire Partnership Trust (CWPT), South Warwickshire Foundation Trust (SWFT), Local Authority Public Health, Health of Looked After Children Group (HeLAC) and the Corporate Parenting Board in place to understand the contributing factors and to improve performance. • Coventry profiling of health needs to inform Joint Strategic Needs Assessment (JSNA) and commissioning intentions. This cannot be fully achieved until LAC population data is consistently reliable, all children receive their statuary health assessment and the process to inform the CCG of children placed into Coventry is strengthened. • The Providers do not produce a LAC annual report to inform the LAC Annual report

The Forward plan for 2019/20: Quality Governance and performance including Health assessments and meeting statutory duties • CRCCG Lead for Safeguarding to chair Strategic and Commissioning HeLAC meetings and all partners, providers and relevant commissioners to attend in order to provide a holistic system for the provision of health care for Looked after Children • All providers to provide assurance and evidence of robust Quality Assurance processes for their respective services to their commissioners • All providers to provide data on performance against agreed priorities and timescales in order to share collaborative responsibility for the health outcomes for LAC. LAC health assessment and Care Leaver Health Summary pathways to be reviewed by all providers to ensure all are meeting responsibilities in line with statutory guidance and to collaboratively identify and address blockages that may prevent efficient and effective working together. • CWPT to implement the Pre-LAC pathway to inform placement planning, especially for children with a plan to be placed outside of Coventry before children come into care. • Recommendations of the Education and Health Care Plan (EHCP) and LAC health plan should be mutually consistent and informative. The EHCP and health care plan should be discussed at LAC review meetings led by social care and embedded in care planning performed by social care. Providers of LAC health assessments should consider how to co-ordinate assessments and reviews of the child’s care plan and EHC plan to ensure that taken together, they meet the child’s needs without duplicating information unnecessarily. Education partners should be encouraged to work with the LAC health to co-ordinate EHCP assessments and reviews with LAC health reviews as far as possible. • Agree accurate mechanisms for recording and uploading electronic data.

Physical, emotional and mental health wellbeing • LAC population reviews and audits completed by Providers to be invited for presentation at HeLAC and Corporate Parenting Board. As Public Health commission services that promote healthy weight, CWPT will be encouraged to discuss their findings with Public Health in order to inform ongoing strategy to decrease childhood obesity in the Coventry LAC population • To agree a plan for a repeat audit of obesity in the LAC population. • To increase attendance at dental checks to achieve >95% • To increase achievement of ‘up to date’ immunisation status for each Looked after child. • In light of the national and local data that LAC are at increased risk of Child Sexual Exploitation (CSE), county lines, gangs and association with substance misuse, increase strategic working with the various agencies working with these groups. • Annual CSE report to be presented to HeLAC and strategy shared.

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NHS Coventry and Rugby Clinical Commissioning Group Enc K

• Outcome star data to be reported as per specification and update to be shared via LAC Annual report by providers in February 2020 to inform CRCCG LAC Annual report

Voice of Children/young people & engagement • CRCCG to seek assurance that all care leavers aged 16 and 17 have a meaningful care leavers health summary • Development and implementation of health promotion interactive ‘Grab Guides’ to support transition of young people aged 15-18 years to adult health services and promote self - management and self-care related to dentist, optician, and GP registration and accessing immunisation • Facilitate and collate specific service user feedback regarding the health provision for LAC in addition to Friends and Family test. • Expand awareness of the role of NSPs across the foster carer network and young people who are looked after. • For Unaccompanied Asylum seeking children in Coventry to have access to health pathways to meet their needs- trauma, blood borne virus screening and Tuberculosis (TB) screening.

Commissioning of services • Coventry profiling of health needs to inform Joint Strategic Needs Assessment (JSNA) and commissioning intentions • Ongoing monitoring of the performance of LAC health services against agreed targets in the context of local and national trends in the population of LAC. • Work in partnership with Public health to ensure delivery and partnership working between Public health and CCG commissioned services, including provision of school nursing, health visiting, life style services, immunisation services and health screening for asylum seeking young people.

Recommendation: The Governing Body is asked to: • NOTE the evidence of the strong partnership working between CRCCG, CWPT, Public Health, HeLAC and the Corporate Parenting Board; • NOTE the collaborative remedial actions in place across the partnership to improve the performance for indicators which are off target; • ENDORSE the recommendations for consolidating progress and improving outcomes for LAC; • RECOGNISE the challenges in the operationalisation of the model by CWPT and the impact of commissioning changes within partner organisation on the delivery of health services to Looked after Children; and • APPROVE the Forward plan for 2019-20.

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NHS Coventry and Rugby Clinical Commissioning Group Enc K

Implications

Objective(s) / Plans supported by this See LAC Annual Report 2018/19 report: Conflicts of Interest: None identified Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance relating to the provision of health assessments within statutory timescales and the completion of Care Leavers Health summaries for 16 and 17 year olds leaving care has reduced. This performance issue has resulted in a contract notice served to CWPT in December 2018, and a recovery plan and trajectory is in Performance: place led by Contracting and Performance to address the backlog managed through CRCCG contracting. In addition, work with CRCCG, CWPT, SWFT, Public Health, HeLAC and the Corporate Parenting Board in place to understand the contributing factors and improve performance. The impact of the performance relating to the provision of health assessments within statutory timescales and the completion of Care Leavers Health summaries for 16 and 17 year olds leaving care from a quality perspective are that the child’s health needs are not identified and those caring for them will not know what the health needs are. Quality and Safety: These results in delays in health needs being met and referrals being made to specialist services as well as an inappropriate placement of child where their need cannot be met because the social worker does not know what the child’s needs are. All of these can lead to placement breakdown, the child not being a stable environment and potential further deterioration in the child’s health and wellbeing General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public The report will be shared with Corporate Parenting Board, which is attended by Engagement: Looked After Children and Carer representatives. The report has been prepared by Dr Anita Morgan Designated Doctor LAC CRCCG Clinical Engagement: and Lyn Parsons Designated Nurse LAC CRCCG Risk and Assurance: CWPT performance issues are at level 2 on the Corporate Risk Register

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The Health of Coventry Looked after Children Annual Report June 2019

Anita Morgan Designated Doctor for Looked after Children and Lyn Parsons, Designated Nurse for Looked after Children NHS Coventry and Rugby Clinical Commissioning Group

Table of Contents 1. Executive Summary ...... 3 2. Purpose of the Report ...... 8 3. Local and National context ...... 9 4. 2017-18 Performance ...... 9 4.1 2017-18 Performance: Key Health Outcomes monitored at a national level (903 return data)…………………………………………………………………………………………………………………………………..9 4.2 LAC numbers and demographics ...... 10 4.3 Provision of LAC Health Assessments………………………………………………………………………………..10 4.4 Developmental Assessments ...... 11 4.5 Dental Health ...... 12 4.6 Immunisations ...... 12 4.7 Mental Health Outcomes (SDQ scores) ...... 13 4.8 Substance Misuse ...... 15 5. 2017-18 Performance: Key health outcomes monitored at a local level ...... 16 5.1 Initial health assessments and Pre-LAC health pathways ...... 16 5.2 Leaving care summaries ...... 17 5.3 Outcomes star ...... 17 6. 2018-19: Key changes in Commissioned services in 2018-19 ...... 17 6.1 HeLAC ...... 17 6.2 Provision of Family and health lifestyle services including school nursing and health visiting services ...... 18 6.3 Provision of Looked after Children physical health services ...... 19 6.4 Provision of LAC CAMHS ...... 19 6.5 Strengthening the relationship between LAC and Primary Care: Role of Named Safeguarding Professional (NSPs) ...... 20 6.6 Provision of shared administration through the Joint HeLAC administration Hub ...... 21 6.7 Corporate Parenting Board ...... 21 6.8 Impact on Looked After young people and carers ...... 21 7. Current Successes and Challenges ...... 23 7.1 Successes ...... 23 7.2 Challenges ...... 23 7.2.1 Quality Governance and performance including Health assessments and meeting statutory duties and care leavers health summaries for all 16-17 year olds leaving care ...... 23 7.2.2 Physical, Emotional and Mental Health Wellbeing ...... 24 7.2.3 Voice of Children/young people & engagement ...... 24

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7.2.4 Commissioning of services ...... 24 7.2.5 Significant Challenges ...... 255 8. Forward Plan for 2019-2020 ...... 25 8.1 Quality Governance and performance including Health assessments and meeting statutory duties ...... 25 8.2 Physical, emotional and mental health wellbeing ...... 25 8.3 Voice of Children/Young People and Engagement ...... 26 8.4 Commissioning of services ...... 26 9. Equality and Diversity considerations and implications ...... 26 10. Risk implications ...... 26 11. Recommendations ...... 27

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1. Executive Summary

1.1 This Looked after Children Annual Report outlines to the Governing Body of NHS Coventry and Rugby Clinical Commissioning Group (CRCCG) how the statutory responsibilities to promote the health and wellbeing of Looked after Children (LAC) from Coventry and placed into City are discharged under:

• Section 11 of the Children Act (2004) • The NICE Quality Standard on the Health and Wellbeing of Looked after Children and Young People. (National Institute for Health and Care Excellence, 2013, updated 2015). • Statutory guidance ‘Promoting the Health and Wellbeing of Looked after Children’ (DH and DFE, 2015). • Children and Social Work Act (2017) in respect of LAC and Care Leavers. • Safeguarding Children and Young People: Roles and Competences for Healthcare Staff (Fourth edition: January 2019). • Looked after Children: Knowledge, Skills and Competences of Health Care Staff Intercollegiate role framework. (March 2015). • Care Quality Commission Essential Standards of Quality and Safety National Guidance.

1.2 The purpose of the report is to provide an overview of the Health of Looked after Children.

1.3 This report relates specifically to those children looked after by Coventry City Council or placed into Coventry by other local authorities. It is not related to activity in Warwickshire or aligned to the Looked after Children Mental Health (CAMHS) specification and only relates to Coventry and Rugby CCG.

1.4 The Looked after Children physical health specification is commissioned by Coventry and Rugby CCG. This ensures that children in the care of the Coventry Local Authority have their health needs assessed. It is well known that children who have been abused and neglected and come into care are the main cohort of Looked after Children, who have complex health needs and are disadvantaged in relation to their peers. There are two types of health assessment, an initial assessment on entering care and a health care plan which is shared with the local authority that are responsible for ensuring these health needs are addressed. If the child remains in care, an updated health care plan is produced via a review health assessment at intervals throughout the duration of the time in care. In addition, all 16 and 17 year olds leaving care should be furnished with a summary of their health records so they understand their health needs into adulthood. This is called a leaving care health summary.

1.5 The CCG have a responsibility to support the local authority to deliver this statutory duty and we commission a service from Coventry and Warwickshire Partnership NHS Trust (CWPT) to undertake these assessments. In addition to this CCG commissioned service specification, the local authority public health department have commissioned a 0-19 service to undertake a proportion of the overall number of review health assessments required. This provides a degree of choice for young people and assists in accessing some of the harder to reach and non-engaging children and young people.

1.6 The CCG, as a host to children placed into city by other local authorities, have a duty to comply with requests to undertake health assessment on behalf of the originating CCG. This offer is currently delivered via CWPT as outlined in the service specification.

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1.7 There have been performance issues identified in relation to CWPT as a provider since December 2018 which have impacted on the numbers of children who have a health assessment or a review of their health care plan or a leaving care health summary within the statutory timescales. There are indications that this may be due to staffing levels in the team, delays in recruiting staff and a delay in adopting new ways of working. It is evident that the current provider has not implemented the full specification to date. The poor performance is impacting on the quality of care that children and young people receive as they are not receiving their assessment. However, when a child does have a health assessment the quality of this assessment is good.

1.8 The impact of these delays from a quality perspective is that the child’s health needs are not identified and those caring for them will not know what the child’s health needs are. There are also then delays in health needs being met and referrals being made to specialist services. In addition, there can be inappropriate placement of a child in a place where their needs cannot be met because the social worker does not know what the child’s needs are. All of these can lead to placement breakdown, the child not being in a stable environment and a further deterioration in the child’s health and wellbeing.

1.9 There have been some challenges across the system including data accuracy, timeliness of requests by the local authority, lack of information provision and availability of social workers to attend the initial health assessment. There has also been some reluctance by foster carers and young people to engage with this health assessment. The CCG quality team and contracting and performance teams are working together with the provider and the local authority to address the system issues, this is achieved through the Health of Looked after Children Steering Group led by the CCG.

1.10 Commissioners at NHS Coventry & Rugby CCG have served a performance notice which is being managed through the contracting and performance team. This has led to an improvement in performance associated with a recovery plan and recovery trajectory that is in place to ensure that more assessments are completed within statutory timescales. We expect compliance to be achieved and the backlog addressed by the end of August 2019. Monitoring also takes place through Clinical Quality Review meetings. There is significant scrutiny by other stakeholders of the health element as this significantly impacts on local authority statutory duties. This brings oversight by the Coventry Safeguarding Children Board as Looked after Children are one of its priorities, as well as via the Corporate Parenting Board. The report includes the position at the end of 2019. The delivery of health services to meet the health needs of Looked after Children has changed in 2018-19, with contract arrangements for the 0-19 service moving from Coventry and Warwickshire Partnership Trust to South Warwickshire NHS Foundation Trust (SWFT).

1.11 The key national outcome measures of the health of Looked after Children are determined by the Department of Education. These quantitative outcomes are reported via statutory annual data submissions provided by Coventry City Council. The health outcomes for Looked after Children in the care of Coventry City Council continue to improve. Performance on the delivery of health assessments, dental assessments, immunisation rates, developmental checks and Strengths and Difficulties Questionnaires (SDQ) has improved each year, is better than national average and compares well with our statistical neighbours. The average SDQ score that determines the emotional needs of our Looked after Children is on par with the national average. The mental health of Looked after Children has been a key priority over the last year, as demonstrated by the co-commissioning and implementation of a Looked after Children Child and Adolescent Mental Health (Looked after Children CAMHS) Service.

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The rates of substance misuse in our Looked after Children population are reported to be within the all England average and Coventry City Council continues to invest in services that prioritise interventions for Looked after Children as a specific group.

1.12 NHS Coventry and Rugby CCG is working with partners to address challenges that are common to all CCG’s in the delivery of health care to Looked after Children, particularly information sharing, data collection, quality assurance, the transition of children leaving care and the management of health provision for children placed out of area.

* Looked after Children will be abbreviated to LAC throughout the Annual Report.

2018-19 Performance as outlined in last year’s LAC Annual Report:

Performance against Local Strategic Goals and Key Health Priorities for 2018-19

Priority Area Key Priorities for 2018-19 Performance for 2018-19 Quality 1. Quality Assurance (QA) of health 1. Achieved: Governance and assessments for all children, especially those QA of all health assessments performance placed out of area as per Looked after performed by CWPT including Children specification ( including completion health of the Outcomes star Framework). assessments and meeting statutory 2. Health assessments completed to meet 2. Part Achieved : duties statutory timescales. Performance issues impacting on % of children receiving their statutory health assessment. Recovery plan in place to resolve by August 2019.

3. Placement planning to meet health needs 3. Not achieved for physical via Pre-Looked after Children pathway. health but increasing input in placement planning via Looked after Children CAMHS.

4. Staff receive Looked after Children 4. Achieved (monitored via training as per intercollegiate guidance. annual appraisal)

5. Education and Health care plan is 5. Not achieved ( see later embedded in care planning. comments)

6. Governance arrangements of HeLAC 6. Achieved meeting to be strengthened and reporting mechanisms reviewed. Physical, emotional 1. Local SDQ pathways are in place to meet 1.Achieved 93% and mental health 95% compliance. wellbeing 2. Clear pathways in place for SDQ to be 2. Achieved ( pathway agreed shared to inform the health assessment, via Health of LAC (HeLAC) EHWB/ mental health of children looked action plan) after to ensure needs are identified and addressed early.

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3.Improve vaccination uptake to meet 95% 3. Partially achieved. Data compliance. quality issues persist.

4. Decrease childhood obesity in the 4. Awareness has been raised Coventry LAC population. amongst relevant commissioners and providers of services to improve access and uptake of interventions.

5. CWPT to generate population data. 5. Achieved via Outcomes Framework and specific audit and review projects. Voice of 1. All care leavers aged 16 and 17 have a 1. Not achieved- action plan in children/young high quality, meaningful care leavers’ health place to resolve by August people & summary. 2019. engagement 2. To improve access, involvement and to 2. Achieved identify a named health professional to be known to the child or young person and their carer to work in partnership with the Local Authority professional aiming to develop relationships for all Looked after Children including those children where staff struggle to engage. Commissioning of 1. Clear expectations for service 1. Achieved including role of services commissioning Designated Doctor

2. CWPT, CRCCG Continuing Health Care 2.Pathways for collaborative (CHC) and Transforming Care Team to work working achieved in partnership for children who are Looked after Children and have CRCCG commissioned services to meet need and ensure health assessments are aligned

3. Coventry profiling of health needs to 3. Not achieved: current data inform Joint Strategic Needs Assessment collection mechanisms are not (JSNA) and commissioning intentions robust.

4. Raise the profile of Looked after Children 4. Achieved within Safeguarding contractual standards

Key health priorities for the coming year, 2019-20 are:

• Delivery of statutory duties as a Commissioner and a host CCG for Coventry - Initial Health Assessments within 20 days to inform the Initial LAC review; Review Health Assessments 6 monthly for 0-5 year olds and annually for 5-18 year olds to inform the subsequent LAC Review meetings for all children originating from Coventry and placed in City. • CWPT to address performance issues and CWPT/SWFT to ensure partnership working and engagement with Commissioners (CCG and Public Heath) to achieve mutual KPI’s

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• To ensure all 16 and 17 year olds leaving care receive a copy of their Care Leavers Health Summary as outlined in the revised LAC service specification. CWPT to address performance issues to achieve this • Production of a Health of Looked after Children Annual Report in February 2020 by the commissioned providers to inform the commissioning requirements for LAC both originating from and being placed into Coventry. This will also inform the Coventry Joint Strategic Needs Assessment (JSNA). • Embedding of Looked after Children CAMHS Service within the service including 18-25 year old’s; increased integration with the specialist Looked after Children health service and demonstration of its outcomes to demonstrate a decreased SDQ for the population. • Development of creative and interactive health transition tools (Grab Guides) to promote an awareness of age appropriate health seeking behaviours for 15-18 year olds in preparation for leaving care (Registration with Dentist, Optician, GP and Immunisations). • Delivery of all aspects of the Looked after Children’s Physical service specification by CWPT, including the development of a Pre- Looked after Children pathway to ensure the health needs of children are known and to inform placement. • Strengthening the Looked after Children Health Assessment and Special Education Needs pathway (Education and Health Care Plan). • Task and Finish Group to focus on improving the health outcomes and strengthen the pathways for Unaccompanied Asylum Seeking Young People (Trauma, Blood-borne Virus and TB screening). • Ensuring the performance reporting arrangements for all Providers are aligned to the Commissioning Organisations – School Nursing/Health Visiting (SWFT) activity reported to Local Authority Public Health Commissioners (circ. 200 Review Health Assessments), and CWPT LAC Health Team (996 items of activity to include Initial, Review and Care Leaver Health Summaries). • Strengthening the Partnership meetings to improve the health outcomes of Looked after Children - HeLAC and Corporate Parenting Board. • Strengthen the role of the joint administration hub and review the data processing activities. • Develop adequate robust data regarding the health needs of Looked after Children to inform the Joint Strategic Needs Assessment (JSNA) and appropriate commissioning decision making. • Strengthen the liaison between LAC Health Team and Named Safeguarding Professions/Named Safeguarding to ensure that there are robust process in place regarding the sharing of information to inform health assessments and that health actions are implemented that are aligned to Primary Care • Annual CSE report to be presented to HeLAC and strategy shared. • Facilitate and collate specific service user feedback regarding the health provision for LAC in addition to Friends and Family Test.

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LAC ANNUAL REPORT 2018-2019

2. Purpose of the Report

2.1 It is well known that children who have been abused or neglected and who have entered local authority care have complex health needs. Research has demonstrated that Looked after Children may have immediate and long-term impairment and disadvantage in relation to their peers in all areas of their lives including their health. In recognition of this, each local authority is expected to ensure that the health needs of the children in their care are assessed through regular health assessments: an initial health assessment on entering care, review health assessments at regular intervals whilst in care and a leaving care health summary aged 16 and 17 years. The local authority is statutorily required to work in partnership with local health commissioners and providers regarding delivery of these services. Clinical Commissioning Groups have a statutory responsibility to meet the health needs of Looked after Children.

2.2 Coventry and Rugby Clinical Commissioning Group (CRCCG) has a statutory responsibility to commission services to deliver health assessments and meet the health needs of Looked after Children in Coventry and Rugby; those who are the responsibility of Coventry City Council or Warwickshire Local Authority and those who are placed in Coventry or Rugby by other local authorities. CRCCG discharges this responsibility in Coventry via the Looked after Children Physical Health Service Specification and the CAMHS Looked after Children Service Specification. In Rugby, this responsibility is delegated to North Warwickshire CCG. Coventry and Rugby CCG work in partnership with the local authority to promote awareness of the health needs of Looked after Children in the commissioning and delivery of public health services commissioned by Coventry City Council (CCC). CRCCG is also required to commission a Designated Doctor and a Designated Nurse for Looked after Children to provide advice to CRCCG and the local health economy on the health needs of Looked after Children in line with nationally agreed role specifications. Coventry and Rugby CCG is statutorily required to produce an annual report about the health needs of Looked after Children within its responsible area. This responsibility is delegated to the Designated Doctor and Designated Nurse.

2.3 The LAC Annual Report informs the commissioning intentions of CRCCG and advises on quality and safety improvement requirements to the Governing Body of NHS Coventry and Rugby Clinical Commissioning Group (CRCCG).

2.4 NHS Coventry and Rugby CCG discharge its duties in partnership with commissioners at Coventry City Council (CCC) and Public Health Services within CCC. The functions were commissioned from NHS Coventry and Warwickshire Partnership Trust (Looked after Children health team and health visiting) and South Warwickshire Foundation Trust (School nursing) during 1 April 2017 – 31 March 2018. Since September 2018, South Warwickshire Foundation Trust (SWFT) has provided health visiting and school nursing services as a component of the Family and Healthy Lifestyles Service. CWPT provides the Looked after Children Physical Health and CAMHS LAC services via a team of Doctors and Nurses. In

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relation to Rugby Looked after Children, South Warwickshire CCG is the lead commissioner and produces an annual report for this cohort of children.

2.5 Multi-agency partnership working is promoted in Coventry through the HeLAC (Health of Looked after Children) Group. This works to agree and implement the Coventry Looked after Children and Care Leaver Health Strategy. This strategy is based upon NICE Guidance Quality Statements with regard to the health provision for Looked after Children. Coventry and Rugby CCG is represented on Coventry City Council Corporate Parenting Board by the Designated Looked after Children Doctor and Nurse.

2.6 A period of transition to the new LAC service specification for Coventry Local Authority responsible children and those placed into city by other Local Authority areas which commenced in May 2017 and there has been a further transition and change in this reporting year 2018-19 as the provision of all the public health services has moved to a different provider. This report looks back to key health outcomes represented in national 903 return outcome data published in December 2018 relating to activity in March 2017- 2018, to the current performance 2018-19 and forward to the future strategy for 2019-2020.

3. Local and National Context

3.1 The number of Looked after Children continued to rise over the last 5 years, following the national trend. The increase is due to an increased number of children starting to be looked after and children staying in care longer. The number of children in the care of each local authority for 12 months or more in March each year is submitted to the Department of Education by each local authority annually. This figure provides a bench mark for trends in the Looked after Children (LAC) population. It does not represent the total number of children who have been looked after by the local authority during the last 12 months.

Year 2014/15 2015/16 2016/17 2017/18 2018/19 Children looked after at year end Coventry 588 579 620 653 703 Statistical neighbour 598 average 2016/17 England average 496 2016/17

4. 2017-18 Performance

4.1 2017-18 Performance: Key Health Outcomes Monitored at a National Level (903 return data)

4.1.1 These are represented in the outcomes of the annual 903 data returns provided via social care data systems to the Department of Education. The data relates to children who have been looked after for more than 12 months at the year-end (March 2018). These are published annually in the following December after the year the data is collected. This can

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be found: https://www.gov.uk/government/statistics/children-looked-after-in-england- including-adoption-2017-to-2018

4.1.2 These outcomes are summarised in the graphs provided. Local data is bench marked against statistical neighbours and the all-England average. The Coventry trend over time is demonstrated.

4.2 LAC Numbers and Demographics

4.2.1 In 2017-18, there were 461 children who had been looked after by Coventry City Council for more than 12 months. 71% of these children were 10-17 years of age and only 14 % were under 5 years of age. Coventry has followed a national trend which has seen a steady shift in the population of Looked after Children to an increasing proportion of teenagers as a percentage of the whole group in local authority care. Inevitably, the health priorities and health outcomes of this group of young people are different to those under 5 years of age. The number of children and young people coming into care each year has fluctuated between 240 and 336 since 2012.

4.3 Provision of LAC Health Assessments:

4.3.1 Every child or young person who is looked after is required to have an Initial health assessment followed by regular review health assessments, as per statutory guidance. The interval of regular health assessment is determined by age. Those under 5 years of age are required to have a health assessment every 6 months and those 5 years and above are required to have a health assessment annually. CRCCG has a statutory responsibility to commission health services to provide these health assessments. Coventry City Council has a statutory responsibility to provide relevant information in advance of the health assessment, to ensure attendance of the Looked After person at the health assessment and for implementation of the recommendations arising from the health assessment.

4.3.2 CRCCG commission the Coventry and Warwickshire Partnership NHS Trust to undertake the statutory health assessments. In addition to this CCG commissioned service specification, the local authority public health commission school nursing and health visiting services to undertake a proportion of the overall number of health assessments required. This provides a degree of choice for young people and assists in accessing some of the harder to reach and non-engaging children and young people.

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% of Children who have had their

Annual Review Health Assessment

120 95 95 96 100 90 94 90 89 88 80 66 67 60

40

20

2013 2014 2015 2016 2017 2018

Year Coventry England

4.3.3 In 2018-19, 255 children and young people came into care of Coventry City Council and required an initial health assessment. National data regarding the delivering of initial health assessments is not collated currently. 903 data consider performance in delivering a timely Review Health Assessment (RHA) to all children and young people who have been looked after for more than 12 months and timely is defined that health assessments must be carried out twice a year for those under the age of 5 years. Both these assessments must be carried out in order for the Annual Assessment requirement to be satisfied for under 5s. The assessment should be carried out once in every period of six months before the child's fifth birthday. This means that one assessment should be carried out in the first six months and one in the second six months. For those aged 5 or over, a single annual assessment fulfils the requirement provided this takes place within the 12 month period. Coventry’s performance regarding timely delivery of RHAs has been consistently good since 2015 achieving between 94-96% each year, consistently above the England average and compares well with our statistical neighbours. In 2017-18, 96% of RHAs were delivered in a timely manner compared with the England average of 88%, however the performance dropped to 79.2% hence the issuing of a performance notice, and the KPI is set at 95%.

4.3.4 Uncleansed data provided to Coventry LSCB in March 2019 indicated that performance in delivery of review health assessments for 2019 had fallen to 79.2% as compared with an All- England average of 88%.

4.3.5 This data is provisional pending data cleansing however it is expected that data will demonstrate a significant reduction in the number of Looked after Children who have received a review health assessment within 12 months for the period 2018-19.

4.4 Developmental Assessments

4.4.1 Performance with regard to providing developmental assessments to children less than 5 years of age has remained exemplary at 100% against an England average of 85%.

4.4.2 Performance in provision of developmental assessments to children less than 5 years of age is expected to remain at 100% for 2018-19.

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4.5 Dental health

4.5.1 The numbers achieving an annual dental check has remained consistent for the last three years achieving 94% compared with the England average of 84%. This is a great achievement when considered in the context of the recent concern regarding the numbers of all children in Coventry who attend the dentist regularly. The LA has not released the data for March 2019.

% of Children with up to date Dental Checks

100 95 94 95 94 90 90 89 84

80

60 61 60

40

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2013 2014 2015 2016 2017 2018 Year

Coventry England 4.6 Immunisations 4.6.1 The numbers of Looked after Children with up to date immunisations fell to 90% in 2017-19. To understand the reasons for this, the Designated Nurse worked in partnership with the Local Authority to audit the recording of data related to immunisations on their system in 2018. The findings were that LA records were not accurate and were updated to reflect the actual data which was 98%. There is no LA dashboard to monitor this KPI. Data regarding annual dental checks and immunisations for period 2018-19 is not yet available.

% of Children with up to Date Immunisations

100% 97% 95% 93% 92% 90% 90% 86% 85% 84% 85% 83%

80%

2015 2016 2017 2018 12 Year Coventry England

4.7 Mental Health Outcomes (SDQ scores)

4.7.1 The SDQ is a brief behavioural screening questionnaire about 4-16 year olds. It exists in several versions to meet the needs of researchers, clinicians and educationalists. All versions of the SDQ ask about 25 attributes, some positive and others negative. These 25 items are divided between 5 scales: SDQs are completed by the local authority for Looked after Children aged between 4 and 16 to evidence that they are taking into account the potential emotional and behavioural difficulties of children. The higher the score, the more pronounced difficulties that child will face:

• emotional symptoms • conduct problems • hyperactivity/inattention • peer relationship problems • prosocial behaviour

4.7.2 The SDQ generates a score, 0-15 Normal, 16-19 Borderline and 20-40 Abnormal

4.7.3 The SDQ can be used in the following ways:

• Clinical assessment • Evaluating outcome. "Before" and "After" SDQs can be used to audit everyday practice (e.g. in clinics or special schools) and to evaluate specific interventions (e.g. parenting groups). • Epidemiology. The SDQ's emphasis on strengths as well as difficulties makes it particularly acceptable to community samples. • Research • Screening: In community samples, multi-informant SDQs can predict the presence of a psychiatric disorder.

4.7.4 Key mental health outcome measures related to the health of young people from Coventry Looked after Children have been below England average for a number of years but with an improving trend for the last two years. Data indicates that outcomes presented for 2017-18 are comparable with England average outcomes and outcomes for 2018-19 indicate a further reduction in average SDQ score for Coventry’s Looked after Children. It is helpful to understand that; the lower the overall SDQ score, the better the mental health and emotional wellbeing of the Looked after Child or young person. The local delivery of SDQ assessments is co-ordinated by Social Care has been above average and again achieved 93% compared with the England average of 78%. Previously the average SDQ score for Coventry’s Looked after Children has been greater than the England average indicating poorer emotional health and wellbeing in our Looked after Children than average. However, the score for 2017-18 was 14.3, only 0.1 higher than the England average. In 2017-18, the numbers of children with a high SDQ score indicating a cause for concern is 39% and was the same as for England as a whole.

4.7.5 Data for 2018-19 indicates that the average SDQ score for Coventry’s Looked after Children has fallen to 11. Based on previous All-England SDQ score averages, this is likely to be considerably lower than the All-England average SDQ score for 2018-19. The positive impact

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of commissioning and performance of local mental health and wellbeing services and the CAMHS LAC Service was discussed at Scrutiny Board in February 2019.

Average scores by category for Coventry children and young people

SDQ Sub- 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20 Period Max Category to date Average Score Emotional 3.1 3.1 3.1 2.9 3.2 2.5 3.1 10 Symptoms Conduct 3.3 3.3 2.9 3.1 2.8 1.3 3.1 10 Problems Hyperactivity 5.3 5.4 5.1 5.2 4.8 4.5 5.2 10 Peer 3.1 3.1 3.1 3.1 2.9 2.8 3.1 10 Relationships Pro-Social 6.9 7.3 7.0 6.8 7.1 8.0 7.0 10 Behaviour

4.7.6 The lower the score the better in SDQ terms. Pro-social behaviour and hyperactivity continue to be the most challenging areas for children and young people, and so intervention should be available in the City to help manage these areas. The guide to SDQs is available here: https://coventrycc.sharepoint.com/Shared%20Documents/Children's%20Services%20- %20SDQs%20-%20Good%20Practice%20Exemplar.pdf#search=SDQ

Children Looked After, aged 5 to 16 with an SDQ score - Average SDQ score

16.0 15.8 15.5 14.9 14.8 14.8 15.0 14.3 14.3 14.2 14.1 14.0 14.0 14.5 13.9 13.9 14.0

13.5

13.0 2013 2014 2015 2016 2017 2018 Year

Coventry England

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4.8 Substance misuse

4.8.1 Previously, data indicated that significantly more Looked After young people from Coventry were troubled by substance misuse than average and that our substance misuse services were struggling more than many other services to engage with looked after young people. Data for 2017-18 indicates that the number of young people known to have problems with substance misuse has reduced to 4%, in line with the England average. The numbers of those with problems who received substance misuse interventions increased to 53%, more than double the figure from the previous year and better than the England average of 46%. However, the numbers who declined to receive help from substance misuse services remained higher than the England average of 36%, at 47%. Data for 2018-19 is not yet available.

% of Children looked after at 31 March, identified with

having a substance misuse problem

12.5

8.0 7.1 7.1

6.0 3.8 3.8 4.1 4.0 4.0 4.0

2.0

0.0 2015 2016 2017 2018 Year

Coventry England

% Children looked after at 31 March, received intervention

for substance misuse

53.0 50.3 48.6 48.5 46.0 46.0 39.3

23.3

0.0 2015 2016 2017 2018

Year

Coventry ENGLAND

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% Children looked after at 31 March, received intervention

for substance misuse - 2019

80.0 78.0

53.0 50.0 46.0

0.0 0.0 0.0

LA Comparator

4.8.2 Where data is not available for some statistical neighbours, this is due to lack of data submitted or data provided in very small numbers.

4.8.3 There is concern regarding the risk to Looked after Children to exploitation - Child Sexual Exploitation (CSE), Contextual Safeguarding including county lines, with association with substance misuse. The newly commissioned Substance Misuse Service in Coventry has attended Corporate Parenting Board to present its strategy for prioritising interventions for Looked after Children. In addition, the CCG and Public Health Commission a CSE Health Service delivered via a Strategic CSE Nurse employed by CWPT and co-located with the LA’s Horizon’s Team. This CSE professional liaises closely with the LAC Health Team and LAC Named Professionals to promote the needs of looked after young people. The Annual CSE report should be presented to HeLAC and strategy shared.

5. 2017-18 Performance: Key health outcomes monitored at a local level

5.1 Initial Health Assessments and Pre-LAC Health Pathways

5.1.1 Statutory guidance states that the delivery of Initial Health Assessments (IHAs) is completed within 20 days of the child coming into care. A Pre-LAC pathway has been outlined in the LAC Specification, to ensure that assessors use the Pre-LAC phase to assess the health needs of children coming into care and inform the placement decision, especially for LAC being placed out of area. This is an area that has not been scoped to date. Although the delivery timescales of Initial Health Assessments (IHAs) is not monitored at a national level, Coventry Local Authority monitors this activity via an internal dashboard. This dashboard indicates that overall delivery of IHAs within statutory timescales, including children placed out of area was 76% in 2017-18. This compared favourably with a reported England average

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performance of approximately 40-50%. The local target for 2017-18 was set at 80%. This target was increased to 95% for 2018-19. The IHA should inform the child’s overall LAC care plan. It is the social workers responsibility to ensure that unmet health needs are addressed as recommended. This continues to be an area for further development. A copy of the completed IHA is sent to each looked after child and young person’s social worker and IRO (Independent Reviewing Officer) for discussion at the next LAC review.

5.1.2 Action for 2019-2020: Pre LAC health assessment pathway to inform placement planning to be developed

5.2 Leaving Care Summaries

5.2.1 The provision of leaving care summaries to all looked after young people prior to leaving care at 18 years of age is not currently monitored at a national level but is outlined in guidance. In addition, it is outlined in the Coventry Care Leavers Offer. Unfortunately, the locally agreed 95% target of completion rate for care leaving summaries for Coventry care leavers age 16-17 year olds was not met in 2017-18. Performance in 2018-19 to date indicated that it was not met by March 2019. The completion rate was less than 50%. CWPT have set out a recovery plan to complete all outstanding summaries by the end of August 2019. This is an ongoing area of development with the local provider.

5.2.2 Action for 2019-2020: For all 16 and 17 years olds leaving care to be furnished with a copy of their Health History.

5.3 Outcomes Star

5.3.1 The LAC physical service specification requires that health outcomes data for an individual looked after child is represented visually in the form of an ‘outcomes star’ and captured to inform commissioners of the health needs of Looked after Children, both Coventry responsible and those placed into area. This data collection began during 2017-18. Unfortunately, due to performance issues affecting the Provider, this aspect of the specification has not been delivered as the primary focus has been to address the backlog of assessments and care leavers’ health summaries.

5.3.2 Action for 2019-2020: Outcome star data to be reported as per specification and update to be shared via LAC Annual Report by providers in February 2020 to inform CRCCG LAC Annual Report

6. 2018-19: Key Changes in Commissioned Services in 2018-19

6.1 HeLAC

6.1.1 The governance arrangements for HeLAC have been reviewed. HeLAC is now chaired by a representative of CRCCG; the Lead/Designated Nurse for Safeguarding Adults and Children and Prevent Lead for CRCCG. HeLAC meetings have been separated into two distinct meetings: a contracting and performance meeting and a core strategy meeting. Representatives from all providers of key services for Looked after Children will be invited to

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attend to ensure oversight of a multiagency system that demonstrates collaborative working between services to deliver a holistic system of care for children and young people who are Looked After.

6.2 Provision of Family and Health Lifestyle Services including School Nursing and Health Visiting Services

6.2.1 Since September 2018, Public Health moved it’s commissioning from CWPT for health visiting services to South Warwickshire NHS Foundation Trust (SWFT). Health visiting and school nursing services are required to provide a minimum of 100 review health assessments for Looked after Children under 5 years of age and 100 for Looked after Children and young people 5 years and over.

6.2.2 The timeliness and quality assurance of these health assessments and supervision of clinicians who provide health assessments is the responsibility of SWFT. The total number was increased by 10% in 2018 to reflect the increase in the number of children coming into care.

6.2.3 SWFT also provides services to support children and families affected by obesity. Representatives from Public Health and SWFT attended Corporate Parenting Board in 2019. Assurance was given that Looked after Children would be prioritised for interventions within their service.

6.2.4 Public Health Commissioners and SWFT have been requested to attend HeLAC meetings on a regular basis in order to achieve and provide assurance that appropriate governance arrangements are in place and provide a collaborative, holistic system in order to meet the needs of Looked after Children. There has been some uncertainty regarding the reporting mechanisms for school nursing and health visiting services. This is being reviewed by PH Commissioners, in partnership with CRCCG.

6.2.5 Public Health provides Public Health Commissioners with assurance that:

- Robust QA mechanisms for RHAs are maintained in SWFT with actions taken to address emerging QA issues where appropriate - The appropriate quantity of RHAs are delivered by health visitors and school nurses as agreed - Completion of developmental assessments continues and is recorded on PROTOCOL to ensure accurate 903 data return

6.2.6 CRCCG requires assurance that:

- Information sharing processes with Coventry social care ensure that data is provided for inclusion on PROTOCOL to ensure accurate 903 data return.

6.2.7 Action 2019-2020: The reporting arrangements between Public Health Commissioners and SWFT and CRCCG and CWPT to be reviewed to ensure KPI’s aligned to each service.

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6.3 Provision of Looked after Children Physical Health Services

6.3.1 Coventry and Warwickshire NHS Partnership Trust is commissioned to provide the Looked after Children’s physical health service in line with the new service specification as outlined by CRCCG, in partnership with Public Health Commissioners.

6.3.2 Previously, CWPT held the contracts for the Looked after Children health service, school nursing (up until September 2017) and health visiting services with access to a shared electronic record. Outcomes regarding developmental assessments were achieved collaboratively across services reducing duplication. Outcomes regarding developmental assessments continue to be achieved collaboratively across systems.

6.3.3 Performance reported against the agreed KPIs related to the statutory timescales for Initial and Review Health Assessments, and Leaving Care Health Summaries for all 16-17 year olds has fallen below the agreed 95%. CRCCG has issued a performance notice to CWPT in January 2019 for failure to achieve its KPI’s associated with Review Health Assessments and Care Leavers Health Summaries. Performance of school nursing and health visiting component of 200 health assessments is being reviewed by Public Health Commissioners. In addition, CWPT have not implemented an outreach model for Health Assessments, as outlined in the Service Specification, and are still requesting out of area health providers to see Coventry children.

6.3.4 CRCCG also has to have arrangements in place to comply with Statutory Health Assessment for LAC placed into Coventry by other LA’s. CWPT currently provides this service, and recharges the Originating CCG for this additional work.

6.3.5 Action 2019-2020: CWPT Action plan to be reviewed and CWPT to implement the outreach model to see Coventry children placed outside area.

CRCCG requires assurance that: - Measures are in place to improve performance, meeting local KPI and statutory requirements - Collaborative arrangements are in place to ensure appropriate information sharing with SWFT and other partners - Data collection regarding developmental assessments for Looked after Children under 5 years of age and input to relevant social care records remains robust. - Services work effectively and efficiently within the scope of their commissioned activity to ensure time is utilised to deliver CCG commissioned activity. - Further review of the into area arrangements to include other Providers. - Providers are using the Friends and Family Test to explore user experience and the voice of the child/carer

6.4 Provision of LAC CAMHS

6.4.1 Coventry and Warwickshire NHS Partnership Trust and MIND are co-commissioned by CRCCG and Coventry LA through a pooled budget. The emotional and mental health services are delivered by ‘RISE’. This service also delivers the LAC CAMHS service, which commenced in 2017. The LAC CAMHS service was initially commissioned to work with 0-18 year olds. This was extended to work up to 25 years of age. The current provision is working with young

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people up to the age of 21 years, with further development under discussion to expand the provision to 25 year olds.

6.4.2 Action 2019-2020: Development of the LAC CAMHS service to 18-25 year olds

6.4.3 The LAC CAMHS Service and CRCCG shared a report to Scrutiny Board in February 2019. The Service was reported to be performing well. As indicated in this report, SDQ scores have reduced over the last 2 years as the LAC CAMHS service has embedded indicating improved mental health outcomes for Looked after Children.

Key features of the LAC CAMHS Service include:

• Consultations to social workers and other professionals to ensure that the needs of children/young people are understood within the context of their lived experience • Assessments – These include carers, emotional wellbeing assessments and Initial Mental Health assessments. • Delivery of therapeutic interventions with the child/young person following an assessment where a targeted or specialist response is required • Consultation and training for residential staff that draws on attachment theory • Nurturing Attachment Training for foster carers • Foster carer drop-in sessions to support placement stability (Coventry only) • Telephone advice and guidance for carers and professionals • Support to social workers when they are working therapeutically with young people

6.4.4 Children with complex mental health needs may also need support through mainstream CAMHS services. The LAC CAMHS service facilitates for referral when appropriate.

6.4.5 The LAC CAMHS service has been commissioned to extend its service to include support to the adoption service.

6.5 Strengthening the Relationship Between LAC and Primary Care: Role of Named Safeguarding Professional (NSPs)

6.5.1 Named Safeguarding Professionals (NSPs) have been established in nearly all GP practices across Coventry. The role of the NSP includes supporting the care of Looked after Children in primary care. This includes liaison with the professionals completing statutory health assessments, providing health data to inform assessments and the implementation of care plans with actions for primary care. The role also includes facilitating access to primary care services such as GP and nurse appointments for Looked after Children. Liaison between CWPT LAC Services and NSPs has commenced but it is not yet consistent and needs to be further embedded.

6.5.2 Action 2019-2020: Embedding the liaison between LAC Health Team, Foster Carers and NSPs to ensure sharing of information to inform health assessments and health actions are implemented that are aligned to Primary Care

6.5.3 Another area of development in 2018-19 has been to strengthen the liaison between Primary Care (via NSPs and Named Safeguarding GPs) and the new private children’s

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residential homes in the city. The Designated LAC Nurse has visited all the new provisions and organised meetings between NSPs and the children’s home managers. Details of the new LAC CAMHS service have been shared, with pathways strengthened to ensure care packages are transferred and new referrals to CAMHS made through the LAC pathway route. In addition, the Designated LAC Nurse has provided training to all the NSPs regarding LAC health, including the expedited records transfer to decrease delays in meeting health need.

6.6 Provision of Shared Administration Through the Joint HeLAC Administration Hub

6.6.1 Effective and timely information sharing is essential for delivery of effective health services for Looked after Children. This should be facilitated through a shared admin hub between health and social care, which commenced in 2014. This LAC admin hub has not fully realised its’ potential yet as health and local authority administrators are not co-located. The LA provides one dedicated member of staff, whilst CWPT provides 4. The admin hub has experienced increased demand for its services due to increased numbers of Looked after Children.

6.6.2 Recommendation 2019-2020: Joint review of the functions of the co-located LAC Admin Hub. Also, review of the administrative arrangements related to School Nursing/Health Visiting

6.6.3 Data accuracy is essential in order to understand health outcomes for individual children and the LAC population as a whole. Data accuracy is required to inform the Joint Strategic Needs Assessment (JSNA) and commissioning intentions. Data issues continue to be problematic and have a negative impact on data quality and quantity. CWPT staff have access to PROTOCOL. There is an ongoing plan to improve input of accurate up to date information.

6.6.4 Recommendation 2019-2020: Review of data sharing agreement and access/uploading of data to be reviewed by CWPT/SWFT. Also, task and finish group to be established to scope data accuracy and impact to children.

6.7 Corporate Parenting Board

6.7.1 Following the Local Government elections last autumn, the Chair of the Corporate Parenting Board is Councillor Pat Seaman. These meetings are held bi-monthly. The agenda includes monthly performance data from social care. Corporate Parenting Board has requested a regular briefing report from HeLAC. This will be provided on a quarterly basis consistent with agreed HeLAC reporting mechanisms and with the agreement of the Chair of the HeLAC meeting.

6.8 Impact on Looked After Young People and Carers

6.8.1 Voices of Care, Foster Carers and looked after young people are now represented at every Corporate Parenting Board and have a voice that can be heard at the heart of council with Councillors and health professionals who have oversight for the care of Looked after

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Children. This ensures that Young People and Foster Carers have awareness of changes in service, providers and can contribute to LA strategy. Designated Health Professionals have worked collaboratively with the Chair of Corporate Parenting Board and the Strategic Lead for LAC in the Local Authority to ensure that the health needs of LAC are represented at each meeting. Messages from Corporate Parenting Board are fed back to the CCG via the Designated Professionals who attend Corporate Parenting Board.

6.8.2 Designated Professionals have attended local foster carers meetings and contribute regularly to the monthly foster carers’ newsletter in order to hear the experience of foster carers, promote the health of Looked after Children and promote awareness of local services.

6.8.3 Designated professionals have provided teaching and education in multiple settings to multi- agency and multidisciplinary groups across Coventry to ensure that providers and individual professionals are aware of the health needs of Looked after Children and are aware of local care pathways.

6.8.4 Recommendation 2019-2020: The LAC Health Team are commissioned to provide the training function and it would be anticipated that this would be delivered by the commissioned services rather than the Designated Professionals.

6.8.5 Designated professionals have worked in partnership with the Transforming Care Team and Continuing Health Care Team to meet the needs of children with complex needs.

6.8.6 Local providers, including CWPT, have worked collaboratively with looked after young people to develop a welcome pack for young people on entering care. CWPT have contributed information regarding health care and health assessments. Professionals delivering health assessments have offered choice to foster carers and young people regarding venue, date and time of health assessments, wherever possible. The LAC Health Team have offered a very limited outreach offer than School Nursing and Health Visiting. This has led to some challenge from Carers.

6.8.7 The CAMHS Looked after Children Service provides a service for children and young people. The service also delivers training for Foster Carers and drop in clinics for Foster Carers who wish to discuss concerns regarding children in their care. Messages from Corporate Parenting Board are communicated to service providers where appropriate. Foster Carer representatives raised questions about the new CAMHS LAC Service and communication with the Foster Carers about the service. As a result, the Designated Doctor arranged for the Lead for the CAMHS Looked after Children Service to communicate with Foster Carers through email and face to face about the service. There was also additional information provided for the Foster Carers’ newsletter about the CAMHS LAC Service.

6.8.8 In autumn 2018, a 28 bed private residential children’s home and school for children and young people with complex health needs in Coventry was determined to be inadequate following inspection by OFSTED and CQC. Young people had been accommodated in this provision by Local Authorities from all over England. The CRCCG Designated Professionals worked closely with the provider, Warwickshire North Clinical Commissioning Group (WNCCG), CQC and OFSTED and the originating LA’s to successfully find homes for the remaining seventeen young people with complex health needs over a short period of time. This work included advocacy for the young people and parents with regard to safeguarding and health needs. The work performed by CRCCG and Designated Professionals has been recognised by NHS England as an example of good practice. Designated Professionals

22

ensured that every young person who moved to a new residential placement received a summary of the health care and health needs to ensure the children’s health needs could be met and their care packages transferred. Designated Professionals worked in partnership with the NSP at the GP Practice (Park Leys) to ensure all the young people’s health care packages were transferred.

7. Current Successes and Challenges

7.1 Successes

7.1.1 As illustrated, the health outcomes for Coventry’s Looked after Children have consistently been on a par or better than the England average. There has been a steady trend in improvement in outcomes for the last 5 years until 2018.

Particular areas of success have been:

- Embedding of quality assurance systems for Looked after Children’s health assessments including the establishment of peer review mechanisms within the health provider CWPT. This has resulted in significant improvement in the quality of LAC health assessments. - Improved timeliness of LAC health assessments against statutory timescales to 2017- 18 especially with regard to Initial health assessments. - Improvement in SDQ scores for our LAC population based on 903 return data ( see previous graph) - Recognition of the increased risk of obesity in the LAC population as demonstrated in research and evident in our own population with a multi-agency focus to address the needs of Coventry’s Looked after Children. - The commissioning of Named Safeguarding Professionals (NSP’s) to improve access and engagement with primary care. - Engagement with foster carers and Looked After Young People through Corporate Parenting Board, attendance at Foster Carer Meetings and contribution to the Coventry Foster Carers’ Newsletter. - Relocation of young people from a private residential home and school to new accommodation at various localities across England and Wales.

7.2 Challenges

There are a number of objectives that were not fully achieved in the previous year. 7.2.1 Quality Governance and Performance Including Health Assessments and Meeting Statutory Duties and Care Leavers Health Summaries for all 16-17 year olds Leaving Care

• Placement planning to meet health need via Pre-Lac Pathway has not taken place from a physical health perspective in advance of LAC health assessments. However, the CAMHS LAC service is contributing to this process for children and young people with mental health concerns.

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• There are some challenges related to shared records access due to CWPT and SWFT having different IT systems, with the potential for duplicate records and activity. • Strengthening the pathways between LAC health and SEND/Education and health care plans. 25% of Coventry children who are looked after have an EHCP (Education and Health Care Plan). The Looked after child’s EHCP should work in harmony with their LAC Health care plan to provide a coherent and comprehensive story about the child’s health needs when accessing education and when in foster care. Health and educational professionals should consider how to co-ordinate assessments and reviews of the child’s care plan and EHCP to ensure that taken together, they meet the child’s needs without duplicating information unnecessarily.

Recommendation 2019-2020: Strengthening the pathways between LAC Health and SEND/Education and Health Care Plans.

7.2.2 Physical, Emotional and Mental Health Wellbeing

• Decrease childhood obesity in the Coventry LAC population: CWPT are reported to have strengthened awareness of lifestyle interventions to staff, foster carers and Looked after Children. Referrals are offered to services, but staff reported to the Designated Doctor that there is reluctance from young people to engage with services that are aimed at improvement in BMI. CWPT have performed data review and audit to assess current levels of obesity in the LAC population. The results will be presented in the coming year.

Recommendation 2019-2020: Partnership to address obesity in the LAC population across all services, young people and carers.

7.2.3 Voice of Children/Young People & Engagement

• All care leavers aged 16 and 17 have a high quality, meaningful care leaver’s health summary. Less than 50% have been delivered to children aged 16 and 17 leaving care in 2018/19, and there is a trajectory to address the shortfall by August 2019. A leaving care summary supports the life story work performed by social care. It equips the young person leaving care to complete relevant occupational health data in order to access further education or employment. It provides the looked after young person with an understanding of the implications of their health on future health and any future children. This will be discussed further at Corporate Parenting Board in April 2019 when the theme is transition.

7.2.4 Commissioning of Services

• Coventry profiling of health needs to inform Joint Strategic Needs Assessment (JSNA) and commissioning intentions. This cannot be fully achieved until Looked after Children population data is consistently reliable and all children receive their statuary health assessment.

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7.2.5 Significant Challenges

• During 2018-19, performance regarding provision of health assessments with statutory timescales has reduced. Work with partners and providers is in place to understand the contributing factors and improve performance by August 2019.

8. Forward Plan for 2019-2020

8.1 Quality Governance and Performance Including Health Assessments and Meeting Statutory Duties

• CRCCG Lead for Safeguarding to Chair Strategic and Commissioning HeLAC meetings 2019- 2020. • All partners, providers and relevant commissioners to attend HeLAC meetings as agreed, in order to provide a holistic system for the provision of health care for Looked after Children • All providers to provide assurance and evidence of robust QA processes for their respective services to their Commissioners • All Providers to provide data on performance against agreed priorities and timescales in order to share collaborative responsibility for the health outcomes of Looked after Children. Discussion with providers regarding implementation of the Pre-Lac Pathway prior to health assessments, in addition to the current input from the LAC CAMHS service. • Looked after Children health assessment pathways to be reviewed by all providers to ensure all are meeting responsibilities in line with statutory guidance and to collaboratively identify and address blockages that may prevent efficient and effective working together. • Recommendations of the EHCP and Looked after Children health care plans should be mutually consistent and informative. The EHCP and health care plan should be discussed at LAC review meetings led by social care and embedded in care planning performed by social care. Providers of LAC health assessments should consider how to co-ordinate assessments and reviews of the child’s care plan and EHC plan to ensure that taken together, they meet the child’s needs without duplicating information unnecessarily. Education partners should be encouraged to work with LAC health to co-ordinate EHCP assessments and reviews with LAC health reviews as far as possible. • Agree accurate mechanisms for recording and uploading electronic data.

8.2 Physical, Emotional and Mental Health Wellbeing

• Looked after Children population reviews and audits completed by Providers to be invited for presentation at HeLAC and Corporate Parenting Board. As Public Health commission services that promote healthy weight, CWPT will be encouraged to discuss their findings with Public Health in order to inform ongoing strategy to decrease childhood obesity in the Coventry Looked after Children population • To agree plan for repeat audit of obesity in the LAC population. • To increase attendance at dental checks to achieve >95% • To increase achievement of ‘up to date’ immunisation status for each looked after child.

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• In light of concerns regarding increased risk of Looked after Children for CSE, county lines and association with substance misuse, Annual CSE report to be presented to HeLAC and strategy shared.

8.3 Voice of Children/Young People and Engagement

• CRCCG seeking assurance that all care leavers aged 16 and 17 to have a meaningful care leavers health summary • Development and implementation of ‘Grab Guides’ to support transition of young people to adult health services and promote self-management and self-care related to dentist, optician, and GP registration and accessing immunisation • Facilitate and collate specific service user feedback regarding the health provision for Looked after Children in addition to Friends and Family Test. • Expand awareness of the role of NSPs across the foster carer network and young people who are looked after. • For Unaccompanied Asylum Seeking Children in Coventry to have access to health pathways to meet their needs- trauma, blood borne virus screening and TB screening.

8.4 Commissioning of Services

• Coventry profiling of health needs to inform Joint Strategic Needs Assessment (JSNA) and commissioning intentions • Ongoing monitoring of the performance of Looked after Children health services against agreed targets in context of local and national trends in the population of LAC. • Work in partnership with Public health to ensure delivery and partnership working between Public Health and CCG commissioned services including provision of school nursing, health visiting, life style services, immunisation services and health screening for asylum seekers.

9. Equality and Diversity Considerations and Implications

9.1 All Looked after Children are treated according to their safeguarding and health needs. Their background cultural and diversity needs are considered as part of their assessments.

10. Risk Implications

10.1 Lack of improved delivery of Looked after Children health assessments will impair health outcomes for Looked after Children

10.2 Lack of improved provision of leaving care health summaries will lead to reduced health and wellbeing outcomes for care leavers

10.3 Lack of robust systems for accurate data collection will result in inaccurate data provided for national performance monitoring by DoE and CQC.

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10.4 If there is inadequate robust data regarding the health needs of Looked after Children, the JSNA and appropriate commissioning decision making is impaired.

11. Recommendations

11.1 The Governing Body of CRCCG is requested to: -

1. Note the evidence of the strong partnership working between CRCCG, CWPT, Public Health, HeLAC and the Corporate Parenting Board. 2. Note collaborative remedial actions are in place across the partnership to improve the performance for indicators which are off target. 3. To endorse the recommendations for addressing performance issues, consolidating progress and improving outcomes for Looked after Children in 2018-19. 4. To recognise the challenges of the operationalisation of the model by CWPT and the impact of commissioning changes within partner organisation which have provided challenge in the delivery of health services to Looked after Children 5. To approve the Forward Plan for 2019 -20.

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc L

Report To: Governing Body Meetings in Common

Report Title: Annual Audit Letters

Report From: Clare Hollingworth, Chief Finance Officer

Date: 17 July 2019

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision: Assurance:  Information:  Confidential

Purpose of the Report: The external auditors (Ernst & Young) are required to issue an annual audit letter following completion of audit procedures for the year ended 31 March 2019.

Key Points: The audit has resulted in no changes to the financial position previously presented for month 12.

CRCCG Financial statement: Unqualified – the financial statements give a true and fair view of the financial position of the CCG as at 31 March 2019 and of its expenditure and income for the year then ended

Value For Money (VFM) – unqualified.

WNCCG Financial statement: Unqualified – the financial statements give a true and fair view of the financial position of the CCG as at 31 March 2019 and of its expenditure and income for the year then ended. EY’s audit report includes an Emphasis of Matter paragraph in relation to a dispute in relation to CHC recharges of £3.1 million made by South Warwickshire CCG to Warwickshire North CCG. EY’s opinion is not modified in respect of this matter. The CCG has included a disclosure in Note 14 of the financial statements in relation to this item.

VFM – unqualified.

Recommendation: Members are requested to receive the Annual Audit Letters for ASSURANCE and INFORMATION

Implications

Objective(s) / Plans supported by this N/A report: Conflicts of Interest: N/A Financial: Non-Recurrent Expenditure: N/A

Page 1 of 2

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc L

Recurrent Expenditure: N/A Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: N/A Quality and Safety: N/A General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public N/A Engagement: Clinical Engagement: N/A Risk and Assurance: N/A

Page 2 of 2

NHS Coventry and Rugby Clinical Commissioning Group Annual Audit Letter for the year ended 31 March 2019

June 2019

Ref: EY-000092651-01 Contents

Page Section 1 Executive Summary 2 Section 2 Purpose 5 Section 3 Responsibilities 7 Section 4 Financial Statement Audit 9 Section 5 Value for Money 12 Section 6 Other Reporting Issues 15

The contents of this report are subject to the terms and conditions of our appointment as set out in our engagement letter dated 16 December 2016. This report is made solely to the Governing Body, Audit Committee and management of NHS Coventry and Rugby Clinical Commissioning Group (CCG) in accordance with our engagement letter. Our work has been undertaken so that we might state to the Governing Body, Audit Committee and management of the CCG those matters we are required to state to them in this report and for no other purpose. To the fullest extent permitted by law we do not accept or assume responsibility to anyone other than the Governing Body, Audit Committee and management of the CCG for this report or for the opinions we have formed. Our Complaints Procedure – If at any time you would like to discuss with us how our service to you could be improved, or if you are dissatisfied with the service you are receiving, you may take the issue up with your usual partner or director contact. If you prefer an alternative route, please contact Steve Varley, our Managing Partner, 1 More London Place, London SE1 2AF. We undertake to look into any complaint carefully and promptly and to do all we can to explain the position to you. Should you remain dissatisfied with any aspect of our service, you may of course take matters up with our professional institute. We can provide further information on how you may contact our professional institute.

Ref: EY-000092651-01 1 Section 1 Executive Summary

Ref: EY-000092651-01 Executive Summary

We are required to issue an annual audit letter to NHS Coventry and Rugby Clinical Commissioning Group (the CCG) following completion of our audit procedures for the year ended 31 March 2019. The tables below set out the results and conclusions on the significant areas of the audit process

Area of Work Conclusion Opinion on the CCG’s:

► Financial statements Unqualified – the financial statements give a true and fair view of the financial position of the CCG as at 31 March 2019 and of its expenditure and income for the year then ended.

► Regularity of income and expenditure Unqualified – financial transactions were conducted within the CCG legal framework.

► Parts of the remuneration and staff report to be audited We had no matters to report.

► Consistency of the Annual Report and other Financial information in the Annual Report and published with the financial statements was consistent with the Annual Accounts. information published with the financial statements

Area of Work Conclusion Reports by exception:

► Consistency of Governance Statement The Governance Statement was consistent with our understanding of the CCG.

► Referrals to the Secretary of State and NHS England We had no matters to report.

► Public interest report We had no matters to report in the public interest.

► Value for money conclusion We had no matters to report.

Ref: EY-000092651-01 3 Executive Summary (cont’d)

Area of Work Conclusion Reporting to the CCG on its consolidation schedules We concluded that the CCG’s consolidation schedules agreed, within a £300,000 tolerance, to your audited financial statements. Reporting to the National Audit Office (NAO) in line We had no matters to report. with group instructions

As a result of the above we have also:

Area of Work Conclusion Issued a report to those charged with governance of the Our Audit results report was issued on 16 May 2019, an updated final version was issued on 29 May 2019. CCG communicating significant findings resulting from our audit. Issued a certificate that we have completed the audit in Our certificate was issued on 29 May 2019. accordance with the requirements of the Local Audit and Accountability Act 2014 and the National Audit Office’s 2015 Code of Audit Practice.

We would like to take this opportunity to thank the CCG staff for their assistance during the course of our work.

Maria Grindley

Associate Partner For and on behalf of Ernst & Young LLP

Ref: EY-000092651-01 4 Section 2 Purpose

Ref: EY-000092651-01 Purpose

The Purpose of this Letter The purpose of this annual audit letter is to communicate to Members of the Governing Body and external stakeholders, including members of the public, the key issues arising from our work, which we consider should be brought to the attention of the Clinical Commissioning Group (CCG). We have already reported the detailed findings from our audit work in our 2018/19 audit results report to the 21 May 2019 Audit Committee, representing those charged with governance. We do not repeat those detailed findings in this letter. The matters reported here are the most significant for the CCG.

Ref: EY-000092651-01 6 Section 3 Responsibilities

Ref: EY-000092651-01 Responsibilities

Responsibilities of the Appointed Auditor Our 2018/19 audit work has been undertaken in accordance with the Audit Plan that we issued on 23 January 2019 and is conducted in accordance with the National Audit Office's 2015 Code of Audit Practice, International Standards on Auditing (UK), and other guidance issued by the National Audit Office. As auditors we are responsible for: Expressing an opinion: ► On the 2018/19 financial statements; ► On the regularity of expenditure and income; ► On the parts of the remuneration and staff report to be audited; ► On the consistency of other information published with the financial statements, including the annual report; and ► On whether the consolidation schedules are consistent with the CCG's financial statements for the relevant reporting period. Reporting by exception: ► If the governance statement does not comply with relevant guidance or is not consistent with our understanding of the CCG; ► To the Secretary of State for Health and NHS England if we have concerns about the legality of transactions of decisions taken by the CCG; ► Forming a conclusion on the arrangements the CCG has in place to secure economy, efficiency and effectiveness in its use of resources; and ► Any significant matters that are in the public interest. Reporting on an exception basis any significant issues or outstanding matters arising from our work which are relevant to the NAO as group auditor.

Responsibilities of the CCG The CCG is responsible for preparing and publishing its financial statements, annual report and governance statement. The CCG is responsible for putting in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources.

Ref: EY-000092651-01 8 Section 4 Financial Statement Audit

Ref: EY-000092651-01 Financial Statement Audit

Key Issues The Annual Report and Accounts is an important tool for the CCG to show how it has used public money and how it can demonstrate its financial management and financial health. We audited the CCG’s financial statements in line with the National Audit Office’s 2015 Code of Audit Practice, International Standards on Auditing (UK), and other guidance issued by the National Audit Office and issued an unqualified audit report on 29 May 2019. Our detailed findings were reported to the 21 May 2019 Audit Committee and 22 May 2019 Governing Body meeting. The key issues identified as part of our audit were as follows:

Significant Risk Conclusion Risk of fraud or error • We tested the appropriateness of journal entries recorded in the general ledger and other adjustments made in the preparation of The financial statements as a whole are not free of material the financial statements; misstatements whether caused by fraud or error. • We reviewed accounting estimates for evidence of management bias; • We evaluated the business rationale for significant unusual transactions; As identified in ISA (UK) 240, management is in a unique position to • We enquired of management about risks of fraud and the controls put in place to address those risks; perpetrate fraud because of its ability to manipulate accounting records • We understood the oversight given by those charged with governance of managements processes over fraud; and directly or indirectly and prepare fraudulent financial statements by • We considered the effectiveness of managements controls designed to address the risk of fraud. overriding controls that otherwise appear to be operating effectively. We identify and respond to this fraud risk on every audit engagement. Our testing did not: • Identify any material weaknesses in controls or evidence of material management override and we have not identified any instances We consider that there is a risk that year-end accruals (covering NHS of inappropriate judgements being applied; or & Non NHS) are understated at the year end, thus moving expenditure • identify any other transactions during our audit which appeared unusual or outside the CCG‘s normal course of business. to 2019/20. The work completed in relation to accruals is set out below. Revenue and expenditure recognition - understatement of year In responding to the presumed significant risk of fraud in expenditure recognition we have performed the following procedures: end accruals • Reviewed and discussed with management any accounting estimates on expenditure recognition for evidence of bias; Auditing standards also require us to presume that there is a risk that • Documented our understanding of the processes and controls in place to mitigate the risks identified, and walked through those revenue and expenditure may be misstated due to improper processes and controls to confirm our understanding; recognition or manipulation. • Sample tested accruals based on established testing thresholds; • Reviewed DH agreement of balances data , sample tested Intra NHS transactions/balances and investigated significant differences Due to the nature and value of Income from sale of goods and services (outside of DH tolerances); (£3m) we do not believe that the risk is significant in this area, but that • Reviewed the reconciliation between the trade payables subledger to the general ledger control account; the risk is relevant to expenditure. In respect of expenditure we • Reviewed and tested cut-off at the period end date; and consider the risk is most focussed around those items of expenditure • Performed a search for unrecorded trade payables at period-end. that are non-routine and involve more management estimation and Our testing: judgement such as year-end accruals • We consider that the risk for year-end accruals (covering NHS & Non Did not identify any material misstatements with respect to revenue and expenditure recognition. • NHS) is that they are understated at the year end, thus moving Did not identify any material issues or unusual transactions which indicated that there had been any misreporting of the CCG’s expenditure to 2019/20. financial position.

Ref: EY-000092651-01 10 Financial Statement Audit (cont’d)

Other Key Findings Conclusion Implementation of new accounting standards - International • The disclosure within the accounts for financial assets were updated in line with the disclosure requirements for IFRS 9. Financial Reporting Standard (“IFRS”) 9 – Financial Instruments and IFRS 15 – Revenue from Contracts with Customers, • The disclosure within the accounts for impact of IFRS 15 was updated to include figures. • We concluded IFRS 15 does not have a material impact to the CCG for other income streams.

Our application of materiality When establishing our overall audit strategy, we determined a magnitude of uncorrected misstatements that we judged would be material for the financial statements as a whole.

Item Thresholds applied Planning materiality We determined planning materiality to be £6.997 m (2017/18: £6 m), which is 1% of gross operating expenditure reported in the accounts of £699 m. We consider gross operating expenditure to be one of the principal considerations for stakeholders in assessing the financial performance of the CCG. Reporting threshold We agreed with the Audit Committee that we would report to the Committee all audit differences in excess of £0.3 m (2017/18: £0.3 m)

Ref: EY-000092651-01 [Insert Client Name] 11 Section 5 Value for Money

Ref: EY-000092651-01 Value for Money

We are required to consider whether the CCG has put in place ‘proper arrangements’ to secure economy, efficiency and effectiveness on its use of resources. This is known as our value for money conclusion. Informed decision Proper arrangements are defined by statutory guidance issued by the National Audit Office. They comprise your making arrangements to: ► Take informed decisions; ► Deploy resources in a sustainable manner; and ► Work with partners and other third parties. Proper We identified two significant risks in relation to these arrangements. The table below presents the findings of our arrangements for work in response to the risks identified. securing value We therefore had no matters to report about your arrangements to secure economy, efficiency and effectiveness in for money your use of resources. Sustainable Working with resource partners and deployment third parties

Significant Risk Conclusion Financial Position & Sustainability Our approach focussed on: Discussions with management and review of reporting to Governing Body at planning stage of our audit identified that the CCG was ► Reviewing the reporting to the performance committee of QIPP achievement in 2018/19 and the impact on 2019/20 expectations; expecting its financial position to deteriorate during the remainder of ► Reviewing the financial plans submitted to NHSE for 2019/20 at a level that will identify any issues that would trigger a risk to our the financial year, with expenditure in all areas exceeding forecast vfm conclusion; (Acute, CHC, Prescribing). Additionally achievement of QIPP Savings was, at the planning stage of the audit, forecast to be well below target ► Discussing with management and those charged with governance the process followed in formulating the budget; for the remainder of the year. ► Reviewing the reporting to the Governing body with respect to the forecast 2018/19 financial position; and ► Speaking to NHS England to obtain an update of their assurance assessment.

The CCG has met its performance targets, whilst the savings requirements were challenging, 95% of the £20.6m savings requirements for 2018-19 were met, for 2019-20 £21.8m savings is required, of which 69%, £15m has been achieved. It is important that the CCG ensures future QIPP plans are delivered in full to strengthen the underlying financial position of the CCG and not place reliance on non- recurrent measures. We concluded in respect of sustainable resource deployment, the arrangements have been adequate during the 2018/19 year.

Ref: EY-000092651-01 13 Value for Money (continued)

Significant Risk Conclusion Working with partners and other third parties Our approach focussed on: This risk relates to the CCG working with third parties effectively to deliver strategic priorities. Specifically: ► Reviewing the CCGs procedures for monitoring of provider performance and how the CCG uses its influence to effect performance improvement, through discussion with management, review of documentation and minutes;

► key providers are consistently not meeting national and local performance targets; ► Obtaining an update on the position with regard to the dispute with UHCW; ► The CCG has an outstanding dispute with its main provider in respect of the 2018/19 year-end position; ► Reviewing the CCGs position in respect of putting in place a SLA with the CSU. ► the CCG does not have in place a Service Level Agreement with its CSU for 2018/19 We have reviewed the arrangements for monitoring and reporting provider performance, we have also obtained a signed SLA, the CCG has put in place with the CSU. The CCG has escalated the dispute with UHCW and is currently awaiting the result of expert determination before the dispute can be concluded.

We have concluded that no qualification is required on the ‘working with partners’ criterion.

Ref: EY-000092651-01 14 Section 6 Other Reporting Issues

Ref: EY-000092651-01 Other Reporting Issues

Department of Health and Social Care /NHS England Group Instructions We are only required to report to the NAO on an exception basis if there were significant issues or outstanding matters arising from our work. There were no such issues. Governance Statement We are required to consider the completeness of disclosures in the CCGs governance statement, identify any inconsistencies with the other information of which we are aware from our work, and consider whether it complies with relevant guidance. We completed this work and did not identify any areas of concern. Breach of revenue resource limit and referral to Secretary of State We must report to the Secretary of State any matter where we believe a decision has led to, or would lead to, unlawful expenditure, or some action has been, or would be, unlawful and likely to cause a loss or deficiency. We had no exceptions to report. Report in the Public Interest We have a duty under the Local Audit and Accountability Act 2014 to consider whether, in the public interest, to report on any matter that comes to our attention in the course of the audit in order for it to be considered by the CCG or brought to the attention of the public. We did not identify any issues which required us to issue a report in the public interest. Control Themes and Observations As part of our work, we obtained an understanding of internal control sufficient to plan our audit and determine the nature, timing and extent of testing performed. Although our audit was not designed to express an opinion on the effectiveness of internal control, we are required to communicate to you significant deficiencies in internal control identified during our audit. We have adopted a fully substantive approach and have therefore not tested the operation of controls.

Ref: EY-000092651-01 16 EY | Assurance | Tax | Transactions | Advisory

Ernst & Young LLP

© Ernst & Young LLP. Published in the UK. All Rights Reserved.

The UK firm Ernst & Young LLP is a limited liability partnership registered in England and Wales with registered number OC300001 and is a member firm of Ernst & Young Global Limited.

Ernst & Young LLP, 1 More London Place, London, SE1 2AF. ey.com

Ref: EY-000092651-01 NHS Warwickshire North Clinical Commissioning Group Annual Audit Letter for the year ended 31 March 2019

June 2019

Ref: EY-000092651-01 Contents

Page Section 1 Executive Summary 2 Section 2 Purpose 5 Section 3 Responsibilities 7 Section 4 Financial Statement Audit 9 Section 5 Value for Money 13 Section 6 Other Reporting Issues 16

The contents of this report are subject to the terms and conditions of our appointment as set out in our engagement letter dated 16 December 2016. This report is made solely to the Governing Body, Audit Committee and management of NHS Warwickshire North Clinical Commissioning Group (CCG) in accordance with our engagement letter. Our work has been undertaken so that we might state to the Governing Body, Audit Committee and management of the CCG those matters we are required to state to them in this report and for no other purpose. To the fullest extent permitted by law we do not accept or assume responsibility to anyone other than the Governing Body, Audit Committee and management of the CCG for this report or for the opinions we have formed. Our Complaints Procedure – If at any time you would like to discuss with us how our service to you could be improved, or if you are dissatisfied with the service you are receiving, you may take the issue up with your usual partner or director contact. If you prefer an alternative route, please contact Steve Varley, our Managing Partner, 1 More London Place, London SE1 2AF. We undertake to look into any complaint carefully and promptly and to do all we can to explain the position to you. Should you remain dissatisfied with any aspect of our service, you may of course take matters up with our professional institute. We can provide further information on how you may contact our professional institute.

Ref: EY-000092651-01 1 Section 1 Executive Summary

Ref: EY-000092651-01 Executive Summary

We are required to issue an annual audit letter to NHS Warwickshire North Clinical Commissioning Group (the CCG) following completion of our audit procedures for the year ended 31 March 2019. The tables below set out the results and conclusions on the significant areas of the audit process

Area of Work Conclusion Opinion on the CCG’s:

► Financial statements Unqualified – the financial statements give a true and fair view of the financial position of the CCG as at 31 March 2019 and of its expenditure and income for the year then ended. Our audit report includes an Emphasis of Matter paragraph in relation to a dispute in relation to CHC recharges of £3.1 million made by South Warwickshire CCG to Warwickshire North CCG. Our opinion is not modified in respect of this matter. The CCG has included a disclosure in Note 14 of the financial statements in relation to this item.

► Regularity of income and expenditure Unqualified – financial transactions were conducted within the CCG legal framework.

► Parts of the remuneration and staff report to be audited We had no matters to report.

► Consistency of the Annual Report and other Financial information in the Annual report and published with the financial statements was consistent with the Annual Accounts. information published with the financial statements

Area of Work Conclusion Reports by exception:

► Consistency of Governance Statement The Governance Statement was consistent with our understanding of the CCG.

► Referrals to the Secretary of State and NHS England We had no matters to report.

► Public interest report We had no matters to report in the public interest.

► Value for money conclusion We had no matters to report.

Ref: EY-000092651-01 3 Executive Summary (cont’d)

Area of Work Conclusion Reporting to the CCG on its consolidation schedules We concluded that the CCG’s consolidation schedules agreed, within a £300,000 tolerance, to the audited financial statements.

Reporting to the National Audit Office (NAO) in line We had no matters to report. with group instructions

As a result of the above we have also:

Area of Work Conclusion Issued a report to those charged with governance of the Our Audit results report was issued on 16 May 2019, an updated final version was issued on 29 May 2019. CCG communicating significant findings resulting from our audit. Issued a certificate that we have completed the audit in Our certificate was issued on 29 May 2019. accordance with the requirements of the Local Audit and Accountability Act 2014 and the National Audit Office’s 2015 Code of Audit Practice.

We would like to take this opportunity to thank the CCG staff for their assistance during the course of our work.

Maria Grindley

Associate Partner For and on behalf of Ernst & Young LLP

Ref: EY-000092651-01 4 Section 2 Purpose

Ref: EY-000092651-01 Purpose

The Purpose of this Letter The purpose of this annual audit letter is to communicate to Members of the Governing Body and external stakeholders, including members of the public, the key issues arising from our work, which we consider should be brought to the attention of the Clinical Commissioning Group (CCG). We have already reported the detailed findings from our audit work in our 2018/19 audit results report to the 21 May 2019 Audit Committee, representing those charged with governance. We do not repeat those detailed findings in this letter. The matters reported here are the most significant for the CCG.

Ref: EY-000092651-01 6 Section 3 Responsibilities

Ref: EY-000092651-01 Responsibilities

Responsibilities of the Appointed Auditor Our 2018/19 audit work has been undertaken in accordance with the Audit Plan that we issued on 23 January 2019 and is conducted in accordance with the National Audit Office's 2015 Code of Audit Practice, International Standards on Auditing (UK), and other guidance issued by the National Audit Office. As auditors we are responsible for: Expressing an opinion: ► On the 2018/19 financial statements; ► On the regularity of expenditure and income; ► On the parts of the remuneration and staff report to be audited; ► On the consistency of other information published with the financial statements, including the annual report; and ► On whether the consolidation schedules are consistent with the CCG's financial statements for the relevant reporting period. Reporting by exception: ► If the governance statement does not comply with relevant guidance or is not consistent with our understanding of the CCG; ► To the Secretary of State for Health and NHS England if we have concerns about the legality of transactions of decisions taken by the CCG; ► Forming a conclusion on the arrangements the CCG has in place to secure economy, efficiency and effectiveness in its use of resources; and ► Any significant matters that are in the public interest. Reporting on an exception basis any significant issues or outstanding matters arising from our work which are relevant to the NAO as group auditor.

Responsibilities of the CCG The CCG is responsible for preparing and publishing its financial statements, annual report and governance statement. The CCG is responsible for putting in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources.

Ref: EY-000092651-01 8 Section 4 Financial Statement Audit

Ref: EY-000092651-01 Financial Statement Audit

Key Issues The Annual Report and Accounts is an important tool for the CCG to show how it has used public money and how it can demonstrate its financial management and financial health. We audited the CCG’s financial statements in line with the National Audit Office’s 2015 Code of Audit Practice, International Standards on Auditing (UK), and other guidance issued by the National Audit Office and issued an unqualified audit report on 29 May 2019. Our detailed findings were reported to the 21 May 2019 Audit Committee and 22 May 2019 Governing Body meeting. The key issues identified as part of our audit were as follows:

Significant Risk Conclusion Management override of controls • We tested the appropriateness of journal entries recorded in the general ledger and other adjustments made in the preparation The financial statements as a whole are not free of material of the financial statements; misstatements whether caused by fraud or error. • We reviewed accounting estimates for evidence of management bias; • We evaluated the business rationale for significant unusual transactions; As identified in ISA (UK) 240, management is in a unique position to • We enquired of management about risks of fraud and the controls put in place to address those risks; perpetrate fraud because of its ability to manipulate accounting records • We understood the oversight given by those charged with governance of managements processes over fraud; and directly or indirectly and prepare fraudulent financial statements by • We considered the effectiveness of managements controls designed to address the risk of fraud. overriding controls that otherwise appear to be operating effectively. We identify and respond to this fraud risk on every audit engagement. Our testing has not: • identified any material weaknesses in controls or evidence of material management override and we have not identified any We consider that there is a risk that year-end accruals (covering NHS instances of inappropriate judgements being applied; or & Non NHS) are understated at the year end, thus moving expenditure • identified any other transactions during our audit which appeared unusual or outside the CCG‘s normal course of business. to 2019/20. The work completed in relation to accruals is set out below. Revenue and expenditure recognition - understatement of year In responding to the presumed significant risk of fraud in expenditure recognition we have performed the following procedures: end accruals* • Reviewed and discussed with management any accounting estimates on expenditure recognition for evidence of bias; Auditing standards also require us to presume that there is a risk that • Documented our understanding of the processes and controls in place to mitigate the risks identified, and walked through those revenue and expenditure may be misstated due to improper processes and controls to confirm our understanding; recognition or manipulation. • Sample tested accruals based on established testing thresholds; • Reviewed DH agreement of balances data , sample tested Intra NHS transactions/balances and investigated significant Due to the nature and value of Income from sale of goods and services differences (outside of DH tolerances); (£1m) we do not believe that the risk is significant in this area, but that • Reviewed the reconciliation between the trade payables subledger to the general ledger control account; the risk is relevant to expenditure. In respect of expenditure we • Reviewed and tested cut-off at the period end date; and consider the risk is most focussed around those items of expenditure • Performed a search for unrecorded trade payables at period-end. that are non-routine and involve more management estimation and Our testing: judgement such as year-end accruals • has not identified any material misstatements with respect to revenue and expenditure recognition. We consider that the risk for year-end accruals (covering NHS & Non • has not identified any material issues or unusual transactions which indicated that there had been any misreporting of the CCG’s NHS) is that they are understated at the year end, thus moving financial position. expenditure to 2019/20.

Ref: EY-000092651-01 10 Financial Statement Audit (cont’d)

Significant risk Conclusion From 2018/19 the CCG took over responsibility for commissioning Our approach to each area of primary care commissioning expenditure has been fully substantive. primary care services. The value of expenditure is highly material and the CCG is highly dependent on a third party for calculating payments We have selected key items (by size) together with a representative sample of other transactions to sample test each element of the due. primary care commissioning expenditure as follows:

Our experience of other CCGs suggests that a light touch is often GMS Global Sum taken to the review of expenditure and challenge of suppliers. • Confirmed that there is a valid GMS Contract between the CCG/NHSE and the practice, signed by both parties. Additionally, the CCG can often have limited information to support the • Obtained the calculation of the Global Sum amount being tested from NHS England/Capita. expenditure transactions being recorded. • Validated the Unweighted Patient Numbers figure on which the calculation is based back to third party data. This was achieved by asking for direct confirmation of the patient numbers from the individual GP Practices.

We consider that the risk is most relevant to in year expenditure being PMS Global Sum either incomplete, does not relate to the CCG or is inappropriately • Confirmed that there is a valid PMS Contract between the CCG/NHSE and the practice, signed by both parties. valued. • Obtained the calculation of the Global Sum amount being tested and agree this back to source e.g., signed contract.

QOF Aspiration & Achievement • As in year payments relating to Aspiration are based on prior year achievement (70% of prior year) we obtained details of prior year payments and ensured that 2018/19 Aspiration is in line with that paid in 2017/18. • Achievement is the remaining 30% (usually accrued as not paid until post year-end). We obtained a CQRS system report providing confirmation of achievement of the required quality standards.

Enhanced Services • Ensured that the practice has signed up for the services being provided by examining the contract in place. • Obtained the calculation supporting the payment made and agree the number of transactions back to supporting evidence (e.g., returns from practices).

Other transactions • Agreed back (on a sample basis) to supporting evidence in the form of invoices/rates demands etc.

Our testing: • Did not identify any material misstatements with respect to Primary Care Commissioning expenditure.

Ref: EY-000092651-01 11 Financial Statement Audit (cont’d)

Other Key Findings Conclusion Implementation of new accounting standards - International • The disclosure within the accounts for financial assets were updated in line with the disclosure requirements for IFRS 9. Financial Reporting Standard (“IFRS”) 9 – Financial Instruments and IFRS 15 – Revenue from Contracts with Customers, • The disclosure within the accounts for impact of IFRS 15 was updated to include figures. • We concluded IFRS 15 does not have a material impact to the CCG for other income streams.

Our application of materiality When establishing our overall audit strategy, we determined a magnitude of uncorrected misstatements that we judged would be material for the financial statements as a whole.

Item Thresholds applied Planning materiality We determined planning materiality to be £2.7 m (2017/18: £2.4 m), which is 1% of gross operating expenditure reported in the accounts of £273 m. We consider gross operating expenditure to be one of the principal considerations for stakeholders in assessing the financial performance of the CCG. Reporting threshold We agreed with the Audit Committee that we would report to the Committee all audit differences in excess of £0.137 m (2017/18: £0.122 m)

Ref: EY-000092651-01 12 Section 5 Value for Money

Ref: EY-000092651-01 Value for Money

We are required to consider whether the CCG has put in place ‘proper arrangements’ to secure economy, efficiency and effectiveness on its use of resources. This is known as our value for money conclusion. Informed decision Proper arrangements are defined by statutory guidance issued by the National Audit Office. They comprise your making arrangements to: ► Take informed decisions; ► Deploy resources in a sustainable manner; and ► Work with partners and other third parties. Proper We identified two significant risks in relation to these arrangements. The table below presents the findings of our arrangements for work in response to the risks identified. securing value We therefore had no matters to report about your arrangements to secure economy, efficiency and effectiveness in for money your use of resources. Sustainable Working with resource partners and deployment third parties

Significant Risk Conclusion Financial Position & Sustainability Our approach focussed on: The CCG has In conjunction with NHS England set a £1m deficit budget for 2018-2019. ► Reviewing the reporting to the performance committee of QIPP achievement in 2018/19 and the impact on 2019/20 expectations; Review of reporting to Governing Body identified that whilst the CCG ► Reviewing the financial plans submitted to NHSE for 2019/20; was forecasting (at Month 6) that it will achieve the 1.0m deficit financial position agreed with NHSE at the end of the current ► Discussing with management and those charged with governance the process followed in formulating the budget; financial year, ► Reviewing the reporting to the Governing body with respect to the forecast 2018/19 financial position; ► expenditure in many key areas is running well above Plan; ► Actions taken during the year to improve the position; and

► QIPP is forecasting 79% achievement (£2.2m under achievement) ► Speaking to NHS England to obtain an update of their assurance assessment. before application of reserves. The CCG was able to meet its control total, and breakeven in the year as a result of Commissioner Sustainability Fund of £1m, the QiPP for 2019/20 is of a similar challenge to 2018/19, with 56% considered as already achieved. Whilst the cumulative deficit remains, the arrangements to deploy resources in line with NHSE expectations and to monitor performance is in place. We concluded that no qualification is required on the ‘financial position & sustainability’ criterion.

Ref: EY-000092651-01 14 Value for Money (continued)

Significant Risk Conclusion Working with partners and other third parties Our approach focussed on: This risk relates to the CCG working with third parties effectively to deliver strategic priorities. Specifically: ► Reviewing the CCGs procedures for monitoring provider performance and how the CCG uses its influence to effect performance ► key providers are consistently not meeting national and local improvement, through discussion with management and review of documentation and minutes. performance targets; ► Reviewing the CCGs position in respect of putting in place a SLA with the CSU.

► the CCG does not have in place a Service Level Agreement with its CSU for 2018/19 We have reviewed the arrangements for monitoring and reporting provider performance, we have also obtained a signed SLA, the CCG has put in place with the CSU. We concluded that no qualification is required on the ‘working with partners’ criterion.

Ref: EY-000092651-01 15 Section 6 Other Reporting Issues

Ref: EY-000092651-01 Other Reporting Issues

Department of Health and Social Care /NHS England Group Instructions We are only required to report to the NAO on an exception basis if there were significant issues or outstanding matters arising from our work. There were no such issues. Governance Statement We are required to consider the completeness of disclosures in the CCGs governance statement, identify any inconsistencies with the other information of which we are aware from our work, and consider whether it complies with relevant guidance. We completed this work and did not identify any areas of concern. Breach of revenue resource limit and referral to Secretary of State We must report to the Secretary of State any matter where we believe a decision has led to, or would lead to, unlawful expenditure, or some action has been, or would be, unlawful and likely to cause a loss or deficiency. We had no exceptions to report. Report in the Public Interest We have a duty under the Local Audit and Accountability Act 2014 to consider whether, in the public interest, to report on any matter that comes to our attention in the course of the audit in order for it to be considered by the CCG or brought to the attention of the public. We did not identify any issues which required us to issue a report in the public interest.

Control Themes and Observations As part of our work, we obtained an understanding of internal control sufficient to plan our audit and determine the nature, timing and extent of testing performed. Although our audit was not designed to express an opinion on the effectiveness of internal control, we are required to communicate to you significant deficiencies in internal control identified during our audit. We have adopted a fully substantive approach and have therefore not tested the operation of controls.

Ref: EY-000092651-01 17 EY | Assurance | Tax | Transactions | Advisory

Ernst & Young LLP

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The UK firm Ernst & Young LLP is a limited liability partnership registered in England and Wales with registered number OC300001 and is a member firm of Ernst & Young Global Limited.

Ernst & Young LLP, 1 More London Place, London, SE1 2AF. ey.com

Ref: EY-000092651-01 Blank Page NHS Coventry and Rugby Clinical Commissioning Group Enc M NHS Warwickshire North Clinical Commissioning Group

Report To: Governing Body Meetings in Common

Report Title: Future arrangements for Coventry Safeguarding Children Partnership; Warwickshire Safeguarding Children Partnership; and Child Death Review

Report From: Jo Galloway Chief Nursing Officer

Date: 17 July 2019

Previously Considered by: Clinical Quality Governance Committees in Common

Action Required (delete as appropriate)

Decision:  Assurance:  Information: Confidential

Purpose of the Report: To set out changes to statutory requirements regarding child safeguarding partners and child death review, as set out in Working Together 2018.

To endorse the arrangements for local safeguarding partnerships and child death review.

Key Points: Working Together 2018 provides statutory guidance covering the legislative requirements and expectations on individual services to safeguard and promote the welfare of children. It also sets out a clear framework for the three local “child safeguarding partners” (the local authority; a clinical commissioning group for an area within a local authority area; and the chief officer of police for an area within the local authority area) to make arrangements to work together to safeguard and promote the welfare of local children, including identifying and responding to their needs.

Once agreed, local safeguarding arrangements must be published and must include:

 Arrangements for the safeguarding partners to identify and respond to the needs of children in the area.  Arrangements for commissioning and publishing local learning reviews.  Arrangements for Independent Scrutiny of the effectiveness of the arrangements.

Working Together 2018 replaces the need for Safeguarding Children Boards to ensure that child death reviews are undertaken by a child death overview panel (CDOP) with the requirement for ‘child death review partners’ (consisting of local authorities and any clinical commissioning groups for the local area) to make arrangements to review child deaths.

Local arrangements for safeguarding children partnerships and for child death review must be published by 29 June 2019 and implemented by 29 September 2019.

The proposed safeguarding partnership arrangements for Coventry and Warwickshire have been presented and discussed at Clinical Quality Committees in Common. The committees in common recommended the draft arrangements to Governing Bodies for agreement.

Proposed arrangements for child death review have been developed in partnership with South Page 1 of 3 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group

Warwickshire Clinical Commissioning Group, Warwickshire North Clinical Commissioning Group, Coventry and Rugby Clinical Commissioning Group, Birmingham and Solihull Clinical Commissioning Group, Warwickshire County Council, Coventry City Council and Solihull Metropolitan Council. The proposed arrangements were presented to Clinical Quality Governance Committees in Common on 27 June 2019.

Due to the associated timescales for publication of the new arrangements for local safeguarding partnerships and child death review, delegated authority was given by Governing Bodies to the Accountable Officer and Chief Nursing Officer to agree the future arrangements for Coventry Safeguarding Children’s Partnership; Warwickshire Safeguarding Children’s Partnership; and Child Death Review.

The arrangements have now been agreed by the respective organisations and published in line with requirements. The arrangements are available on the CCG web sites and can be accessed via the following hyperlinks:

 Coventry Safeguarding Children’s Partnership

 Warwickshire Safeguarding Children’s Partnership

 Child Death Review

Recommendation: Members are asked to:

1. Endorse the arrangements for:

 Coventry Safeguarding Children’s Partnership;

 Warwickshire Safeguarding Children’s Partnership; and

 Coventry, Warwickshire and Solihull Statutory Child Death Review Arrangements

2. Note the further work that will be undertaken during the transition period in relation to child death review arrangements to develop operational processes and commission a Sudden Unexpected Deaths in Childhood (SUDIC) service across Coventry and Warwickshire.

Implications

Objective(s) / Plans Compliance with CCGs statutory safeguarding duties outlined in the Children and supported by this Social work act and Working Together 2018 report: Conflicts of Interest: None Non-Recurrent Expenditure: Not applicable CCG contributions to safeguarding partnership Recurrent Expenditure: arrangements and CDOP arrangements will Financial: continue. Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate)

Page 2 of 3 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group

Supports the CCGs responsibility to perform effectively within Safeguarding Performance: Partnership Activity Underpinning principles of the change are to ensure that children are safeguarded Quality and Safety: within a quality safeguarding system. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Will provide sufficient assurance that the CCG is undertaking its responsibilities to work in partnership with Police and Local authority as one of the 3 statutory Risk and Assurance: safeguarding partners and with the Local authority as one of the 2 partners for child death review arrangements.

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Blank Page NHS Coventry & Rugby Clinical Commissioning Group Enc N NHS Warwickshire North Clinical Commissioning Group

Report To: Governing Body Meetings in Common

Report Title: 2019/20 Financial Plan - Update

Report From: Clare Hollingworth, Chief Finance Officer

Date: 17th July 2019

Previously Considered by: Finance & Performance Committee – 4th July 2019 Requirement noted at May meeting of the Governing Bodies (Closed session)

Action Required

Decision:  Assurance: Information  Confidential

Purpose of the Report:

To seek approval for the acceptance of revised CCG financial control totals for 2019/20 as requested by the Regional team.

Key Points:

• The combined Commissioner and Provider plans submitted in April did not deliver the required NHS financial position. The new combined NHSE/I Regional Teams have been instructed that they must deliver to the control totals that they have been assigned. Dale Bywaters, Regional Director wrote to all Chief Executive and Accountable Officers on the 10th May asking for collective action to “secure financial improvement such that the Midlands region achieves financial balance against its aggregate control total”. • It is understood that forty organisations were asked to improve their plan; the amount of improvement varied based upon an assessment of the ability to deliver. NHSE also reviewed its direct commissioning budgets. • Collectively the three Coventry & Warwickshire CCGs were asked to deliver a £2.1m improvement compared to previously notified control totals, comprising £1.7m for CRCCG, £0.3m for SWCCG and £0.1m for WNCCG. • In order to achieve mandated national timelines, CCGs were asked to submit revised Plans by close of play on the 14th May 2019. • Revised Plans were submitted on behalf of CRCCG and WNCCG but with the caveat that these remained subject to Governing Body ratification. For CRCCG, assurance was also sought that any ‘excess’ surplus generated (ie. above the required 1.0% cumulative surplus) would be released back to the CCG in a future financial year. The Regional Director has confirmed that this has now been agreed at a national level and that written confirmation should be received shortly. • The NHSE/I request was discussed at the last meeting in common of the Finance & Performance Committees who to recommend acceptance of the of the new control totals on this basis that this demonstrated commitment to the new system based approach. • Agreeing to improved control totals clearly reduces the level of mitigation available to manage already high-risk Plans. The Finance & Performance Committees were informed that the risk profile of each CCG will be re-assessed at the end of July when it is anticipated that a final year end position with UHCW will have been agreed and the CHC/S117 budget review concluded.

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Recommendation:

Members of the CRCCG Governing Body are asked to: • APPROVE the acceptance of a £1.7m increase in the required 2019/20 control total, taking this from £0.4m surplus to £2.1m surplus. Members of the WNCCG Finance & Performance Committee are asked to: • APPROVE the acceptance of a £0.1m increase in the required 2019/20 control total, taking this from £0m (break-even) to a £0.1m surplus. Members of both Governing Bodies are asked to: • NOTE the resultant increased risk profile for each CCG and require the CFO to provide regular updates on both potential risks and mitigations.

Implications

Objective(s) / Plans supported by this Achievement of Financial Duties report: Conflicts of Interest: None identified. Non-Recurrent Acceptance of the revised control total may require each CCG to Expenditure: reduce discretionary non-recurrent spending. Acceptance of the revised control total reduces the level of Recurrent mitigations available to manage any cost pressures that emerge Expenditure: in year. Financial: Is this expenditure included within – as revised on the the CCG’s Yes th No N/A 14 May 2019 Financial Plan? (Delete as appropriate) The 19/20 Financial Plan seeks to be explicit as to the level of investment set aside to secure improvement against key national targets. It is not anticipated that the Performance: acceptance of the revised control totals will have any additional impact upon performance levels. The annual budgets and contracts determined by the CCG should be adequate to secure acceptable levels of quality and service in commissioned services. It is not Quality and Safety: anticipated that the acceptance of the revised control totals will have any additional impact upon quality levels. All cost reduction plans will be subject to a Quality Impact Assessment. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non- discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any Equality and Diversity: decision that is finalised without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact assessment been undertaken? Yes No N/A  (Delete as appropriate) Patient and Public No immediate requirements identified in addition to the CCGs’ ongoing engagement Engagement: activities. Clinical engagement across primary and secondary care will be essential to the Clinical Engagement: redesign of pathways and hence securing improved use of resources within the CCG allocations available.

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HIGH – potential risks currently exceed available mitigations; until this is addressed there is risk that both CCGs will fail to deliver the revised control total for 2019/20 Risk and Assurance: The risk profile for WNCCG is higher than that for CRCCG and there remains a risk that WNCCG will not achieve the statutory duty to remain within the notified revenue Resource Limit. The Finance & Performance Committee will monitor the risk position and escalate to the Governing Body as required. .

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NHS Coventry & Rugby Clinical Commissioning Group Enc O

Report To: Governing Body Meetings in Common

Report Title: Finance & QIPP Report – Month 2

Report From: Clare Hollingworth – Chief Finance Officer

Date: 17th July 2019

Previously Considered by: Finance and Performance Committee - 4th July 2019

Action Required(delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report:

To advise Members of the financial position of the CCG up to 31st May 2019 (Month 2 – 2019/20) and to advise of any other financial issues likely to impact in the current financial year.

Key Points:

• The Month 2 budget reflects the revised 19/20 control total surplus of £2.1m as required by NHS Improvement (NHSI) / NHS England (NHSE). • Negotiations in relation to lower value contracts where concluded have resulted in changes to individual budget lines. This has resulted in a £0.15m worsening of the reserves position. Budgets will continue to be re-assessed as sign-off with budget holders is concluded. • With a paucity of data at this stage in the year, it is reasonable to assume that expenditure will perform in line with the approved budgets; there are, however, a range of risks that will need to be managed during the course of the year. A full update on the net risk position is to be provided to the Finance & Performance Committee in July when it is anticipated a final 2018/19 position will have been agreed with University Hospitals Coventry and Warwickshire (UHCW). • With the above caveats, at month 2 the CCG is forecasting delivery of its revised 19/20 control total, a £2.1m surplus. This is then increased by the brought forward combined surplus of £6.0m to reach an anticipated cumulative surplus of £8.1m by year end. • The Acute position is reported as breakeven due to the lack of robust contract monitoring data. At the time of reporting only unvalidated month 1 monitoring data is available. As previously reported, an Aligned Incentives contract has been agreed with the main provider UHCW, with tariff based contracts in place with all other Providers. • The Mental Health & Learning Disability (LD) and Community positions are currently reported as breakeven. • Work continues with Continuing Healthcare (CHC) to ensure that budgets have been set at appropriate levels. At Month 2, expenditure is marginally below the current budget. Due to the volatility of data, the budget is forecast to breakeven until further analysis is undertaken. Likewise for Section 117 packages, where growth year to date appears to be higher than plan. • The Primary Care position is reported as breakeven due to the early stage in the year. Prescribing data will not be available until month 3. • Running Costs are expected to be contained within the agreed budget, which is lower than the target set by NHS England • As reported previously, £14.3m of the £21.0m Efficiency requirement was secured through budget setting and contract negotiations. Data is not yet available to report reliably against the remaining schemes: CHC/S117 packages, Medicines Optimisation and Running Costs. Reporting should be possible from Month 3 onwards • The joint work programme with UHCW is starting to take shape. The Trust has appointed a dedicated Programme Director who starts on the 1st July and will focus initially on accelerating the musculoskeletal (MSK) work programme. As agreed through Finance & Performance Committee, Page 1 of 2

NHS Coventry & Rugby Clinical Commissioning Group Enc O

once validated contract data is available, activity trends will begin to be tracked and key variances and remedial actions reported. • The recurrent underlying surplus is currently assessed at £1.5m.

Recommendation: Members are asked to receive the report for INFORMATION and: • NOTE that at this early stage in the year when there is a paucity of reliable data available, the CCG is forecasting delivery of its revised control total; and • NOTE that a number of risks will need pro-active management throughout the year to secure this forecast position.

Implications

Objective(s) / Plans Financial Plan Delivery, achievement of statutory financial duties, QIPP Programme supported by this Delivery report: Conflicts of Interest: Not applicable Non-Recurrent Expenditure: Sufficient data not yet available to assess actual Recurrent Expenditure: level of expenditure compared to Plan. Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Performance: Failure to deliver agreed Plan will impact negatively upon the CCG’s assurance rating Quality and Safety: Not directly applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical engagement imperative to the efficient deployment of NHS resources and Clinical Engagement: successful delivery of service redesign. HIGH – a number of risks will need pro-active management throughout the year if the Risk and Assurance: CCG is to deliver its agreed control total.

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Finance and QIPP Month 2

1 1.1 Headlines

At this early stage in the year, with limited information available, the CCG is reporting an overall balanced position for Month 2 in line with the agreed financial plan.

The key points to note are:

• The Month 2 budget reflects the revised 19/20 control total surplus of £2.1m as required by NHSI/E.

• Negotiations in relation to lower value contracts where concluded have resulted in changes to individual budget lines. This has resulted in a £0.15m worsening of the reserves position. Budgets will continue to be re-assessed as sign-off with budget holders is concluded.

• With a paucity of data at this stage in the year, it is reasonable to assume that expenditure will perform in line with the approved budgets; there are, however, a range of risks that will need to be managed during the course of the year. A full update on the net risk position is to be provided to the Finance & Performance Committee in July when it is anticipated a final 2018/19 position will have been agreed with UHCW.

• With the above caveats, at month 2 the CCG is forecasting delivery of its revised 19/20 control total, a £2.1m surplus. This is then increased by the brought forward combined surplus of £6.0m to reach an anticipated cumulative surplus of £8.1m by year end.

• The Acute position is reported as breakeven due to the lack of robust contract monitoring data. At the time of reporting only un-validated month 1 monitoring data is available. As previously reported, an Aligned Incentives contract has been agreed with the main provider UHCW, with tariff based contracts in place with all other Providers.

• The Mental Health & LD and Community positions are currently reported as breakeven.

• Work continues with Continuing Healthcare to ensure that budgets have been set at appropriate levels. At Month 2, expenditure is marginally below the current budget. Due to the volatility of data, the budget is forecast to breakeven until further analysis is undertaken. Likewise for Section 117 packages, where growth year to date appears to be higher than plan.

• The Primary Care position is reported as breakeven due to the early stage in the year. Prescribing data will not be available until month 3.

• Running Costs are expected to be contained within the agreed budget, which is lower than the target set by NHS England

2

Headlines

• As reported previously, £14.3m of the £21.0m Efficiency requirement was secured through budget setting and contract negotiations. Data is not yet available to report reliably against the remaining schemes: CHC/S117 packages, Medicines Optimisation and Running Costs. Reporting should be possible from Month 3 onwards

• The joint work programme with UHCW is starting to take shape. The Trust has appointed a dedicated Programme Director who starts on the 1st July and will focus initially on accelerating the MSK work programme. As agreed through Finance & Performance Committee, once validated contract data is available, activity trends will begin to be tracked and key variances and remedial actions reported.

• The recurrent underlying surplus is currently assessed at £1.5m.

Recommendations

• Note that at this early stage in the year when there is a paucity of reliable data available, the CCG is forecasting delivery of its revised control total.

• Note that a number of risks will need pro-active management throughout the year to secure this forecast position.

3

1.2 Financial Duties

In Month YTD Description of Financial Duties Target Variance Variance RAG Explanation RAG RAG The CCG has an agreed annual financial plan with NHS England with a cumulative control total of £6m Ensure revenue expenditure does not exceed the Statutory duty to breakeven Green Green surplus and an in year surplus position on £2.1m. The CCG is currently on plan to achieve these control agreed allocation totals. Maintain expenditure within the revenue resource limit Position greater than or equal to Green Green The overall CCG position remains in balance. and deliver against NHS England agreed control total Plan Cash Drawdown less than or Maintain expenditure within the allocated cash limit Green Green The CCG is within the monthly cash target, and had a remaining cash balance of £5k. equal to Plan Maintain capital expenditure within the delegated limit Expenditure less than or equal Green Green The CCG capital expenditure is within its capital allocation limits. from NHS England to Plan Expenditure less than or equal Ensure running costs are within the agreed allocation Green Green Running costs are within the agreed allocation. to Plan

The CCG has not utilised its contingency in Month 2. £3.7m is available to offset emerging risks during the Ensure a minimum of 0.5% contingency is held Greater than or equal to 0.5% Green Green financial year.

Ensure compliance with the better payment practice Greater than or equal to 95% by The CCG continues to comply with the Better Payment Practice Code (BPPC) for both NHS and Non-NHS Green Green code (BPPC) Number/Value validated invoices.

RAG Rating Not achieving financial duty and Red unlikely to without remedial action. Based upon current information Amber there is a risk that the financial duty will not be achieved. Green Achieving financial duty

4 1.3 Trends

Year to date (YTD) Forecast Outturn (FOT) Monthly Cash Drawdown Gross Net Gross Net Plan CCG expenditur Income expenditur expenditur Income expenditur Opening Ca sh CCG Cash Total Cash Ca sh Service Area e e e e Period Balance Drawdown Drawdown Available Net Spend Balance £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s In Year Allocation 118,890 729,425 April 155 89,600 89,600 89,755 89,735 20 May 20 43,300 43,300 43,320 43,315 5 Programme Costs 117,457 (273) 117,184 719,757 (1,001) 718,756 June 5 60,978 Running Costs 1,371 (18) 1,353 9,930 (109) 9,821 July 60,191 Reserves 0 0 0 (1,254) 0 (1,254) August 60,416 Grand Total 118,828 (291) 118,537 728,433 (1,110) 727,323 September 60,079 October 61,779 Surplus / (deficit) 353 2,102 November 59,738 December 60,762 Movement on underspend/(deficit) 2018/19 2019/20 January 60,152 Brought forward underspend/(deficit) 6,000 6,000 February 57,447 In-year change from plan/In-year deficit 0 2,102 March 51,671 Balance carried forward 6,000 8,102 Total CCG Cash Drawdown 132,900 Underspend/(Deficit) % 1.0% 1.2% NHSBA Cash Drawdown 9,698 Total Drawdown 142,598

Monthly Expenditure Run Rate Maximum Cash Drawdown (MCD) 726,113 697,040.48 20,240 20,240 80,000 % of MCD utilised 19.6% 70,000 % of months completed 16.7%

60,000

50,000 The MCD utilised in April was higher than the 1/12 monthly target as a result of UHCW payments and BCF quarterly payments made in advance. 19/20 plan 40,000 19/20 actual 30,000 18/19 actual

20,000

10,000

0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

5 1.4 Summary Financial Position

Original In Month Allocation and YEAR TO DATE FORECAST Underlying Position Budget Budget Adjustments Revised Allocation Budget Annual (Under) / Other NR Adjustments Adjustments Forecast (Under) / NR NR QIPP Recurrent Budget M2 Budget Actual Over Contingency Spend / FYE QIPP Actuals Over spend Allocations Benefit Exp spend Income £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s In Year Allocation 729,425

Acute Healthcare 371,457 (893) 370,564 61,085 61,085 0 370,564 0 370,564 Mental Health & LD 68,367 (723) 67,644 11,274 11,274 0 67,644 0 (986) 66,658 Community Services 64,792 (171) 64,621 10,767 10,767 0 64,621 0 (184) 64,437 Continuing Healthcare 65,690 (1,179) 64,511 10,417 10,335 (82) 64,511 0 64,511 Primary Care 69,564 1,215 70,779 11,519 11,505 (14) 70,779 0 70,779 Delegated Co-Commissioning 71,164 0 71,164 10,597 10,597 0 71,164 0 71,164 Other Programme 9,231 242 9,473 1,613 1,621 8 9,473 0 9,473

Total Commissioning Budgets 720,265 0 (1,509) 718,756 117,272 117,184 (88) 718,756 0 0 0 0 (1,170) 0 717,586

General Reserves (4,748) (165) (4,913) (88) 0 88 (4,913) 0 1,804 (3,109) 0.5% Contingency 3,647 12 3,659 0 0 0 3,659 0 3,659

Total Programme Budgets 719,164 0 (1,662) 717,502 117,184 117,184 0 717,502 0 0 0 0 1,804 0 550

Running Cost Allowance (RCA) 9,821 0 9,821 1,353 1,353 0 9,821 0 9,821

Total Expenditure 728,985 0 (1,662) 727,323 118,537 118,537 0 727,323 0 0 0 0 634 0 727,957

Planned 19/20 Surplus 440 1,663 2,102 350 350 2,102 0 B/f Surplus 6,000 0 6,000 1,000 1,000 0 6,000 0

Cumulative RRL 735,425 0 1 735,425 119,888 119,888 0 735,425 0 Underlying Underspend / (Deficit) 1,468 1.5 Efficiency

• The table below details the planned efficiencies for 2019/20. At this stage in the year these are forecast in line with plan.

• In order to deliver efficiencies in 2019/20 it has been agreed to pool CCG and Provider capacity to create a blended team. The delivery group which is to be established will focus on four main work programmes:

– Planned Care – Frailty – Demand Management – Mental Health

19/20 (net) 18/19 FYE New Risk £m £m Rating Provider-facing 5,466 Achieved CHC/S117 Packages 530 1,280 High Prescribing / Primary Care 1,370 2,505 Medium Running costs 1,000 Low Other cost avoidance 8,900 Achieved 1,900 19,151 2.9% of RRL

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8 NHS Warwickshire North Clinical Commissioning Group Enc P

Report To: Governing Body Meetings in Common

Report Title: Finance & QIPP Report – Month 2

Report From: Clare Hollingworth – Chief Finance Officer

Date: 17th July 2019

Previously Considered by: Finance and Performance Committee 4th July 2019

Action Required(delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report: To advise Members of the financial position of the CCG up to 31st May 2019 (Month 2 – 2019/20) and to advise of any other financial issues likely to impact in the current financial year.

Key Points: • The Month 2 budget reflects the revised 1209/20 control total surplus of £0.1m as required by NHS Improvement (NHSI) / NHS England (NHSE). • Negotiations in relation to lower value contracts, where concluded, have resulted in changes to individual budget lines. Given the financial position a review of budgets has been undertaken. The budgets have also been adjusted for the previously identified risk on delegated budgets of £1.2m. Committed investments of £0.8m have also been moved from Reserves. Overall, this has resulted in a £2.9m worsening of the Reserves position. • With a paucity of data at this stage in the year, it is reasonable to assume that expenditure will perform in line with budget; there are, however, a range of risks that will need to be managed throughout the course of the year. A full update on the net risk position is to be provided to the Finance & Performance Committee in July after an assessment of the adequacy of 2018/19 accruals based upon final expenditure commitments. • With the above caveats, at month 2 the CCG is forecasting delivery of its revised 19/20 control total, a £0.14m surplus. This is then decreased by the brought forward combined deficit of £17.98m to reach an anticipated cumulative deficit of £17.84m by year end. • The Acute position is reported as breakeven due to the paucity of reliable monitoring data at this stage of the financial year. At the time of reporting only unvalidated month 1 monitoring data is available. As previously reported a block contract has been agreed with the main provider GEH with an overall risk share in relation to achievement of the Joint Transformation Programme, with a £2.0m per organisation cap on aggregate risk. Tariff based contracts have been agreed with all other Providers. • The Mental Health & Learning Disability (LD) and Community positions are currently reported as breakeven. • Work continues with Continuing Healthcare to ensure that budgets have been set at appropriate levels. At Month 2, expenditure on Continuing Healthcare (CHC) is performing in line with the current budget but expenditure on Section 117 packages is above plan. At this early stage, the combined budget has been forecast to breakeven. • The Primary Care position is reported as breakeven due to the early stage in the year. Prescribing data will not be available until month 3. • Running Costs are expected to be within the budget set by NHS England. • As reported previously, £5.7m of the £9.3m Efficiency requirement was secured through budget setting and contract negotiations. Data is not yet available to report reliably against the remaining schemes: CHC/S117 packages, Medicines Optimisation and Running Costs. Reporting should be possible from Month 3 onwards • The joint work programme with George Eliot Hospital (GEH) has resulted in the establishment of a

Page 1 of 2

NHS Warwickshire North Clinical Commissioning Group Enc P

joint transformation board; the first meeting will take place on 21st June and review progress achieved in Quarter 1 and the robustness of plans for the remainder of the year . • The recurrent underlying deficit is currently assessed at £0.7m.

Recommendation: Members are asked to receive the paper for INFORMATION and: • NOTE that at this early stage in the year when there is a paucity of data available, the CCG is forecasting delivery of its agreed control total; • NOTE that a number of risks will need pro-active management throughout the year; and • NOTE that management of in-year risks and the adequacy of 2018/19 accruals will both have a bearing on the ability to achieve the 2019/20 Plan.

Implications

Objective(s) / Plans Financial Plan Delivery, achievement of statutory financial duties, QIPP Programme supported by this Delivery report: Conflicts of Interest: Not applicable

Non-Recurrent Expenditure: Expenditure higher than planned for many budget Recurrent Expenditure: areas. Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Performance: Failure to deliver agreed Plan will impact negatively upon the CCG’s assurance rating Quality and Safety: Not directly applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical engagement imperative to the efficient deployment of NHS resources and Clinical Engagement: successful delivery of service redesign. HIGH – unless all known and emerging financial can be mitigated, there is a real risk Risk and Assurance: that the CCG will not be able to deliver the required 2019/20 control total.

Page 2 of 2

Finance and QIPP Month 2

1 1.1 Headlines

At this early stage in the year, with limited information available, the CCG is reporting an overall balanced position for Month 2 in line with the agreed financial plan.

The key points to note are:

• The Month 2 budget reflects the revised 1209/20 control total surplus of £0.1m as required by NHSI&E

• Negotiations in relation to lower value contracts, where concluded, have resulted in changes to individual budget lines. Given the financial position a review of budgets has been undertaken. The budgets have also been adjusted for the previously identified risk on delegated budgets of £1.2m. Committed investments of £0.8m have also been moved from Reserves. Overall, this has resulted in a £2.9m worsening of the Reserves position.

• With a paucity of data at this stage in the year, it is reasonable to assume that expenditure will perform in line with budget; there are, however, a range of risks that will need to be managed throughout the course of the year. A full update on the net risk position is to be provided to the Finance & Performance Committee in July after an assessment of the adequacy of 2018/19 accruals based upon final expenditure commitments.

• With the above caveats, at month 2 the CCG is forecasting delivery of its revised 19/20 control total, a £0.14m surplus. This is then decreased by the brought forward combined deficit of £17.98m to reach an anticipated cumulative deficit of £17.84m by year end.

• The Acute position is reported as breakeven due to the paucity of reliable monitoring data at this stage of the financial year. At the time of reporting only unvalidated month 1 monitoring data is available. As previously reported a block contract has been agreed with the main provider GEH with an overall risk share in relation to achievement of the Joint Transformation Programme, with a £2.0m per organisation cap on aggregate risk. Tariff based contracts have been agreed with all other Providers.

• The Mental Health & LD and Community positions are currently reported as breakeven.

• Work continues with Continuing Healthcare to ensure that budgets have been set at appropriate levels. At Month 2, expenditure on Continuing Healthcare is performing in line with the current budget but expenditure on Section 117 packages is above plan. At this early stage, the combined budget has been forecast to breakeven.

• The Primary Care position is reported as breakeven due to the early stage in the year. Prescribing data will not be available until month 3.

• Running Costs are expected to be within the budget set by NHS England.

2

Headlines

• As reported previously, £5.7m of the £9.3m Efficiency requirement was secured through budget setting and contract negotiations. Data is not yet available to report reliably against the remaining schemes: CHC/S117 packages, Medicines Optimisation and Running Costs. Reporting should be possible from Month 3 onwards

• The joint work programme with GEH has resulted in the establishment of a joint transformation board; the first meeting will take place on 21st June and review progress achieved in Quarter 1 and the robustness of plans for the remainder oi the year .

• The recurrent underlying deficit is currently assessed at £0.7m.

1.2 Recommendations

• Note that at this early stage in the year when there is a paucity of data available, the CCG is forecasting delivery of its agreed control total.

• Note that a number of risks will need pro-active management throughout the year.

• Note that management of in-year risks and the adequacy of 2018/19 accruals will both have a bearing on the ability to achieve the 2019/20 Plan.

3

1.2 Financial Duties

In Month YTD Description of Financial Duties Target Variance Variance RAG Explanation RAG RAG The CCG has an agreed annual financial plan with NHS England with a cumulative control total of £17.98m Ensure revenue expenditure does not exceed the Statutory duty to breakeven Green Green deficit and an in year surplus position on £0.136m. The CCG is currently on plan to achieve these control agreed allocation totals. Maintain expenditure within the revenue resource limit Position greater than or equal to Green Green The overall CCG position remains in balance. and deliver against NHS England agreed control total Plan Cash Drawdown less than or Maintain expenditure within the allocated cash limit Green Green The CCG is within the monthly cash target, and had a remaining cash balance of £11k. equal to Plan Maintain capital expenditure within the delegated limit Expenditure less than or equal Green Green The CCG capital expenditure is within its capital allocation limits. from NHS England to Plan Expenditure less than or equal Ensure running costs are within the agreed allocation Green Green Running costs are within the agreed allocation. to Plan

The CCG has not utilised its contingency in Month 2. £1.4m is available to offset emerging risks during the Ensure a minimum of 0.5% contingency is held Greater than or equal to 0.5% Green Green financial year.

Ensure compliance with the better payment practice Greater than or equal to 95% by The CCG continues to comply with the Better Payment Practice Code (BPPC) for both NHS and Non-NHS Green Green code (BPPC) Number/Value validated invoices.

RAG Rating Not achieving financial duty and Red unlikely to without remedial action. Based upon current information Amber there is a risk that the financial duty will not be achieved. Green Achieving financial duty

4 1.3 Trends

Year to date (YTD) Forecast Outturn (FOT) Monthly Cash Drawdown Gross Net Gross Net Plan CCG expenditur Income expenditur expenditur Income expenditur Opening Ca sh CCG Cash Total Cash Ca sh Service Area e e e e Period Balance Drawdown Drawdown Available Net Spend Balance £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s In Year Allocation 47,798 282,741 April 23 20,300 20,300 20,323 20,319 4 May 4 21,800 21,800 21,804 21,793 11 Programme Costs 47,160 (24) 47,136 283,736 (143) 283,593 June 11 21,000 Running Costs 641 (2) 639 3,759 0 3,759 July 23,406 Reserves 0 0 0 (4,748) 0 (4,748) August 23,323 Grand Total 47,801 (26) 47,775 282,748 (143) 282,605 September 22,916 October 24,479 Surplus / (deficit) 23 136 November 24,026 December 22,965 Movement on underspend/(deficit) 2018/19 2019/20 January 22,573 Brought forward underspend/(deficit) (17,979) (17,979) February 23,483 In-year change from plan/In-year deficit 0 136 March 31,903 Balance carried forward (17,979) (17,843) Total CCG Cash Drawdown 42,100 NHSBA Cash Drawdown 4,450 Total Drawdown 46,550

Monthly Expenditure Run Rate Maximum Cash Drawdown (MCD) 282,174 697,040.48 20,240 30,000 20,240 % of MCD utilised 16.5% 25,000 % of months completed 16.7%

20,000

19/20 plan 15,000 19/20 actual 18/19 actual 10,000

5,000

0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

5 1.4 Summary Financial Position

Original In Month Allocation and YEAR TO DATE FORECAST Underlying Position Budget Budget Adjustments Revised Allocation Budget Annual (Under) / Other NR Adjustments Adjustments Forecast (Under) / NR NR QIPP Recurrent Budget M2 Budget Actual Over Contingency Spend / FYE QIPP Actuals Over spend Allocations Benefit Exp spend Income £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s In Year Allocation 282,742

Acute Healthcare 154,319 (76) 154,243 25,907 25,907 0 154,243 0 154,243 Mental Health & LD 21,551 121 21,671 3,612 3,612 0 21,671 0 (302) 21,369 Community Services 22,696 (99) 22,597 3,766 3,766 0 22,597 0 22,597 Continuing Healthcare 21,637 1,426 23,063 3,783 3,996 214 23,063 0 23,063 Primary Care 29,838 1,468 31,306 5,164 5,119 (44) 31,306 0 31,306 Delegated Co-Commissioning 26,351 0 26,351 4,012 4,012 0 26,351 0 26,351 Other Programme 4,438 (77) 4,361 727 724 (3) 4,361 0 4,361

Total Commissioning Budgets 280,830 0 2,764 283,593 46,971 47,137 166 283,593 0 0 0 0 (302) 0 283,291

General Reserves (3,258) (2,903) (6,161) 0 0 0 (6,161) 0 1,125 (5,036) 0.5% Contingency 1,414 (0) 1,414 166 0 (166) 1,414 0 1,414

Total Programme Budgets 278,986 0 (140) 278,846 47,137 47,137 0 278,846 0 0 0 0 1,125 0 (3,623)

Running Cost Allowance (RCA) 3,759 0 3,759 639 639 0 3,759 0 3,759

Total Expenditure 282,745 0 (140) 282,605 47,776 47,776 0 282,605 0 0 0 0 823 0 283,428

Planned 19/20 Surplus 0 136 136 23 23 0 136 0 B/f Deficit (17,979) 0 (17,979) (2,997) (2,997) 0 (17,979) 0

Cumulative RRL 264,766 0 (4) 264,762 44,802 44,802 0.00 264,762 0 Underlying Underspend / (Deficit) (686) 1.5 Efficiency

• The table below details the efficiencies for 2019/20.

• In order to deliver efficiencies in 2019/20 it has been agreed to pool CCG and Provider capacity to create a blended team. The delivery group which is to be established will focus on five main work programmes:

– U&EC (medicine GEH) – Medicines optimisation (pharmacy GEH) – Demand management (Surgery & CSS GEH) – Mental Health – MSK, Dermotology, Ophthalmology

19/20 (net) 18/19 FYE New Risk £m £m Rating Provider-facing 40 2,100 Achieved CHC/S117 Packages 470 460 High Prescribing / Primary Care 640 1,810 Medium Running costs 200 Low Other cost avoidance 3,600 Achieved 1,150 8,170 3.3% of RRL

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8 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc Q

Report To: Governing Body Meetings in Common

Report Title: Complaints Policy

Report From: Anita Wilson – Associate Director of Governance and Corporate Affairs

Date: 17th July 2019

Previously Considered by: Clinical Quality and Governance Committee, 27th June 2019

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report: To present the revised CCG Complaints Policy which combines the previous Complaints Policy and the Unreasonably Persistent and Vexatious Complainant Policy.

Key Points: • The Policy sets out the CCGs’ complaints policy and processes for complaints that are investigated by or coordinated by the CCGs. • An additional section (Table 1) has been added to assist staff in correctly redirecting complaints that fall outside of this policy. • The section on unreasonably persistent and vexatious complainants has been amended to include additional information on possible action to take. It is emphasised that this would be a last resort; each case would be assessed on an individual basis and the decision to employ this part of the policy would be made by the Accountable Officer. • The document has been reformatted in line with joint CCG policies. • The document contains an updated Equality Impact Assessment. • The Clinical Quality and Governance Committee reviewed the policy at its meeting on 27th June and recommended it to the Governing Body for approval and adoption.

Recommendation: Governing Body Members are requested to APPROVE the Complaints Policy for adoption by both Coventry and Rugby and Warwickshire North CCGs.

Page 1 of 2

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc Q

Implications

Objective(s) / Plans Compliance with The Local Authority Social Services and National Health Service supported by this Complaints (England) Regulations 2009. report: Conflicts of Interest: None identified Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Compliance with The Local Authority Social Services and National Health Service Performance: Complaints (England) Regulations 2009. Complaints reports will continue to be presented to the Clinical Quality and Quality and Safety: Governance Committee. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken?  No N/A (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable An up to date Complaints policy reduces the risk of mismanagement of complaints Risk and Assurance: and provides our patients and public with a clear policy.

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Complaints Policy

NHS Coventry and Rugby Clinical Commissioning Group and Page 1 of 19 NHS Warwickshire North Clinical Commissioning Group

VERSION CONTROL

Version: 8.0

Ratified by: TBC

Date ratified: TBC

Name of originator/author: Anita Wilson, Associate Director of Governance and Corporate Affairs

Name of responsible committees: Clinical Quality and Governance Committee

Date issued: TBC

Review date: 3 years from data of ratification or sooner as required

VERSION HISTORY

Date Version Comment / Update 31/10/2012 V1 JH - submitted as authorisation evidence.

10/12/2012 V2 Updated to reflect comments made by Complaints Lead B Jacques. 17/01/2013 V3 Flowchart updated. For approval by Clinical Quality, Safety and Governance Committee (CQSG).

10/03/2013 V4 Policy updated to reflect comments raised by CQSG on 24/01/13. 04/04/2013 V4 Policy ratified and adopted by the Governing Body 04/04/2013.

17/04/2014 V5 Policy updated to reflect change in the way complaints are being managed from 1/04/2014. Approved by CQSG with amendments on 17/04/2014, recommended for ratification by Governing Body. 22/05/2014 V6 Updated following comments made at CQSG on 17/04/14, and ratified by the Governing Body on 22/05/14. 18/06/2015 V7 Policy reviewed and updated for consideration and approval by the CQSG. Subject to making minor amendments, the policy was recommended to the Governing Body for approval to 23/07/2015 V7 CQSG amendments made. The Governing Body approved the adoption of the policy. June 2019 V8 Policy updated for CR and WN CCGs.

NHS Coventry and Rugby Clinical Commissioning Group and Page 2 of 19 NHS Warwickshire North Clinical Commissioning Group

Contents

1. Introduction ...... 4 2. Objectives ...... 5 3. Scope of Policy ...... 5 4. Definitions ...... 7 5. Roles and Responsibilities ...... 8 6. Basic Principles of Good Complaints Handling ...... 9 7. Recognising a complaint ...... 10 8. How to register a complaint ...... 10 9. Time limits for Complaints ...... 10 10. Extensions ...... 11 11. Coordinated working across boundaries ...... 11 12. Publicising the Policy ...... 12 13. Issues affecting complaints ...... 12 14. Unreasonably persistent and vexatious complaints ...... 13 15. Management of complaints ...... 14 16. Parliamentary and Health Service Ombudsman (PHSO) ...... 15 17. Training ...... 15 18. Equality and Diversity ...... 16 19. Data Protection Act 2018 ...... 16 20. Freedom of Information Act 2000 ...... 16 Appendix 1: Summary: “A user led vision for raising concerns and complaints” ...... 17 Appendix 2: Extracts from The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 ...... 18 Appendix 3: Equality Impact Assessment ...... 20

NHS Coventry and Rugby Clinical Commissioning Group and Page 3 of 19 NHS Warwickshire North Clinical Commissioning Group

1. Introduction

1.1. Throughout this policy, NHS Warwickshire North Clinical Commissioning Group and NHS Coventry and Rugby Clinical Commissioning Group are referred to as WNCCG and CRCCG or ‘the CCGs’.

1.2. WNCCG and CRCCG Complaints Policy applies from the date of ratification and is based on The Department of Health published Regulations (Local Authority Social Services and NHS Complaints (England) Regulations 2009), which were introduced on 1 April 2009. The Regulations provide the statutory basis for the single approach to complaints handling in health and social care.

1.3. This Policy has been produced in line with the principles set out in the report entitled “My expectations for raising concerns and complaints’ published in November 2014 by the Parliamentary and Health Service Ombudsman, Local Government Ombudsman and Healthwatch England which sets out a user led ‘vision’ of the complaints system. This report is available on the Ombudsman’s website1 with a summary provided at Appendix 1.

1.4. The complaints approach is structured around three main principles: listening, responding and improving. These have also been mapped to the user led ‘vision’ for raising complaints:-

• Listening (considering a complaint) - taking an active approach to asking for people’s views by working in partnership; • Responding (making a complaint and staying informed) - dealing with complaints effectively by finding out what the complainant wants to happen; and • Improving (receiving outcomes and reflecting on the experience) - using the information received to learn and improve services by agreeing a clear plan of action.

1.5. To achieve this, it is essential that people who use our services understand that we want to know what they think, and that we will listen to, act on and learn from their feedback. The CCGs recognise that suggestions and complaints provide valuable insight into services that we commission. We will use this information about the services we commission to ensure that they are high quality, safe and accessible and responsive to patients as we place patients and quality at the heart of what we do.

1.6. The Regulations are intended to make the complaints process more responsive and flexible and provide closer integration with the arrangements for responding to social care and multi-agency complaints. The complaints policy describes how the CCGs manage, respond and learn from formal complaints made about its services and the way in which they are provided and commissioned. The policy details how

1 https://www.ombudsman.org.uk/sites/default/files/Report_My_expectations_for_raising_concerns_and_com plaints.pdf NHS Coventry and Rugby Clinical Commissioning Group and Page 4 of 19 NHS Warwickshire North Clinical Commissioning Group

complaints are investigated through processes which reflect the different management arrangements within the organisation, allowing the most effective and responsive resolution for complainants.

1.7. All patients have the right to have their complaint treated as a formal complaint, which can be made verbally, in writing (including email) or through a third party.

2. Objectives

2.1. The purpose of this policy is to ensure that the objectives of the Local Authority Social Services and NHS Complaints (England) Regulations 2009 are achieved and that complaints are managed in line with the principles set out in the November 2014 report entitled “My expectations for raising concerns and complaints’

2.2. The CCGs need to have a consistent approach to complaints and ensure that anyone making a complaint about NHS services understands how their complaint will be handled and their involvement in the process. the CCGs are committed to meeting the standards laid down in these regulations and guidance with the objective to respond positively in a timely and effective manner, learning from complaints and implementing changes to prevent problems from recurring.

2.3. Information from complainants or their relatives and carers can provide an opportunity for:

• our organisation to see itself as others see it; • a clear identification of issues that concern service users; • rectifying past mistakes to improve services; • increasing the patient’s trust in our staff and services and in those that we commission; • identifying adverse events that may go undetected; • identifying possible problem areas before people feel the need to make a complaint; and • learning from adverse events.

2.4. The way in which all staff within the CCGs respond to comments, suggestions, enquiries, concerns and complaints is a direct reflection on the CCGs’ attitude to the quality of the patient services it commissions. A consistent and responsive complaints system, focused on early resolution of complaints, will lead to improved relations with patients and their relatives and carers as well as increasing the confidence of staff and patients that the CCGs are committed to reviewing and improving services.

3. Scope of Policy

3.1. A complaint may be made by: • A patient or service user

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• Any person who is affected by or likely to be affected by the action, omission or decision of the CCGs • A representative in either of the above cases when that person: o Has died o Is a child o Is unable by reason of physical or mental incapacity to make the complaint themselves o Has given consent for a representative to act on their behalf (a representative may include a parent, guardian, relative, civil partner).

3.2. In the case of a patient or person affected who has died or who is not able to give consent , the representative must be a relative or other person who, in the opinion of the Complaints and Enquiries Officer, had or has a sufficient interest in their welfare and is a suitable person to act as representative. If in any case the Complaints and Enquiries Officer is of the opinion that a representative does or did not have a sufficient interest in the person’s welfare or is unsuitable to act as a representative, they must notify that person in writing, stating their reasons

3.3. In the case of a child, age 16 or under who does not meet the Fraser Competency, the representative must be a parent, guardian or other adult person who has care of the child and where the child is in the care of a local authority or voluntary organisation, the representative must be a person authorised by the local authority or the voluntary organisation. Fraser competence is a term used in medical law to decide whether a child (16 years or younger) is able to consent to his or her own medical treatment, without the need for parental permission or knowledge.

3.4. Some complaints raise issues regarding services which are funded by the CCGs, but not provided by them. In these cases, if the complaint is solely about the staff or service provided by the organisation concerned, for example a care home or a private hospital undertaking NHS treatment under arrangement with the NHS, the complainant will be asked to direct their complaint to the relevant organisation which will follow their own complaints procedure in the first instance.

3.5. There are some types of complaint that fall outside of the scope of this procedure. The suggested route for these complaints is shown in Table 1: Full details of the types of complaint which fall outside this procedure can be found in Regulation 8 of the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.

Full details of the types of complaints which fall outside this policy can be found in Section 8 of the Local Authority Social Services and National Health Service Complaints (England) Regulations 20092.

2 http://www.legislation.gov.uk/uksi/2009/309/regulation/8/made NHS Coventry and Rugby Clinical Commissioning Group and Page 6 of 19 NHS Warwickshire North Clinical Commissioning Group

Table 1: Complaints that fall outside of the scope of this policy

Complaint Subject Complaint Route A complaint relating to the provision of Relevant provider of healthcare e.g. hospital, Healthcare GP, community services etc. A complaint that has already been Health Service Ombudsman investigated through the CCGs’ complaints process. A complaint made by a current or past Relevant HR policy e.g. Grievance Policy, employee about any matter relating to their Whistleblowing Policy etc. employment (including complaints about managers and colleagues) A complaint that is or has been investigated Health Service Ombudsman by the Health Service Ombudsman A complaint arising out of the CCGs’ alleged Information Commissioner’s Office failure to comply with the Data Protection Act 2018 or Freedom of Information Act 2000 A complaint made about another health Relevant Health organisation or Local organisation or local authority Authority Private services or treatment (unless Relevant Private Provider provided under arrangements with the NHS) GP practice relating to a member of practice Practice Manager of the GP practice or NHS staff or service received England

Where complainants are unsure of the most appropriate complaint route, the CCGs’ Complaints and Enquires Officer can provide advice.

All public areas must display notices advising on how and to whom complaints may be made. Information leaflets must also be readily available giving this information.

4. Definitions

4.1. The Regulations: Local Authority Social Services and NHS Complaints (England) Regulations 2009.

4.2. Formal Complaint: it is important for staff to be able to identify those issues which, even if raised verbally, need to be brought to the attention of senior managers in the organisation, for example, where they raise patient safety concerns. All patients have the right to have their complaint treated as a formal complaint.

4.3. Commissioning Complaints: these may be in respect of funding issues or, services provided by other organisations which are funded by the CCGs.

4.4. Investigating Officer: a manager or senior person allocated to carry out an investigation into a formal complaint and to draft a report/response on their findings as well as any lessons to be learnt, within a specified time.

.

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4.5. PHSO: an acronym for the Parliamentary and Health Service Ombudsman.

4.6. IFR: an acronym for Individual Funding Request.

4.7. Conciliation/Mediation: is a way of dealing with complaints that helps to avoid adversarial situations. By bringing the two sides together with a neutral conciliator/mediator it aims to achieve a satisfactory conclusion for both the complainant and the CCGs.

4.8. Fraser Competence: is a term used in medical law to decide whether a child (16 years or younger) is able to consent to his or her own medical treatment, without the need for parental permission or knowledge.

4.9. HealthWatch provides the Independent Complaints Advocacy Service (ICAS) for people living in Coventry. ICAS provides free, independent, confidential information and support for people using the different stages of NHS complaints process (but not medical negligence legal action).

VoiceAbility provides the Independent Complaints Advocacy Service (ICAS) for people living in Rugby and Warwickshire North. ICAS provides free, independent, confidential information and support for people using the different stages of NHS complaints process (but not medical negligence legal action).

5. Roles and Responsibilities

5.1. The CCGs have a duty to ensure compliance with the regulations. The Governing Body will be kept informed of any risks or issues in relation to compliance with the policy via the Clinical Quality and Governance Committee (CQG).

5.2. The Chief Officer has ultimate responsibility for compliance with the regulations.

5.3. The Director of Integrated Governance is responsible for complaints across WNCCG and for overseeing the implementation of the Regulations. The Director of Integrated Governance will regularly report to the Governing Body, via the CQSG, in relation to complaints, activities and compliance and is responsible for dealing with and making decisions on all formal complaints. The Director of Integrated Governance will liaise with the Complaints and Enquiries Officer.

5.4. The Associate Director of Governance and Corporate Affairs is responsible for the NHS Publication Scheme of the CCG

5.5. The Complaints and Enquiries Officer is responsible for processing and handling all formal complaints received by the CCGs, and for advising and providing assistance to those who request it. The Complaints and Enquiries Officer will assist with the implementation of this policy and will keep the Associate Director of Governance and Corporate Affairs and the CQSG informed of any issues. However the overall responsibility and accountability for all complaints received falls with the Associate Director of Governance and Corporate Affairs.

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5.6. The Complaints and Enquiries Officer will be responsible for maintaining a complaints database to record and monitor complaints received by the CCGs.

5.7. Other Senior Managers within the CCGs are responsible for: • ensuring that complaints are fully and fairly investigated by an appropriate manager (Investigating Officer) and that fully completed Complaints Investigation toolkits are forwarded to the Complaints and Enquiries Officer within the specified time • ensuring that all committed actions as a result of a complaint being made are implemented within the specified time; and • ensuring that all their staff are aware of their duties under the regulations and that they adhere to this policy.

5.8. All staff of the CCGs will comply with the most up-to-date version of this policy.

5.9. The CQG Committee is responsible for

• The approval of this policy and submission to the Governing Body for approval to adopt; and • Receiving quarterly reports on complaints from the Associate Director of Governance and Corporate Affairs.

6. Basic Principles of Good Complaints Handling

6.1. No-one is infallible and we can all make mistakes. Complaints sometimes arise from differences of understanding, perceptions and belief and are often about organisational matters rather than individuals. Patients are greatly influenced by the attitudes of professionals towards them.

6.2. The following basic principle will apply to all complaints received by the CCGs:

• Find out how the complainant would like their complaint resolved. Options include: o Face-to-face meetings with the complainant and parties involved o Resolution of the complaint by telephone o The use of an independent advocate or mediator

• There will be an emphasis on early resolution of complaints working with the person who has made the complaint. • Arrangements will ensure that the complainants know they have acted appropriately and that the organisation is open to comments on performance and willing to make changes when necessary. • Lessons learned from complaints will be used to support continuous quality improvements in service delivery. • Staff must be able to recognise when a complaint is being made and need to feel confident about dealing with complaint. • There is a need to ensure confidentiality at all stages of the complaints process not only for the complainant but also for those staff involved in the investigation. • It is important that staff involved in complaints receive feedback on the outcome of the investigation. Feedback will be requested by the Complaints and Enquiries Officer by way of a prepaid questionnaire sent to the complainant to complete and return. NHS Coventry and Rugby Clinical Commissioning Group and Page 9 of 19 NHS Warwickshire North Clinical Commissioning Group

• Anyone making a complaint needs to be assured that they will not be treated any differently by any NHS organisation as a result of voicing their concerns.

7. Recognising a complaint

7.1. Comments and suggestions about the CCGs as a commissioner of services are welcomed. It is important for staff to acknowledge all comments and suggestions and to let the person making them know that they will be treated constructively and confidentially.

7.2. Not all issues raised are formal complaints and it is important that staff who are handling complaints understand the difference. Staff must be able to recognise when a person is making an enquiry, asking for advice or making a constructive suggestion and not to misconstrue this as a complaint. Many concerns can be addressed by the member of staff in direct communication with the contact. This should be the normal practice and staff will be empowered to resolve these quickly without the need for them to go through a more formal complaints process.

7.3. However, it is important that the organisation learns from all feedback, and the person who resolves the concern informally must provide the Complaints team, in writing or by email, brief details for the actions they have taken to resolve a concern. The Complaints team will record the information.

7.4. In all instances staff must clarify with the complainant what their concerns are and, if possible, the remedy. Where the complainant accepts the response as being satisfactory and appropriate there will be no need for further action.

8. How to register a complaint

8.1. All formal complaints should be registered with the Complaints team who will: • Register the complaint on the complaints database and give it a unique number, acknowledge and request consent (where appropriate) and manage expectation of the process and expected timescales direct with the complainant • Allocate an Investigating Officer and provide a Complaints Investigation Toolkit for completion which will advise on the date by which the investigation should conclude and be submitted • Prepare the letter of response for signature by the Chief Officer (or designated deputy) of the CCGs. • Monitor the learning and recommendations as identified in the Complaints Investigation Toolkit

Complaints that fall within the scope of this policy will be investigated by the CCGs.

9. Time limits for Complaints

9.1. A complaint must be made within 12 months from the date on which a matter occurred or the matter came to the notice of the complainant unless there are exceptional circumstances (as per 12 (1) of the Local Authority Social Services and NHS Complaints (England) Regulations 2009 - see Appendix 2).

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9.2. The time limit will not apply if is the CCGs are satisfied that the complainant had good reasons for not making the complaint within the time limit and, notwithstanding the delay, it is still possible to investigate the complaint effectively and fairly.

9.3. The CCGs will endeavour to acknowledge all formal complaints within 3 working days from receipt and offer the complainant the opportunity to discuss how the complaint is to be handled.

9.4. The Department of Health have not set out a detailed prescriptive process for timescales for response (as per 14 (1) of the Local Authority Social Services and NHS Complaints (England) Regulations 2009 - see Appendix 3). However, the CCGs expect the majority of complaints to be investigated and a response sent to the complainant within 25 working days or within 35 working days in the case of:

• Retrospective Review Service; • A joint complaint involving several partner Agencies; or • Where a complaint is being investigation by the Provider and the CCG is being asked to review the findings. These deadlines may be extended by agreement with the complainant.

10. Extensions

10.1. The need for an extension should be identified at the earliest possible opportunity and not be left until the deadline nears. This is sometimes the case, for example where the complaint is more complex and/or crosses over into other organisations and requires a joint response.

10.2. If it is clear either on receipt of the complaint or at any stage during the investigation that the investigation cannot be completed on time, the Investigating Officer must contact the complainant immediately to agree this and give reasons for the delay and advise about a new estimated time for completing the investigation. The Investigating Officer should then advise the Complaints Team who will update the database and follow this up in writing to the complainant.

11. Coordinated working across boundaries

11.1. The Complaints Regulations (2009) introduced a single system for all Health and Local Authority Adult Social Care Services in England and a duty to ensure co- ordinated handling of complaints.

11.2. When the CCGs receive a complaint which appears to span both Health and Adult Social Care Services and/or other organisation and including independent contractors, it will work with the other organisation(s) to ensure co-ordinated handling and to provide the complainant with a single response which covers all aspects of the complaint.

11.3. With consent from the complainant, a copy of the complaint will be forwarded to the organisation concerned. The lead organisation will be established by discussion with the complainant and organisation(s) concerned, which may

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depend on which organisation has to address the majority of the issues raised and whether the complainant is happy with the proposed lead.

11.4. Joint complaints can be more complex and may require more time in which to respond and deadlines will be agreed between all parties concerned. If a complainant remains unhappy with the other organisation after receiving a joint response, the CCGs will endeavour to arrange a meeting with appropriate staff from that organisation for further resolution (a conciliation/mediation will be offered to the complainant).

12. Publicising the Policy

12.1. It is important that patients and their relatives or carers know about the CCGs’ Complaints Policy and how to make comments, compliments, suggestions or complaints about services which the CCGs commission.

12.2. There are sections on the CCGs’ websites3 which include the Policy and contain details on how to make a complaint. The guides on how to complain, comment or compliment on NHS Health Services can be found on the CCGs websites and in reception areas.

12.3. Complainants may contact the Complaints and Enquiries Officer if they have any questions or concerns about the complaints procedure. Complainants may be advised to speak to the local Healthwatch organisation if they wish to discuss their concerns informally. Complainants may also contact POhWER if they need help in making a complaint. The Complaints team will have contact details for the local Healthwatch and POhWER and these are also available in the complaints leaflet.

12.4. It is important to remember that complainants may be unable to read or write; may not have English as their first language or may suffer from disabilities which make formal written complaints difficult to make. The CCGs have access to interpretation/translation services and other services for those unable to put their complaint into writing and details can be obtained from the Complaints team.

13. Issues affecting complaints

13.1. Confidentiality: it is essential when dealing with complaints that employees of the CCGs observe the legal obligation not to release information relating to the patient to a third party without written consent. Should a complainant choose to make their complaint by email, they must be made aware that this system of communication is not considered secure whilst in transit and therefore no guarantee of privacy can be given.

13.2. Consent In accordance with the Data Protection Act and patient confidentiality, when a complainant is not the patient, written consent is required from the patient and this must be dealt with in discussion with the complainant. Exceptions would be if

3 https://www.coventryrugbyccg.nhs.uk/ https://www.warwickshirenorthccg.nhs.uk/ NHS Coventry and Rugby Clinical Commissioning Group and Page 12 of 19 NHS Warwickshire North Clinical Commissioning Group

the complainant has a Lasting Power of Attorney over the patient’s affairs or if the patient is a child who is not ‘Fraser competent’ or is very ill or has died. When a patient has died or is unable by reason of physical or mental incapability to give consent, their representative must be a relative or other person who had, or has, a sufficient interest in their welfare and is a suitable person to act as a representative. Staff should use their discretion on this issue, however they must not hesitate to contact the Complaints team if guidance is needed

13.3. Discrimination: making a complaint should not affect the standard of care received by the complainant at any time. If a complainant feels they are being discriminated against for making a complaint, they should contact the Complaints and Enquiries Officer (refer to Section 18 for further information regarding equality and diversity.

13.4. Allegations of theft: with regard to allegations of theft made against CCG staff, CCG will not register it as a formal complaint unless the complainant is prepared to inform the police.

13.5. If a complaint relating to alleged theft is received, these cases are reported to the CCG who will undertake to investigate the allegation. If the complainant has been directly to the police, the CCGs will co-operate with the police investigation and any legal proceedings. In these cases no further internal investigations will proceed as this may be detrimental to any legal proceedings.

14. Unreasonably persistent and vexatious complaints

14.1. Unreasonably persistent or vexatious complainants are becoming an increasing problem for NHS staff, causing undue stress to staff as well as placing a strain on time and resources. Staff are trained to respond with patience and sympathy to the needs of all complainants, but there are times when there is nothing further which can reasonably be done to assist them or to rectify a real or perceived problem.

14.2. The CCGs will ensure that the Complaints Policy and procedure is followed so far as possible and that no material element of a complaint is overlooked, as unreasonably persistent complaints may have some substance. the CCGs will use the following criteria in determining when a complaint has become unreasonably persistent. It is emphasised that this procedure will only be used as a last resort after all reasonable measures have been taken to try to resolve complaints through the NHS Complaints procedure.

14.3. To be considered unreasonably persistent or vexatious the complainant will usually have one or more of the following:

• Persists in pursuing a complaint when the NHS Complaints Policy and procedure has been exhausted; • changes the substance of a complaint or continually raised new issues; • is unwilling to accept documented evidence of treatment given as being factual e.g. GP manual or computerised records, drug charts, nursing records; • does not clearly identify the precise issues they wish to be investigated; • focused on a trivial matter to an extent which is out of proportion to its significance; NHS Coventry and Rugby Clinical Commissioning Group and Page 13 of 19 NHS Warwickshire North Clinical Commissioning Group

• threatens or uses actual physical violence towards staff at any time; • had an excessive number of contacts with the CCGs by telephone, letter, fax, email or in person; and • harasses or is abusive or verbally aggressive towards staff dealing with their complaint; is known to have recorded meetings or face-to-face/telephone conversations without the prior knowledge and consent of other parties involved; • displays unreasonable demands or expectations and fails to accept that these may be unreasonable (for example, insists on responses being provided more urgently than is reasonable or than is set out in national guidance on complaints handling).

14.4. In these circumstances, the Associate Director of Governance and Corporate Affairs will discuss the individual case with the Chief Officer and decide what action to take. This may include a review of all complaints documentation or seeking legal advice. Once a decision has been made the Chief Officer will write to the complainant and a record will be kept of the reasons why a complainant has been classed as vexatious.

14.5. Action taken may include: • Declining contact with the complainant either in person, by telephone, by email, by letter or any combination of these provided that one form of contact is maintained. • Assigning a designated person within the CCGs to be the single point of contact for the complainant. • Temporarily suspending all contact with the complainant or investigation of a complaint whilst seeking legal advice or guidance from NHS England or other relevant agencies. • Informing the complainant that in extreme circumstances, the CCGs reserve the right to pass unreasonable or vexatious complaints to the CCGs’ solicitors.

14.6. In cases where a complainant’s behaviour is deemed to be abusive or verbally aggressive, the Complaints and Enquiries Officer may deem it necessary to alert other staff, who may come into contact with the complainant (for example Personal Assistants, or reception staff), of the complainant’s name so that the complainant may be directed to the most appropriate person as directed by the Complaints and Enquiries Officer when the complainant contacts the CCGs to ensure one point of contact.

14.7. All complainants defined as unreasonably persistent or vexatious will have their status review on a regular basis, for example, every 6 months.

14.8. Disposal of complaint files Complaints files will be retained and disposed of in accordance with the Records Management Code of Practice for Health and Social Care. .

15. Management of complaints

15.1. Conciliation/Mediation - in the event that the complainant is not satisfied with the outcome of the complaint investigation: the CCGs will offer conciliation and/or mediation as a way of dealing with complaints to help to avoid adversarial situations. By bringing the two sides together with a neutral

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conciliator/mediator it aims to achieve a satisfactory conclusion for both the complainant and the CCGs. Complainants wishing to engage in conciliation/mediation should notify the CCGs within 12 months of the date their complaint was answered.

15.2. The conciliator’s/mediator’s role is to identify any outstanding issues of complaint, establish what is hoped to be achieved by pursuing the complaint and to try and assist in addressing these issues in discussions or a meeting with the complainant and staff involved. If the complainant is not satisfied with the outcome of the complaint they can choose whether to engage in conciliation/mediation or whether to escalate the complaint to the PHSO. If the complainant chooses to engage in conciliation/mediation they still have the right to escalate the complaint to the PHSO if they are still not satisfied with the outcome.

15.3. The conciliator/mediator is a lay person who is used by the CCGs on an ad hoc basis; they are not employees of the CCGs. The conciliator/mediator is not an advocate for either party. Their role is to give impartial support to both parties. The conciliator/mediator will adopt procedures that are most appropriate for conducting the conciliation/mediation process. Conciliation/Mediation can be joint, both parties present, or a separate meeting for each party with feedback from the conciliator/mediator.

15.4. Local Healthwatch: is available to assist and advise patients, their relatives and carers should they have any concern about care or services commissioned or provided. Information is available from the complaints team on how the local Healthwatch services can be accessed.

15.5. POhWER: has an important role in supporting individual complainants and particularly in representing the needs of vulnerable groups when making complaints. POhWER is a free independent service. If appropriate, complainants should be advised about how POhWER can help them and how they can access this service.

16. Parliamentary and Health Service Ombudsman (PHSO)

16.1. The PHSO provides a service to the public by undertaking independent investigations into complaints that the NHS in England has not acted properly or fairly, or has provided a poor service. The PHSO will normally only take on a complaint after the NHS organisation complained about has first tried to resolve the issues and has responded to the complainant. The PHSO believes that the CCG or provider should be given a chance to respond and, where appropriate, put things right before the PHSO become involved. The PHSO is, therefore, the second stage of the NHS complaints process.

17. Training

17.1. The CCGs require all staff to be familiar with the Complaints Policy and to know who they should contact for advice on handling complaints. A copy of the Complaints Policy will be made available to all staff. General training on the Complaints Policy is provided as part of induction training for all new staff. Specific training is given to: NHS Coventry and Rugby Clinical Commissioning Group and Page 15 of 19 NHS Warwickshire North Clinical Commissioning Group

• Front line staff (handling complaints, identifying issues of concern, • Investigating officers (root cause analysis, investigations, Complaints Investigation Toolkit); and

18. Equality and Diversity

18.1. The CCGs are committed to ensuring that services it commissions and all complaints received are dealt with fairly, regardless of race, age, gender, disability, religion or sexual orientation.

18.2. Monitoring and data collection: an anonymised prepaid Data Collection Form, identifiable only by the complaint number, will be forwarded by the Complaints and Enquiries Officer to all complainants regarding formal complaints made to WNCCG. The information will be included on a database and a report presented to CQSG

18.3. Diversity monitoring will be undertaken where complainants have provided information on complaint consent forms. This information will be submitted to NHS Digital on a quarterly basis.

18.4. The CCGs are committed to ensuring that it treats all its members fairly, equitably and reasonably and that it does not discriminate against individuals or groups on the basis of any protected characteristic. An Equality Impact Assessment has been undertaken and included in this Policy at Appendix 3.

19. Data Protection Act 2018

19.1. The Data Protection Act 2018 and General Data Protection Regulation outlines the ways in which information about living people may be legally used and handled and protects against misuse or abuse of personal information (see the Confidentiality and Data Protection Policy). The NHS relies on maintaining the confidentiality and integrity of its data through the implementation of the NHS Confidentiality Code of Practice. Unlawful or unfair processing of personal data may result in the CCGs being in breach of their Data Protection obligations.

20. Freedom of Information Act 2000

20.1. Any information that is held by the CCG may be subject to disclosure under the Freedom of Information Act 2000. From 1st January 2005, the Freedom of Information Act 2000 allows anyone, anywhere to ask for recorded information to be disclosed (subject to limited exemptions). Further information is available in the CCGs’ Freedom of Information Policy.

21. Review

This policy will be reviewed every three years or earlier if necessary.

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Appendix 1: Summary: “A user led vision for raising concerns and complaints” Extract from “My expectations for raising concerns and complaints4”, published in November 2014. A report produced by the Parliamentary and Health Service Ombudsman, the Local Government Ombudsman and Healthwatch England.

4 https://www.ombudsman.org.uk/sites/default/files/Report_My_expectations_for_raising_concerns_and_complaints.pdf NHS Coventry and Rugby Clinical Commissioning Group and Page 17 of 19 NHS Warwickshire North Clinical Commissioning Group

Appendix 2: Extracts from The Local Authority Social Services and National Health Service Complaints (England) Regulations 20095

Time limit for making a complaint

12.—(1) Except as mentioned in paragraph (2), a complaint must be made not later than 12 months after—

(a)the date on which the matter which is the subject of the complaint occurred; or

(b)if later, the date on which the matter which is the subject of the complaint came to the notice of the complainant.

(2) The time limit in paragraph (1) shall not apply if the responsible body is satisfied that—

(a)the complainant had good reasons for not making the complaint within that time limit; and

(b)notwithstanding the delay, it is still possible to investigate the complaint effectively and fairly.

Investigation and response

14.—(1) A responsible body to which a complaint is made must—

(a)investigate the complaint in a manner appropriate to resolve it speedily and efficiently; and

(b)during the investigation, keep the complainant informed, as far as reasonably practicable, as to the progress of the investigation.

(2) As soon as reasonably practicable after completing the investigation, the responsible body must send the complainant in writing a response, signed by the responsible person, which includes—

(a)a report which includes the following matters—

(i)an explanation of how the complaint has been considered; and

(ii)the conclusions reached in relation to the complaint, including any matters for which the complaint specifies, or the responsible body considers, that remedial action is needed; and

(b)confirmation as to whether the responsible body is satisfied that any action needed in consequence of the complaint has been taken or is proposed to be taken;

(c)where the complaint relates wholly or in part to the functions of a local authority, details of the complainant’s right to take their complaint to a Local Commissioner under the Local Government Act

1974(22); and

(d)except where the complaint relates only to the functions of a local authority, details of the complainant’s right to take their complaint to the Health Service Commissioner under the 1993 Act.

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(3) In paragraph (4), “relevant period” means the period of 6 months commencing on the day on which the complaint was received, or such longer period as may be agreed before the expiry of that period by the complainant and the responsible body.

(4) If the responsible body does not send the complainant a response in accordance with paragraph (2) within the relevant period, the responsible body must—

(a)notify the complainant in writing accordingly and explain the reason why; and

(b)send the complainant in writing a response in accordance with paragraph (2) as soon as reasonably practicable after the relevant period.

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Appendix 3: Equality Impact Assessment

Directorate Corporate Affairs Team Corporate Affairs Name of lead person Anita Wilson

Piece of work being assessed Complaints Policy

Aims of this piece of work To set out the policy and procedure for investigating and responding to CCG complaints

Date of EIA June 2019 Other partners/stakeholders involved n/a

Who will be affected by this piece of work? All staff must adhere to the policy

Single Equality Baseline data and research on the population that this piece of work will affect. Is there likely to be Scheme Strand What is available? Eg population data, service user data. What does it show? Are there any gaps? Use both a differential quantitative data and qualitative data where possible. impact? Include consultation with service users wherever possible Yes, no, unknown Gender n/a No Race n/a No Disability Complaints can be made verbally or in writing and assistance can be provided on request No Religion/ belief n/a No Sexual orientation n/a No Age n/a No Social deprivation n/a No Carers n/a No Human rights n/a No

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc R

Report To: Governing Body Meetings in Common

Report Title: Secondment Policy and Procedure

Report From: Anita Wilson – Associate Director of Governance and Corporate Affairs

Date: 17th July 2019

Previously Considered by: Staff Forum Task and Finish Group, 10th April 2019 SMT, 26th April 2019 Staff Consultation, 26th April - 10th May 2019 Clinical Quality and Governance Committees in Common, 27th June 2019

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report: As part of the process of HR Policy harmonisation between Warwickshire North and Coventry and Rugby CCGs, this policy has been reviewed and the revised joint version is presented to Governing Body Members for approval.

Key Points: • Policy confirms that all internal or external secondments must comply with the appropriate procedures and must be confirmed in writing and that a Secondment Agreement must be completed in all cases. • Appendix 1 is a template letter confirming the Secondment to the employee. • A Secondment Agreement, include the schedule of details covering the secondment, is provided as Appendix 2. • The duration of a secondment will be for a minimum of three months and a maximum of 12 months, with any extensions or exceptions to this period to be arranged with the relevant line manager. • Policy confirms that staff who undertake a secondment will be entitled to return to their substantive post on completion of the secondment. However, should the substantive post be subject to organisational change this will be dealt with in line with the CCG Change Management procedure if the secondment is an internal arrangement, or with the organisational change process of the individual’s employer if external. • 'Acting Up' arrangements should apply for up to a maximum of 12 months. • Policy confirms that for all internal secondments, the initiating manager must ensure that the transfer of another CCG employee to the vacancy will not compromise the business of the service from where the individual is to be appointed. The initiating manager must liaise with the line manager of the individual selected for transfer, and it would be expected that the contractual notice period of the individual would apply from the point of selection to the date of the secondment commencing to allow time to back fill the vacancy created. This may be varied by agreement between the managers. However, particular attention should be given to situations where more than 2 secondments arise as a consequence of the initial secondment. • Policy confirms that, in all cases, secondment opportunities will be advertised in line with the CCGs’ Recruitment policy, including Vacancy Approval and Authority to Recruit forms and at least one reference, normally from the employee's current line manager. • The Clinical Quality and Governance Committee reviewed the policy at its meeting on 27th June and recommended it to the Governing Body for approval and adoption.

Page 1 of 2

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc R

Recommendation: Governing Body Members are requested to APPROVE the Secondment Policy for adoption by both Coventry and Rugby and Warwickshire North CCGs.

Implications

Objective(s) / Plans supported by this Harmonisation of HR Policies. report: Conflicts of Interest: Not applicable Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: Not applicable Quality and Safety: Not applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? (attached  No N/A (Delete as appropriate) to policy) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Risk and Assurance: Not applicable

Page 2 of 2

Secondment Policy and Procedure

NHS Coventry and Rugby Clinical Commissioning Group and Page 1 of 19 NHS Warwickshire North Clinical Commissioning Group

VERSION CONTROL

Version: 2.0

Ratified by: Governing Body Meetings in Common

Date ratified: TBC

Name of originator/author: Tim Clewett – HR Business Partner (AGCSU)/Kay Goode – HR Business Partner (UHCW) Replacing CRCCG ‘Acting Up and Secondment Policy’

Name of responsible committees: Clinical Quality and Governance Committee

Date issued: TBC

Review date: TBC

VERSION HISTORY

Date Version Comment / Update

25/9/14 1.0 Approved by Governing Body for adoption

2.0

NHS Coventry and Rugby Clinical Commissioning Group and Page 2 of 19 NHS Warwickshire North Clinical Commissioning Group

Contents

1. INTRODUCTION ...... 4 2. ROLES & RESPONSIBILITIES ...... 4 3. PRINCIPLES ...... 5 4. PROCEDURE ...... 6 5. APPEAL ...... 9 6. DATA PROTECTION ...... 9 7. EQUALITY ...... 9 8. MONITORING & REVIEW ...... 9 APPENDIX 1 – Letter to Secondee ...... 10 APPENDIX 2 - Secondment Agreement ...... 11 Appendix 3 - Equality Impact Assessment ...... 21

NHS Coventry and Rugby Clinical Commissioning Group and Page 3 of 19 NHS Warwickshire North Clinical Commissioning Group

1. INTRODUCTION

1.1 This policy facilitates the secondment of Coventry and Rugby CCG (CRCCG) and Warwickshire North CCG (WNCCG) staff both internally within either CCG and externally within the wider NHS, and exceptionally with non NHS Bodies. It is also designed to facilitate the secondment of staff from other CCGs and other NHS organisations to take up a secondment where available within either CCG, for the mutual benefit of both organisations.

1.2 A secondment may assist with individual development needs as a result of an appraisal or Personal Development Review, or be arranged to undertake project work where specific skills or specialist knowledge are required.

1.3 CRCCG and WNCCG also recognise the need for employees to provide temporary cover for vacant posts or posts which need to be covered for a limited duration. The CCGs are committed to equality of opportunity for all staff and will apply this principle in recruitment and selection. Therefore, all secondments will be advertised. This policy seeks to enable development opportunities during the acting-up arrangement or the term of the secondment.

1.4 This policy sets out the circumstances under which staff may be offered secondment opportunities and highlights the procedures to be followed, including the payments and other arrangements which must be applied.

1.5 All arrangements, whether internal or external secondments, must comply with the principles and procedures outlined in this policy, and must be confirmed in writing. Appendix 1 is a template letter confirming the Secondment to the employee. A Secondment Agreement, including the schedule of details covering the secondment, is provided as Appendix 2. A Secondment Agreement must be completed in all cases.

1.6 Secondments by their very nature are temporary appointments, and will be established in each case for a fixed term period.

2. ROLES & RESPONSIBILITIES

2.1 Line Manager Responsibilities

• To ensure that employees are aware of the Secondment Policy, its principles and the procedure outlined in this document.

• To apply the policy and its procedure correctly, ensuring the fixed term nature of each secondment is made clear to individuals who apply, to integrate the secondee into the relevant service team, and support their development during the secondment.

• For managers who are accountable for managing the secondee it will be their responsibility to outline at the start what their objectives are for the duration of the secondment. Managers must also conduct performance reviews/appraisals in line with local CSU/Organisation policies.

• To seek HR advice where any clarification is needed over the policy and its

CRCCG/WNCCG Secondment Policy April 2019 Page 4 of 22

application.

• To ensure all HR/Electronic Staff Record system (ESR) documentation is completed and recorded on ESR, and to keep copies of appropriate written documentation, including the secondment agreement.

2.2 Employee Responsibilities

• To read the policy and be aware of the principles and procedure contained within this document.

• To engage with any action taken in line with the policy

2.3 Human Resources Responsibilities

• To assist managers in the fair and consistent application of the policy.

• To provide advice to employees and managers concerning any issues raised over policy content.

3. PRINCIPLES

3.1 Secondment requests will be considered in line with business needs and may be refused on that basis.

3.2 Employees have the right to apply for any secondment opportunity either internal or external. However, there is no right to automatic approval and CRCCG/WNCCG reserve the right to refuse such a request where it would be deemed detrimental to the service. Employees must have detailed discussions with their line manager about the secondment opportunity prior to applying for the secondment. To enable the line manager to give proper consideration of the employee’s request the following points must be discussed:

• The impact on the service. • How the service could be covered during the employee’s absence. • The duration of the secondment. • The right to return to their existing job. However, should organisational change occur during the secondment which affects a CCG employee’s substantive job, the CCGs will seek a suitable alternative role, as required and defined in the Change Management and Redeployment policies. • The skills and experience to be gained by the employee which may address personal and professional issues identified through their appraisal process and/or contribute to business plans.

3.3 Staff who enter into secondment agreements will be asked to sign a secondment agreement outlining the terms and parameters of the secondment.

3.4 Any individual who agrees to undertake a secondment will be expected to keep any information, which may be made available to them as a direct result of the secondment, (e.g. personnel, salary, business sensitive information) confidential.

3.5 Employees on secondment with either CCG will retain all of their continuity of service rights with the CCG.

3.6 Staff who undertake a secondment will be entitled to return to their substantive post on

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completion of the secondment. However, should the substantive post be subject to organisational change this will be dealt with in line with the CCG Change Management Policy.

3.7 The duration of a secondment will vary depending on the circumstances. However each secondment will be for a minimum of 3 months and a maximum of 12 months, with any extensions or exceptions to this period to be arranged with the relevant line manager and support from Human Resources.

3.8 Training and support will be provided to all Line Managers in the implementation and application of this policy.

3.9 The line manager is responsible for ensuring that the individual is properly inducted into the new role and ensuring that support is provided to the employee. Any Performance issues relating to an internal secondment will be dealt with in line with the CRCCG/WNCCG Managing Work Performance Policy. Where performance issues arise relating to an external secondee to either CCG, the performance issues must be raised with the secondee and their employer notified in order that action can be taken under that employer’s policy, by the individual’s line manager, with supporting evidence provided by the CCG’s hosting manager.

3.10 “Acting up” is a term which may apply to roles that deputise for a senior position during a period of absence, often stipulated in the job description. Such arrangements often apply to periods of annual leave or sickness absence, but may also apply during longer periods of maternity leave for example or long term sickness absence. They may also be considered where it is necessary to fill a post on a temporary basis when a vacancy is unfilled, but being advertised, or the post is being held open for an employee who is due to return, for example from maternity leave, secondment, or from long-term extended training. Deputising in such a way would not be classified as a secondment, for example, requiring a Secondment Agreement.

3.11 Where ‘Acting up’ is undertaken for a period of up to one month, and is a requirement in the job description, there will be no payment at the higher band to the individual acting up. However, if this requirement extends beyond one month (4 weeks), temporary movement in to a higher pay band should apply. This should not normally last more than 6 months. Any acting up arrangement should be reviewed every 3 months to assess the need for continuation, and should last no longer than 12 months in total. If after 12 months the acting-up period needs to be extended, then the manager should discuss an extension with the Human Resources Department.

3.12 Where the temporary acting up into a higher band results in only one extra pay point the incremental date remains the same. If, however it results in more than one extra point the incremental date for the period of the temporary move becomes the date the acting up began.

3.13 However, if an acting-up opportunity is likely to be for a period of longer than over 12 months then the CCGs’ recruitment process should apply.

4. PROCEDURE

Requesting Internal Secondments within the CCGs

4.1 Where a Department within CRCCG or WNCCG identifies that a secondment opportunity exists, consideration should be given to the length of the secondment, any training

CRCCG/WNCCG Secondment Policy April 2019 Page 6 of 22

required and the skills set or specialist knowledge required of staff undertaking the secondment.

4.2 Where the purpose of the secondment is to complete a specific task/assignment/project then a Job Description and Person Specification must be prepared and submitted for Job Evaluation to determine the appropriate pay band for the secondment post.

4.3 Where a secondment is intended to be advertised and filled internally, the initiating manager must ensure that the transfer of another CCG employee to the vacancy will not compromise the business of the service from where the individual is to be appointed. Therefore, the initiating manager must liaise with the line manager of the individual selected for transfer, and it would be expected that the contractual notice period of the individual would apply from the point of selection to the date of the secondment commencing to allow time to back fill the vacancy created. This may be varied by agreement between the managers. However, particular attention should be given to situations where more than 2 secondments arise as a consequence of the initial secondment.

4.4 In tandem with 4.3 above, where the individual undertaking a secondment wishes to terminate the secondment before its intended end date, they must provide their contractual notice to the host manager and their line manager for their substantive job in order to facilitate any arrangements for their return to their substantive role.

4.5 In all cases, secondment opportunities will be advertised in line with the CCGs’ Recruitment policy. Therefore, the relevant authorised approval forms for filling a vacancy will be required in all cases. At least one reference should also be sought, and this should normally be from the employee’s current line manager.

4.6 There is no explicit obligation on the manager to release an individual, but proper consideration should be given to such a request. Any refusal to allow an individual to uptake a secondment opportunity should be carefully considered and the potential long term benefits to the CCG should not be overlooked. An explanation should be given to the employee if a request is turned down.

4.7 If the secondee is from an external NHS or non-NHS organisation, the line manager hosting the secondment must liaise with that organisation to facilitate an agreement and agree what parameters will be applied to it, detailing very clearly what funding arrangements have been agreed. Advice may be obtained from HR within the CCGs at any time.

4.8 Once agreed between the two organisations, Human Resources may be contacted for advice and to facilitate an agreement and agree what parameters will be applied to it.

Secondments of CRCCG or WNCCG Staff to External Organisations

4.7 Where an individual manager is approached by an external NHS or non-NHS organisation regarding a secondment opportunity for an employee, contact should be made with Human Resources. The opportunity may be advertised depending on the nature of the request. If the secondment is feasible, Human Resources will facilitate the agreement between all parties involved.

4.8 Where an employee wishes to pursue a secondment opportunity with another organisation they should approach their manager indicating that they have applied or wish to apply for an external secondment.

CRCCG/WNCCG Secondment Policy April 2019 Page 7 of 22

4.9 Agreement must be reached on how the secondee/placement individual's salary will be paid and which body will be responsible for meeting any additional expenses such as travel and subsistence allowances.

4.10 During the period of the secondment the individual’s Terms and Conditions will remain the same and continue to be subject to CRCCG/WNCCG policies and procedures. Any exceptions to this will be agreed in advance between the host organisation, the secondee and CRCCG/WNCCG.

4.11 Secondees are responsible for reporting any reasons for absence directly to both the external organisation and their employing CCG in accordance with their own absence management policies.

4.12 Whilst on any secondment employees will continue to accrue annual leave entitlements and be permitted to take annual leave to their entitlement limit with the agreement of the host organisation. Where an employee takes a period of Maternity Leave during the course of the secondment accrual of annual leave entitlements will continue to apply.

Funding Arrangements

4.13 Prior to the secondment taking place the appropriate manager(s) must liaise with Human Resources and CRCCG/WNCCG Finance to agree who will be funding the secondment and how the payment arrangements are to be facilitated. Depending on the individual agreements, it may be appropriate to submit an HR Change Form for an internal secondment, or arrange for a debtors invoice to be raised if an individual is seconded from an external organisation.

4.14 Where the grade of the secondment post is higher than the grade of the employee’s substantive post, the full salary cost will be paid by CRCCG or WNCCG, and recovered from the host organisation. On return to CRCCG/WNCCG the employee will revert to their substantive grade and salary.

Working Arrangements

4.15 For the duration of the secondment or work placement the individual will be required to comply with the working/cover arrangements of the department or host employer. Any request or requirement to exceed/reduce their contractual working hours will be subject to agreement at the initiation of the secondment and the conditions of Working Time Regulations.

Communication

4.16 When a secondment is confirmed, it must be agreed by all parties that three-way communication between the secondee, host organisation and the employer is maintained.

4.17 Any secondee from CRCCG or WNCG must be kept informed of, and consulted about any organisational change that takes place during their period of secondment.

Termination or Extension of Secondment

4.18 A request for an extension of an existing secondment should be considered in accordance with the needs of the service, and be mutually agreed by all parties and confirmed in writing. If an extension is refused, an explanation should be given to the employee.

CRCCG/WNCCG Secondment Policy April 2019 Page 8 of 22

4.19 The secondment may be terminated by either party in writing with the appropriate or previously agreed notice period.

Secondment resulting in Permanent Appointment

4.20 As a full recruitment process should be carried out for all secondments (under Paragraph 4.5), the individual may be offered the post should it become permanent.

5. APPEAL

5.1 An employee may use the Grievance Procedure if they feel that they have been treated unfairly in relation to application of this policy.

6. DATA PROTECTION

6.1 In applying this policy, the Organisation will have due regard for the Data Protection Act 2018 and the requirement to process personal data fairly and lawfully and in accordance with the data protection principles. Data Subject Rights and freedoms will be respected and measures will be in place to enable employees to exercise those rights. Appropriate technical and organisational measures will be designed and implemented to ensure an appropriate level of security is applied to the processing of personal information. Employees will have access to a Data Protection Officer for advice in relation to the processing of their personal information and data protection issues”.

7. EQUALITY

7.1 In applying this policy, the CCG will have due regard for the need to eliminate unlawful discrimination, promote equality of opportunity, and provide for good relations between people of diverse groups, in particular on the grounds of the following characteristics protected by the Equality Act (2010); age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, and sexual orientation, in addition to offending background, trade union membership, or any other personal characteristic.

8. MONITORING & REVIEW

8.1 The application of this policy and procedure will be monitored by the Human Resources team, and the policy and procedure formally reviewed every 3 years in conjunction with CCG Governing Body. Where review is necessary due to legislative change, this will happen immediately.

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APPENDIX 1 – Letter to Secondee

CRCCG OR WNCCG LOGO AND HEADED PAPER

Personal – To be opened by Addressee Only

NAME

ADDRESS

Date

Dear

SECONDMENT TO THE POST OF - (JOB TITLE)

I am pleased to confirm that it has been agreed your secondment to the above role will commence/continue for the period (START DATE) to (END DATE).

A Secondment Agreement has been drawn up (copy enclosed) which all three parties to the secondment will be required to sign.

Your salary for the period of the secondment whilst undertaking the duties will be based on an annual salary of £XXX per annum .

Please note you will need to ensure that both your hosted and substantive line manager are aware of any unplanned absences, and agree to any annual leave you wish to book. Expenses should continue to be submitted for approval to your substantive line manager, although your host line manager will need to sign to confirm they are a true record. All other terms and conditions remain unchanged.

If you have any questions in relation to this Secondment Agreement please do not hesitate to contact me.

Yours sincerely

(Signing for and behalf of Chief Officer)

Prepared by

CRCCG/WNCCG Secondment Policy April 2019 Page 10 of 22

APPENDIX 2 - Secondment Agreement

SCHEDULE 1 - SPECIFIC CONDITIONS OF EMPLOYMENT

1 Date this agreement is prepared: 1a Effective start date of this agreement: 2 Host’s Name and Address:

2a Host’s Contact Telephone Number: 3 Employee’s Name:

3a Employee's Address:

Employee’s Contact Telephone 3b Number: 4 Substantive Job Title: Date current contract of employment 5 issued: 6 Continuation Date of this Secondment:

7 Termination Date of this Secondment:

7a Notice for early termination:

8 Job Title:

9 Duties of the post:

10 Hours of Work: 11 Base:

12 Your Pay Band:

13 Your Salary:

14 Line Managers during secondment:

Name of CCG Signed by the CCG

Name: Date:

SECONDMENT AGREEMENT

The details of this AGREEMENT are contained in Schedule 1 above.

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BETWEEN:

1. The NHS Coventry & Rugby/Warwickshire North* Clinical Commissioning Group (CCG) in Schedule 1 ("the Employer”) 2. “The Host” is detailed in Schedule 1, Section 2 above. 3. “The Employee” is detailed in Schedule 1, Section 3 above.

*Please delete as appropriate

BACKGROUND

(A) The Employee is employed by the Employer under a contract of employment (”the Employment Agreement”) detailed in Schedule 1, Section 5 in the job role detailed in Schedule 1, Section 4. (B) The Employer, has agreed to second the Employee to the Host to work in the post detailed in Schedule 1, Section 8 (“the Post”) pursuant to the terms of this Agreement for the period outlined in Schedule 1, Section 6 and 7 (subject to earlier termination as provided for in Schedule 1, Section 7a) (“the Secondment”).

IT IS AGREED:-

1. SECONDMENT

1.1 With effect from the date detailed in Schedule 1, Section 6, the Employer shall second the Employee to the Host on the terms of this Agreement until and including the the date detailed in Schedule 1, Section 7 (subject to earlier termination as provided for in Schedule 1, Section 7a) (the "Secondment").

1.2 During the Secondment, the Employee shall be located at the Host’s premises detailed in Schedule 1, Section 11 and such other locations as may be reasonably required of the Host.

1.3 The Employee will report to the employee detailed in Schedule 1, Section 14 at the Host. The day-to-day direction and supervision of the Employee and their conduct and actions shall be the exclusive responsibility of, and at the risk of, the Host.

1.4 The Employee agrees to undertake the Post and will devote their time, attention and ability to carry out the hours of work outlined in Schedule 1, Section 10 per week for the performance of the Post. Where this is less than the employees contractual hours the Employer will agree with the Employee any amendment to contract which may be required if they are not to fulfil the balance of the hours in their substantive post. The Employee will comply with the Host’s reasonable requirements and instructions communicated by it to the Employee from time to time.

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2. SECONDEE'S STATUS

2.1 The Employer, the Host and the Employee agree that the Employee shall remain an employee of the Employer at all times and shall not be deemed to be an employee of the Host by virtue of the Secondment. The Host shall take no disciplinary action in respect of, nor purport to terminate the employment of, the Employee.

2.2 The Employee will remain employed by the Employer for the duration of the Secondment and the Employee’s existing terms and conditions of employment (and continuity of service under Agenda for Change) will apply.

2.3 During the Secondment, the Employer shall be responsible for the payment to the Employee of their salary and benefits as its employee in the usual way.

2.4 It is agreed that the Employer shall be solely responsible for all income tax liability and National Insurance contributions or other statutory charges in respect of any payment to the Employee for the provision of services by the Employee to the Host under this Agreement.

2.5 The Employer shall indemnify, and keep indemnified, the Host in relation to any claims, charges or liabilities for (including but not limited to) any income tax, employee National Insurance or similar contributions (including costs interest and penalties), or other statutory charges or remuneration or other compensation arising from or in relation to the services by the Employee under this Agreement or the Employee being found to be an employee of the Host or otherwise. The Host agrees to notify the Employer of any such claims charges or liabilities received by the Host.

3. HOLIDAYS, ILLNESS AND OTHER ABSENCE

3.1 The Employee shall be entitled to holidays during the period of the Secondment in accordance with the Employment Agreement. The Employee and the Host and the Employer shall agree holiday dates.

3.2 The Employer shall not be obliged to make available to the Host the services of the Employee (or any other replacement employee of the Employer) during any period of incapacity on the part of the Employee due to illness, injury or maternity leave or as otherwise permitted under the Employment Agreement. For the avoidance of doubt, in the event that the Employer does provide the services of a replacement employee in such circumstances, the Host will be required to continue to pay any fees or charges in accordance with this Agreement in addition to any fees or charges agreed in respect of such replacement employee.

3.3 In the event of sickness, the Employee shall notify both the Employer and the Host in accordance with the agreed procedure of each party.

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3.4 All matters relating to annual leave and sickness absence shall be dealt with in accordance with its normal grievance and disciplinary procedures, and be the responsibility of the Employer.

4. HEALTH AND SAFETY

4.1 The Host shall ensure that the Employee observes its health and safety policies and procedures and maintains a safe method of working.

4.2 The Employee shall observe all safety instructions given to him from time to time by the Host and/or the Employer.

5. GRIEVANCE AND DISCIPLINARY PROCEDURES

5.1 All matters of grievance and discipline shall be dealt with by the Employer in accordance with its normal grievance and disciplinary procedures.

5.2 The Host agrees to co-operate fully and promptly with the Employer to resolve grievances raised by the Employee.

5.3 The Host undertakes to report to the Employer, at the earliest possible opportunity, all matters which may require disciplinary action by the Employer, and to co-operate fully and promptly in any subsequent action which may be necessary.

6. EXPENSES

6.1 The Employer shall reimburse the Employee (on production of such evidence as it shall reasonably require) the amount of all expenses properly and reasonably incurred by him in the course of performing the duties assigned to him by the Host in accordance with the Employer’s policy and subject to approval by the Host.

7. FEE

7.1 In consideration of the Employer seconding the services of the Employee to the Host, the Host shall pay to the Employer during the period of the Secondment a fee equivalent to the total amount paid by the Employer to or in respect of the Employee under the Employment Agreement as amended by 7.2 below, which shall include, but is not limited to:

• The Employee's salary as reviewed by the Employer on an annual basis; • National Insurance and pension contributions made by the Employer in relation to the Employee; • Any overtime payments or other premiums paid to the Employee during the period of the Secondment and approved in advance by the Host; and

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• Payments by the Employer to the Employee in respect of statutory and occupational sick pay, maternity pay, paternity pay, adoption pay and any other pay in respect of any absence from work of the Employee.

7.1.1 These fees may be subject to VAT at the current rate where the secondment is to or from a non-NHS organisation, and the line manager should check with the CCG Finance department for advice in those circumstances.

7.1.2 Where the Employee is part time the host shall pay the proportion of the above associated with the secondment agreement.

7.2 For the duration of the secondment the employee will be paid an annual salary outlined in Schedule 1, Section 12 and 13.

7.3 The Employer shall invoice the Host for the fees set out in clause 7.1 above monthly in arrears.

7.4 In addition to the fees pursuant to clauses 7.1 and 7.2 above, the Employer may charge to the Host:

• The gross cost of any payment of reasonable business expenses made to the Employee by the Employer in respect of work undertaken solely for the Host provided always that the Employer shall upon request by the Host furnish evidence of such expenses as the Host may reasonably require (and the Employer shall invoice such charges to the Host quarterly);and • Any other charges agreed in advance between the Host and the Employer.

7.5 The Host shall pay all invoices under this clause 7 within 30 days of receipt.

8. LIABILITY AND INDEMNITIES

8.1 The Employer shall not be liable for any act or omission on the part of the Employee during the Secondment and shall incur no liability for loss, damage or injury of whatever nature sustained by the Employee during the Secondment.

8.2 The Host hereby indemnifies the Employer and shall keep the Employer indemnified fully at all times against any and all claims, liabilities, actions, proceedings, costs (including legal fees), losses, damages and demands arising out of or resulting from breach of this Agreement or any act or omission or default of the Employee.

8.3 The Host hereby indemnifies the Employer and shall keep the Employer indemnified fully at all times against any and all claims, liabilities, actions, proceedings, costs (including legal fees), losses, damages, demands,

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penalties, fines or expenses suffered or incurred by the Employer arising out of:-

• The employment or termination of employment of the Employee during the Secondment; or • The engagement or termination of engagement of the Employee under the terms of this Agreement during the Secondment; or • Any breach by the Host of any collective agreement or other custom, practice or arrangement (whether or not legally binding) with a trade union, staff association or employee representatives in respect of the Employee including for the avoidance of doubt without limitation liability for personal injury, accident or illness suffered or incurred in whole or in part during the Secondment, breach of contract or in tort, unfair dismissal, redundancy, statutory redundancy, a protective award under the Transfer of Undertakings (Protection of Employment) Regulations 2006 equal pay, discrimination of any kind or under any legislation applicable in the United Kingdom.

9. CONDUCT OF CLAIMS

9.1 If the Host becomes aware of any matter that may give rise to a claim against the Employee and/or the Employer, notice of that fact shall be given as soon as possible to the Employer.

9.2 No admission of liability shall be made by or on behalf of the Host and any such claim shall not be compromised, disposed of or settled without the consent of the Employer.

9.3 The Employer shall be entitled in its absolute discretion to take such action as it shall deem necessary to avoid, dispute, deny, defend, resist, appeal, compromise or contest any such claim or liability (including, without limitation, making counterclaims or other claims against third parties) in the name of and on behalf of the Host and to have the conduct of any related proceedings, negotiations or appeals.

10. CONFIDENTIAL INFORMATION

10.1 It is acknowledged that to enable the Employee to undertake the Post during the Secondment, the Host will provide the Employee with information of a highly confidential nature which is or may be private, confidential or secret, being information or material which is the property of the Host or which the Host is obliged to hold confidential include, without limitation, all trade secrets, lists or details of patients, information relating to the working of any process or invention carried on or used by the Host or any subsidiary or associate, research projects, and any proprietary Host information (any and all of the foregoing being “Confidential Information”).

10.2 The Employee agrees to adopt all such procedures as the Host may reasonably require and to keep confidential all Confidential Information and that the Employee shall not, (save as required by law) disclose the

CRCCG/WNCCG Secondment Policy April 2019 Page 16 of 22

Confidential Information in whole or in part to anyone and agrees not to disclose the Confidential Information other than in connection with the performance of the Post

10.3 Any document, including without limitation, notes, memoranda, diaries, correspondence, computer disks, facsimiles, telexes, reports or other documents or data of whatever nature or copies thereof created by the Employee in the course of the Secondment will be and remain the property of the Host and the Host shall be the absolute beneficial owner of the copyright in any such document.

10.4 The Employee agrees that he/she shall at any time during the continuance of this agreement, if so required by the Host and in the event of the termination of this agreement for whatever reason (whether lawfully or otherwise), surrender to the Host all original and copy documents in their possession, custody or control (including, without limitation, all books, documents, papers, materials) belonging to the Host or relating to the business of the Host together with any other property belonging to the Host.

10.5 The obligations under this agreement apply to all and any Confidential Information whether the Confidential Information was in or comes into the possession of the relevant person prior to or following this agreement and such obligations shall be continuing obligations throughout the continuance of this agreement and at all times following its termination but shall cease to apply to information which may come into the public domain otherwise than through unauthorised disclosure by the Employee.

11. TERMINATION

11.1 Subject to sub-clauses 11.2 and 11.3 below, the Host or the Employer may terminate the Secondment by giving notice as identified in Schedule 1, Section 7a. Otherwise, this Agreement will automatically terminate upon the expiration of the Secondment.

11.2 The Employee may terminate the Secondment by providing contractual notice applicable to their substantive role to the Host manager and their Employer line manager.

11.2 The Employer may terminate the Secondment at any time with immediate effect by notice in writing to the Host if:

• The Employment Agreement is terminated for any reason; or • The Host fails to pay any sum due to the Employer under the Agreement on its due date for payment.

11.3 The Host may terminate the Secondment at any time with immediate effect in writing to the Employer and Employee if:

• The Employee is guilty of any serious misconduct or any other conduct which affects or is likely to affect prejudicially the interests of the Host;

CRCCG/WNCCG Secondment Policy April 2019 Page 17 of 22

11.4 The Host may terminate the Secondment at any time by providing written notice in line with the Agreement to the Employer and Employee if:

• The Employee is unable properly to perform their duties by reason of ill health, accident or otherwise for a period or periods aggregating at least 30 business days. In making a decision in this regard, the Host manager should take HR advice and fully consider the circumstances of the secondment e.g. the length of time remaining for the secondment.

11.4 Upon and following termination of this Agreement, where organisational change applies to the Secondee’s substantive job;

• The Host and the Employer shall use their best endeavours to offer suitable alternative employment (in accordance with section 141 of the Employment Rights Act 1996) or where this is not possible, other alternative and/or continued employment to the Employee.

12. DATA PROTECTION

12.1 The Employee and the Employer consent to the Host holding, disclosing, using or otherwise processing any information about them which they provide to the Host or which the Host may acquire as a result of the Secondment.

13. NOTICES

13.1 Any notice or other document to be given under this Agreement shall be in writing between the parties named in this Agreement.

14. VARIATION OF THE CONTRACT

14.1 The Agreement may only be varied with the express written agreement of the Host and the Employer.

15. GENERAL

15.1 None of the rights or obligations under the Agreement may be assigned or transferred without the prior written consent of the other party, save that the Host and/or the Employer shall be entitle to assign the benefit and burden of the Agreement to any successor organisation without consent.

15.2 Subject to clause 15.1, this Agreement shall be binding upon the successors and assignees of the parties hereto and the name of the party appearing herein shall be deemed to include the names of its successors and assignees.

15.3 Termination of this Agreement shall be without prejudice to any accrued rights and obligations under this Agreement as at the date of such termination and any rights, duties or obligations of any parties which are expressed to survive, or which otherwise by necessary implication survive the expiry or termination

CRCCG/WNCCG Secondment Policy April 2019 Page 18 of 22

for any reason of this Agreement, together with all indemnities, shall continue after such expiry or termination.

15.4 If any provision or term of this Agreement shall become or be declared illegal invalid or unenforceable for any reason whatsoever, including without limitation, by reason of provisions of any legislation or by reason of any decision of any court or other body having jurisdiction over the parties, such terms or provisions shall be divisible from this Agreement and shall be deemed to be deleted in the jurisdiction in question provided always that if any such deletion substantially affects or alters the commercial basis of this Agreement, the parties shall negotiate in good faith to amend and modify the provisions or terms of this Agreement as may be necessary or desirable in the circumstances.

15.5 This Agreement does not create any partnership or agency relationship between the Employer and the Host nor does it create any employment relationship between the Employee and the Host.

15.6 This Agreement shall be in substitution for any previous letters of appointment, agreements or arrangements, whether written, oral or implied, relating to the secondment of the Employee.

15.7 This Agreement shall be governed by and construed in accordance with English law. The Employer and the Host agree that any dispute arising under this Agreement or in connection with it shall be decided in the English Courts which shall have the sole jurisdiction in any such matter.

IN WITNESS of which each of the parties to this Agreement has executed this document on the date first mentioned on page 1:-

EXECUTED AS A DEED by (NAME OF EMPLOYER)

Signed by the Representative of the Employer: ......

Add full name of Representative: …………………………………………….

In the presence of: ………………………………….. (Add Full Name of Witness)

Signed by Witness: ……………………………………………………

EXECUTED AS A DEED by (NAME OF HOST)

Signed by the Representative of the Host: ………………………………………

Add full name of Representative......

In the presence of: ………………………………….. (Add Full Name of Witness)

Signed by Witness: ……………………………………………………

CRCCG/WNCCG Secondment Policy April 2019 Page 19 of 22

EXECUTED AS A DEED by the Employee:

Signed by the Employee: ......

Add full name of Employee: ……………………………………….

In the presence of: ………………………………….. (Add Full Name of Witness)

Signed by Witness: ……………………………………………………

Witness:

Signature ......

Name ......

Address ......

Occupation ......

CRCCG/WNCCG Secondment Policy April 2019 Page 20 of 22

Appendix 3 - Equality Impact Assessment

Directorate Corporate Governance Team Name of lead person Anita Wilson

Piece of work being assessed Secondment Policy and Procedure

Aims of this piece of work To set out the policy and procedure for acting up and secondments

Date of EIA 12/04/19 Other partners/stakeholders involved

Who will be affected by this piece of work? This will apply to all members of staff

Single Equality Baseline data and research on the population that this piece of work will affect. Is there likely to be Scheme Strand What is available? E.g. population data, service user data. What does it show? Are there any gaps? Use both a differential quantitative data and qualitative data where possible. impact? Include consultation with service users wherever possible Yes, no, unknown Gender No Race No Disability No Religion/ belief No Sexual orientation No Age No Social deprivation No Carers No Human rights No

CRCCG/WNCCG Secondment Policy April 2019 Blank Page CRCCG and WNCCG Clinical Quality and Governance Committee in Common Report for the Main Meeting held on 25th April 2019

Achievements/Decisions Made/Items to Note

Integrated Provider Quality Report – The Committee Emergency Preparedness, Resilience and Response The Committee was asked to the scrutinised and was assured of the contents of the (EPRR) Update – note work being undertaken by the Operations Department on Integrated Provider Report. EPRR during 2019 and to support the Operations Coventry and Rugby CCG Safeguarding Assurance Department and Accountable Emergency Officer in Report – The Committee noted the contents of the improving the Business Continuity work enabling CCGs lllllllllllllllll Coventry and Rugby CCG Safeguarding Assurance to reach a higher assurance standard for Business Report. Continuity.

Quality Report – NHS Prescription Ordering Direct Over the Counter Policy – The WNCCG members of (POD) – The Committee noted the Report for assurance the Committee noted the contents of the Draft Policy and advised on guidance for future reporting for POD. and recommended approval to the Governing Body Meeting, subject to the inclusion of mitigating actions to Community Nutrition and Hydration Standards and address areas identified in the impact assessment. It Guidelines for Community Settings – The Committee was agreed to email CRCCG members of the Committee was unable to approve the Report and agreed that it to approve the above recommendation. should be presented at Clinical Executive Group or

Executive Group for CCG clinical sign off before being Shared Care Pathway – The Committee noted the presented to this Committee for approval. Shared Care Pathway for information and assurance and advised that no further action is required. Coventry Local Area SEND Self-Evaluation – The WNCCG members of the Committee approved the Warfarin Pathway – The Committee noted the Warfarin contents of the Coventry Local Area SEND Self- Pathway for information and assurance and advised that Evaluation , subject to further discussion and agreed no further action is required. changes. It was agreed to email CRCCG members of the Committee to approve the above recommendation. Schedule of Business 2019/20 – The Committee was unable to review and approve the 2019/20 Schedule of Business until all staff had completed the Self- NHS England Review of CCG’s Systems and Assessments. Processes for Managing Serious Incident’s in Commissioned Services – The Committee scrutinised Update of Human Resources Policies – The WNCCG the contents of the letter and Action Plan from NHS members of the Committee approved the revisions and England and was assured that the CCGs are taking the updated Human Resources Polices subject to the necessary actions to ensure compliance with the Serious changes in formatting and logo’s being amended. It was Incident Framework. agreed to email CRCCG members of the Committee to approve the above recommendation. Quality Accounts – The WNCCG members of the Committee reviewed the accounts of George Eliot Hospital NHS Trust and University Hospitals Coventry Key Issues for the Governing Body and Warwickshire NHS Trust and the draft agreed None response letter. It was agreed to email CRCCG members of the Committee to review and agree the above recommendation. Matters referred to the Governing Body for approval, debate or further consideration: Briefing on the New Safeguarding Partnership • Briefing on the New Safeguarding Partnership Arrangements for Warwickshire – The WNCCG Arrangements for Warwickshire members of the Committee noted that the three key • Over the Counter Policy partners have acknowledged their shared responsibilities within the new arrangements and support this acknowledgement; noted the proposed safeguarding Key Information: arrangements and the transitional plan and approved the • Committee Chair: Ludlow Johnson paper for submission to the Department of Education by • Date of Next Meeting: 27th June 2019 (Main) the 28th June 2019 following approval from the Governing Body. It was agreed to email CRCCG members of the Committee to approve the above recommendation. Blank Page CRCCG / WNCCG Finance and Performance Committee (F&P) Report for the Meetings in Common held on 2nd May 2019

Achievements/Decisions Made/Items to Note Dementia Diagnosis Rates: Members supported the recommendation for the QIPP Programme Lessons Learned 2018/19: Functional Cognitive Assessment Scheme (FCAS) The Committee acknowledged the content of the report and the to be extended for 6 months. Funding approval additional evidence provided and approved the next steps to beyond this would be, subject to positive implement the recommended actions. evaluation and a short business case.

Conditions for which over the counter (OTC) items should Mental Health Investment Standard 2019/20 not routinely be prescribed: Members agreed to recommend The Committee of each CCG noted the the policylllllllllllllllll for approval, subject to the EIA being signed off by contents of the paper and the risks associated with the Equalities Lead. There was discussion as to how best to achievement of national MH targets; required communicate the policy to stakeholders. further information of the anticipated impact of proposed investments in Early Intervention and CRCCG Financial and Contracting Report – Month 12: The Physical Healthchecks before making a report confirmed the CCG had delivered its controls total recommendation on additional investment; and subject to the outcome of the statutory audit. required that the CCGs’ position with regards to achievement of the MHIS was reported to the WNCCG Financial and Contracting Report – Month 12: Committee at least quarterly. The report confirmed the CCG had delivered its controls total subject to the outcome of the statutory audit. Members noted WNCCG Members agreed to underwrite the that the CCG’s underlying position had deteriorated further immediate reinstatement of weekend AMHAT during Month 12 and determined that this should be escalated cover at GEH (£16k per month) for 3 months on to the Governing Body. the expectation of securing national transformation monies, subject to a rapid evaluation of the entire 2019/20 Financial Plan Update: AMHAT service. The report directed Members to the information regarding QIPP Achievability. Members recommended that a Governing Body Development Session was utilised to ensure a full Key Issues for the Governing Body understanding of changes to the financial plan. Members noted the significant level of risk inherent in the 19/20 Budget Plans and the position with regards to investment set aside in relation WNCCG Financial and Contracting Report – Month 12: to national targets. Members endorsed the recommended supporting action/next steps. The key risks that need to be highlighted are: • Further deterioration of the CCG’s underlying

WNCCG Going Concern Assessment: position WNCCG Members agreed and approved that the CCG was clearly a going concern and it was appropriate for the accounts to be prepared on the going concern basis.

Procurement Update Report: The report directed CRCCG Members to the information regarding the Homeless and Asylum/Refugee Alternative Provider Medical Services contract, confirming that the two new contracts went live on 1st May. Members noted and were Matters referred to the Governing Body for assured as to the progress of the current procurements. approval, debate or further consideration:

Performance Report – Month 11: The key issues for both The Committee recommended approval of the CCGs were continued under achievement of Referral to draft policy on Conditions for which over the Treatment (RTT), A&E 4 hour waits, cancer targets and counter (OTC) items should not routinely be cancelled operations. Ophthalmology patients had been prescribed to the Governing Body, subject to mismanaged by GEH due to a process failure, the CCG was approval from the Equalities Lead. assured that all appropriate actions were being taken. This issue would be escalated to NHS Improvement. Members Members were informed that the Closed Governing Body would receive a recommendation noted the report, including the clinical risk in relation to ophthalmology. on the NHS 111 service procurement.

Key Information:

• Committee Chair: Chris Stainforth (Lay Member) • CCG Lead: Clare Hollingworth (Chief Finance Officer) • Date of Next Meeting: 6th June 2019 Blank Page CRCCG / WNCCG Finance and Performance Committee (F&P) Report for the Meetings in Common held on 6th June 2019

Achievements/Decisions Made/Items to Note Key Issues for the Governing Body

Coventry Walk-in Centre (WiC) – National Urgent Treatment Centre Strategy: Members approved the None extension of the existing WiC sub contract between UHCW and VHC for 12 months until September 2020.

CRCCG and WNCCG Financial and Contracting Report – Month 12:lllllllllllllllll Members noted that both CCGs received an unqualified audit opinion and achieved their agreed control totals for the year 2018/19.

2019/20 Financial Plan & QIPP – Update: Members endorsed the proposed monitoring arrangements for ‘in-house’ QIPPs and both the proposed delivery mechanisms and the proposed monitoring arrangements for joint QIPP/CIP work programmes with Providers.

Transforming Care Programme update on the end of year financial position for 2018/19 and proposed risk share arrangements for 2019/20: Members agreed to the proposed fairs shares agreement for 2019/20 for adults and children. Adults - FTA income be shared as a % of partners overall package costs for the specified cohort. If there is an overall underspend, this will be held and agreed with partners on how the underspend should be used. Children – FTA income be used to recurrently fund community service developments to improve the admission avoidance offer for children and young people. Members also requested a full and clear assessment of the Matters referred to the Governing Body for 2019/20 financial risk to be included in the report for the July approval, debate or further consideration: meeting. None Approval of new Mental Health Investments: Members agreed that additional information was required and requested a comprehensive paper for discussion at the next meeting.

Procurement update: Members noted and were assured as to the progress of the current procurements.

Performance report – Month 12: The key issues for both CCGs were the continued under achievement of Referral to Treatment (RTT) and A&E 4 hour waits. Dementia diagnosis rates have improved by 3% increase in Coventry and 1% in Warwickshire.

Investment Case for Warwickshire North UPCA for 2019/20: Members agreed to request a further report for the August meeting to include evidence on performance and views on the service from GPs for a decision on whether to continue supporting investment in the service.

Key Information: • Committee Chair: Graham Nuttall (Lay Member) • CCG Lead: Clare Hollingworth (Chief Finance Officer) • Date of Next Meeting: 4th July 2019 Blank Page NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc T

Report To: Governing Body Meetings in Common

Report Title: Communications and Engagement Assurance Report

Report From: Jenni Northcote, Chief Strategy and Primary Care Officer

Date: 17 July 2019

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision: Assurance:  Information:  Confidential

Purpose of the Report: This report provides an overview of communications and engagement activity undertaken during May – June 2019.

Key Points: NHS Coventry and Rugby CCG and NHS Warwickshire North CCG continued to undertake a full range of communications and engagement activity during the reporting period.

This report outlines how both CCGs have met their statutory obligations for communications, engagement and involvement in this reporting period.

Recommendation: The Governing Bodies are requested to RECEIVE the report, which is provided for ASSURANCE and INFORMATION.

Implications

Objective(s) / Plans Supports CCG Communications and Engagement statutory obligations. Informs supported by this commissioning and service developments. report: Conflicts of Interest: N/A Non-Recurrent Expenditure: N/A Recurrent Expenditure: N/A Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Performance: N/A Quality and Safety: N/A General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be Equality and Diversity: adjusted in line with any equality analysis or due regard. Any decision that is finalised without being influenced by appropriate due regard could be deemed unlawful. Yes Has an equality impact No  N/A  assessment been undertaken? (attached)

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc T

(Delete as appropriate) Patient and Public The report details patient and public engagement undertaken Engagement: There has been clinical engagement in a range of communications and engagement Clinical Engagement: activity detailed within this report The report provides assurance that the CCG is undertaking its duties in respect to Risk and Assurance: patient/public/stakeholder and clinical engagement.

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc T

NHS Coventry and Rugby CCG and NHS  We received Healthwatch Warwickshire’s Warwickshire North CCG continued to undertake a engagement report on the long-term plan. full range of communications and engagement This engagement, commissioned by NHS activity during May and June 2019. England and Healthwatch England, asked residents of Coventry and Warwickshire to This report outlines how both CCGs have met their complete a number of surveys aimed at what statutory obligations for communications, people wanted to see to make care better, engagement and involvement in this reporting period, get people the support they need, as well as as set out by NHS England’s Patient and public questions around specific long term participation in commissioning health and care conditions. The results of this survey will help guidance: inform the CCG commissioning intentions for 19/20. Summary and key highlights Demonstrate public involvement in annual Both CCGs “Outstanding” in the Improvement reports and assessment framework audit 18/19 for patient  We are finalising a summary annual report and public involvement ready for our upcoming AGMs – this Both Coventry and Rugby CCG and Warwickshire summary version is a more public-friendly North CCG were awarded Green Star / Outstanding summary of the full report and highlights the rating for patient and public involvement in this year’s achievements and outcomes for the year, as IAF audit. well as our performance against statutory measures. The Improvement and Assessment Framework audit  We are currently arranging this year’s AGM is conducted each year by NHS England and is split for both CCGs. Dates are currently into “indicators”. Indicator 57 – compliance with scheduled for 24th July for WN and 25th July statutory guidance on patient and public participation for CR. In addition to the typical AGM in commissioning health and care – 166a looks at business, we are planning an in-depth how the CCG evidences implementation of the engagement session with participants on the revised statutory guidance on patient and public long-term plan and other health and care participation in commissioning health and care and system initiatives and priorities. therefore compliance with the statutory duty to involve the public (section 14Z2). Promote and publicise public involvement  We have used a variety of methods to The scoring is based on a RAGG* system: promote and publicise involvement such as Red – Inadequate surveys, social media, face to face meetings, Amber – Requires improvement our website and through our contacts in the Green – Good community and voluntary sector Green star - Outstanding  We attended Healthwatch Coventry’s steering group in June to update on POD, Involve the public in governance APMS and the future of health  We supported another Patient Group Forum commissioning meeting in June. Topics discussed included a  We will soon be promoting opportunities for full update on primary care including people to get involved in the future of health networks, digital, workforce and the new commissioning and the NHS long-term plan, primary care strategy. all tied in with engagement on the 5 year refresh for the local health and care system Explain public involvement in commissioning plans/business plans Assess, plan and take action to involve  We sent the CCG primary care strategy out  We are still planning how we will involve to key stakeholders for review and comment. patients, the public and wider stakeholders in Participants included patients and public reps the localisation of the NHS Long Term Plan and stakeholders across Coventry and and the STP 5 year refresh Warwickshire to understand if the ambitions  We have spoken to over 200 people across we have for primary care are the right ones 29 venues in Coventry and Warwickshire and whether or not they felt anything else about planned care services to understand should be included. what they find important and what they’d like  We planning the next stage of engagement for the future of health commissioning with to see improve for planned care in the future. key stakeholders including patients and the All frontline staff engagement is also public, our membership and partner complete, with sessions held at GEH, organisations. UHCW, and Rugby St Cross (and the South Warwickshire Foundation Trust (SWFT)

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NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc T

sessions previously completed Aug-Oct  A Health and Wellbeing event is being 2018). organised for Saturday 14th September 2019  We conducted a second round of (11am – 3pm) at Chilvers Coton School in Nuneaton. The event will be led by EQuIP engagement around maternity and paediatric who will work closely with, CCGs, Public services with mothers, mothers to be, Health, Local Authority, voluntary and families, carers, frontline staff and the community organisations and members of community and voluntary sector to “check the public and challenge” our response to their feedback last year. The feedback had been collated into a number of themes or “desirable criteria” including access, person- centred care and service and workforce and quality of care. We asked participants if the themes still made sense, resonated with them, if there was anything they felt missing etc. A full engagement report on our findings is being produced.

Feedback and evaluate  Following extensive engagement with patients, the public and carers of those with dementia, the CCG agreed arrangements in WN to access the Admiral Nurse service to better meet the needs of those living with dementia  The CCG have also provided support via a community services provider to develop a training offer for carers of those with dementia

Implement assurance and improvement systems  We received notification from NHS England that they will not be conducting the annual 360 survey next year as they feel it no longer fit for purpose in light of the changing landscape of commissioning  We received our IAF audit results for indicator 57 – compliance with statutory guidance on patient and public participation in commissioning health and care.

Advance equality and reduce health inequalities  Our planned care engagement has been heavily targeted against the protected characteristics criteria and so far we have spoken to patients from the following groups to listen to their experience of accessing planned care services, what they think works and what they’d like to see improve: o Young people o BME groups including o Travellers and Romany gypsy community o LGBTQ+ o Older people o People with mental health needs or learning disabilities o Working age people o Homeless and vulnerably housed Page 4 of 4