West Essex Clinical Commissioning Group Board Meeting in Public Conference Room, Harlow Health Resource Centre Thursday 27th September 2018 at 9.30am

AGENDA

1. Apologies for absence:

2. Declaration of interests Dr Rob Gerlis Verbal 9.30am i. Register of interest update (to note) Dorothy Blundell Attached

3. Clinical Vice Chair appointment (to ratify) Andrew Geldard Attached 9.35am

4. Minutes of the Board meeting in public held on Dr Rob Gerlis Attached 9.40am Thursday 26th July 2018 (to approve)

5. Matters arising from the minutes of the last Board Dr Rob Gerlis Verbal 9.45am meeting (not covered by the agenda)

Standing Items:

6. Patient story (to note) Bobbie Graham Verbal 9.50am

7. Chairman’s report (to note) Dr Rob Gerlis Verbal 10.00am

8. Chairman’s action (to ratify) Dr Rob Gerlis Verbal 10.05am

9. Chief Officer’s report (to note) Andrew Geldard Attached 10.10am

Strategic Items:

10. Addressing social isolation (to approve) Mike Gogarty Attached 10.40am

11. Integrated Care Programme: James Roach 10.55am i. Proposed ICP governance model (to Attached approve)

ii. ICP delivery plan (to note) Attached

12. Emotional wellbeing and mental health service Jess Thom Attached 11.10am (EWMHS) update (to note)

13. Hertfordshire and West Essex STP 11.20am i. STP Estates Plan (to approve) Peter Wightman Attached

ii. STP update report (to note) Andrew Geldard Attached

Business Items:

14. Safeguarding children and adults annual report Christine Muirden Attached 11.35am 2017-18 (to note) and Phillippa Uren

1

15. Emergency planning, resilience and response Dorothy Blundell Attached 11.45am (EPRR) NHS England core standards (to approve)

16. Policy summary report (to note) Dorothy Blundell Attached 11.50am

17. Red risk report (to approve) Dorothy Blundell Attached 11.55am

18. Board assurance framework (to approve) Dorothy Blundell Attached 12noon

19. Reports from CCG Board Committees (to note): 12.05pm

i. Report from Finance and Performance Dr Rob Gerlis Attached Committee and minutes of the meetings held on 26th June and 31st July 2018 ii. Report from Quality Committee and minutes Jane Kinniburgh Attached of the meeting held on 3rd July 2018 iii. Report from Executive Health and Care Dr Rob Gerlis Attached Commissioning Committee and minutes of the meetings held on 21st June and 19th July 2018 iv. Report from the Audit Committee and Stephen King Attached minutes of the meetings held on 18th July 2018 v. Report from the Primary Care Commissioning David McConnell Attached Committee and minutes of the meeting held on 18th July 2018 vi. Report from the Remuneration Committee Bobbie Graham Attached held on 30th August 2018

20. Any other business Dr Rob Gerlis Verbal 12.15pm

21. Date of next meeting:

The next meeting of the West Essex Clinical Commissioning Group Board will be held on Thursday 29th November in the Council Chamber, Uttlesford District Council offices, Saffron Walden.

End of formal meeting

22. Questions from members of the public Verbal

Resolution to Exclude the Press & Public

As per Section 1 (2) of the Public Bodies Act 1960 (Admissions to Meetings) the Press and Public are excluded from the remainder of the meeting.

2

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 2i

Date of Meeting: 27th September 2018

Report title: Register of Interest

Author: Dannii Owens, Governance Officer Clinical lead (where N/A appropriate): Presented by: Dorothy Blundell, Director of Corporate Services

Recommended actions / The main Register of Interest for decision makers will be uploaded to next steps the internet.

 The next update will be due January 2019.

The Board is asked to: Note the report and advise of any changes.

Executive summary This report details the Declarations of Interests for all members of (maximum 500 word limit) the Board. and purpose of the report: All decision makers will receive a six monthly request to update or confirm their Declaration of Interest, in line with the new Managing Conflicts of Interest Policy.

A Register of Interest for all decision makers will be uploaded to the internet.

CCG Committees / Groups None previously consulted Equality Impact Analysis Not applicable Key issues and risks: None identified Links to CCG The Register of Interests report supports all of the Strategic strategy/objectives Objectives Checklist for completion with all reports: Indicate implications for: Patient and public None identified engagement Resources None identified Health outcomes None identified Quality & Performance None identified Information Governance None identified Legal and/or Procurement None identified Issues Conflict of interests The report details any conflicts of interest the members of the committee have. Francis, Berwick and Keogh Supporting recommendations of:- recommendations Implementing the recommendations – Putting the patients first  F 1&2, B 1,3,5, K 8,

Embedding values and principles  F 9

Principles of Openness and Transparency  F 173, B 5

3

NHS West Essex Clinical Commissioning Group – Board Register of Interests September 2018

Name Current Declared Interest (Name of the organisation Type of Is the Nature of Date of Interest Action taken Date position(s) and nature of business) Interest interest Interest to mitigate signed and

held in the direct or risk confirmed

CCG i.e. indirect Governing ?

Body member; Committee member; Member From To practice; CCG employee or

other Interest Financial

Financial Personal Interest Personal Financial

-

Financial Professional Interest Professional Financial

-

Non Non Amik Harlow Locality GP Partner in Old Harlow Health Centre Verbal Signed Aneja GP √ - - Direct GP Partner - Current declaration to 06/09/2018 Representative Old Harlow Health Centre is a shareholder in Stellar be made at the Healthcare beginning of √ - - Direct Shareholder - Current any meeting

Andrew Chief Officer Spouse is Deputy Director of Finance - Mid Essex Verbal Signed Geldard Hospital - - √ Indirect - Ongoing declaration to 03/09/2018 be made at the I work in a self-employed basis with HFMA on the beginning of delivery of their MBA in Healthcare Business Finance Ongoing any meeting √ - - Indirect - at present

Angus Deputy CMO, GP Partner in Stansted Surgery Verbal DOI Signed Henderson West Essex √ - - Direct Professional Jan-16 To date declaration to 08/01/2018 - CCG be made at the No changes

4

Stansted Surgery is a shareholder in Uttlesford Health beginning of confirmed √ - - Direct Professional Jan-16 To date any meeting 23/07/2018

Sessional GP for PELC √ - - Direct Professional 2012 To date Deputy Chief Medical Officer (previously clinical commissioner) for NHS West Essex CCG - √ - Direct Professional 2013 To date

Involvement in Anglia Ruskin research project – co- working with CCG to design pain self-management tool for older adults - √ - Direct Professional 2016 To date

Representative for West Essex on 2 STP groups - prevention group and technology group (technology group with focus on business intelligence/risk stratification tools using MedeAnalytics) - √ - Direct Professional 2016 To date

Wife employee of Anglian Community Enterprise - - √ Indirect Personal Oct-17 To date

Bobbie Lay Member - No Interests declared Verbal Signed Graham PPE declarations to 25/01/2018 - be made at the No change ------beginning of confirmed any meeting 17/07/2018

Christine Chief Medical GP Principal and Partner in The River Surgery, Verbal Signed Moss Officer Buckhurst Hill √ - - Direct Professional Oct-90 To date declaration to 27/07/2018 be made at the The River Surgery is a shareholder in Stellar beginning of Healthcare √ - - Direct Professional Apr-14 To date any meeting

5

STP Cancer Clinical Lead - 3.5 hours per week - Responsible for contributing clinical leadership to the activities within the STP 1st 1st - √ - Direct Professional Septemb Septemb er 2017 er 2019

Whilst a recorded disclosure has been made, consent is not given for this information to be published. Reasons for this non-disclosure are recorded, with any conflict being raised if relevant. 22nd - √ - Direct Professional Novembe To date r 2012

Support Anglia Ruskin University for research purposes - √ - Direct Professional 2016 To date

David Lay Member - Chair Accuro Care Services Verbal Signed McConnall Primary Care - √ - Indirect Professional Nov-16 Present declaration to 20/02/2018 - be made at the no change Wife sits as Judge on CQC and Mental Health cases beginning of confirmed (not Essex) - - √ Indirect Personal Sep-17 Present any meeting 17/07/2018 Wife is lead judge in special educational needs tribunal (EHC plans) - - √ Indirect Personal May-16 Present

Dean Director of Trustee of Association of Chartered Certified Verbal Signed Westcott Finance, Accountants (ACCA) Staff Pension Scheme declaration to 28/10/2016 Contracting & be made at the - No change Performance beginning of confirmed - √ - Indirect Professional - Current any meeting 15/03/2017, 11/10/17 & 23/07/2018

6

Dorothy Director of No Interests declared Verbal Signed Blundell Corporate declaration to 13/11/2017 - Services be made at the no change ------beginning of confirmed any meeting 17/07/2018

Duncan Secondary Care Provide a Specialist Parkinson's service at Saffron Verbal Signed Forsyth Advisor Walden Community Hospital to some WECCG declaration to 28/10/2016 - residents be made at the No change beginning of confirmed ------any meeting 28/03/2017, 11/10/17 & 17/07/2018

Gagan Board Member Deputy Chairman, Essex Conservatives Verbal Signed Mohindra - √ - Indirect Professional Sep-16 To date declaration to 30/08/2018 be made at the Councillor, Epping Forest District Council Cabinet beginning of Member, Finance June 2006 / any meeting - √ - Indirect Professional To date May 2015

Councillor, Essex County Council Cabinet Member - May Economic Development 2017 / - √ - Indirect Professional To date May 2018 Chairman of Governors, Epping Forest College - √ - Indirect Professional Jan-17 Mar-18

Governor. Ivy Chimneys Primary School - √ - Indirect Professional Mar-15 Aug-18

Chairman, Epping Forest Conservative Association - √ - Indirect Professional Mar-15 Mar-18

Councillor, Chigwell Parish Council - √ - Indirect Professional May-04 Mar-17

7

Ian Perry Board GP Dr Kandasamy is one of my GP Partners and a GP Verbal Signed Representative - Member of the Local Medical Committee North Essex declaration to 30/08/2018 Epping Forest / - - √ Indirect Professional present be made at the Primary Care beginning of Clinical Lead any meeting Dr Tharma will be (from September 2018) another of my GP Partners and is a Orthopaedics GPwSI Stellar Healthcare - - √ Indirect Professional present

GP Partner in Maynard Court Surgery √ - - Direct Professional Jun-16 To date

Maynard Court Surgery is a shareholder in Stellar Healthcare √ - - Direct Professional - To date

Maynard Court Surgery currently planning premises Will not be a development member of the Completi - √ - Indirect Professional Jun-16 Estates on (2019) Steering Group James Programme Director - Conclusio Ltd - Advisory / Social Care Verbal Signed Roach Director declaration to 23/01/2018 - Accountable be made at the Confirmed Care beginning of no change any meeting - 30/08/2018 √ - - Direct Financial Mar-14 Current Ensure no direct links with West Essex CCG

Jane Director of No Interests declared Verbal Signed Kinniburgh Nursing & declaration to 30/07/2018 Quality be made at the ------beginning of any meeting

8

Jen West GP Board Shareholder as partner in practice of Uttlesford Health Verbal Signed Member √ Direct Professional 2009 present declaration to 23/05/2017 - be made at the confirmed no Partner, Newport Surgery beginning of change any meeting 13/10/17 & √ Direct Professional 2001 present 17/7/2018

Kamal GP Board GP with Special interest contracting with Stellar Verbal Signed Bishai Member Healthcare - - √ Direct GP - Current declaration to 16/03/2017 - be made at the No change beginning of confirmed Sessional GP within West Essex CCG - - √ Direct GP - Current any meeting 12/10/2017 & Director of Ophthalmic Solutions Ltd company 05/08/2018 06282864 (a non-trading company) Secondary - - √ Indirect - Current employment

Maggie Consultant in Consultant in Public Health for MECCG Verbal Signed Pacini Public Health declaration to 09/03/2017 - - √ - Direct Professional - Ongoing be made at the Confirmed beginning of no change any meeting 22/01/2018 Conflict would be raised if relevant & 17/07/2018 - - √ Indirect Personal - Ongoing

Peter Director of No Interests declared Verbal Signed Wightman Primary Care declaration to 15/08/2018 and Localities ------be made at the beginning of any meeting Peter Lay Member - Specialist Advisor - CQC Verbal Signed Boylan Quality declaration to 12/01/2017 - √ - Direct Personal - Current be made at the - No change beginning of confirmed District Councillor - East Hertfordshire any meeting 10/04/2017, 11/10/17 & - √ - Indirect Personal - Current 17/07/2018

9

Rob Gerlis CCG Chair Verbal Signed GP Locum at Ross Practice and potentially other √ - - Direct Professional - Current declaration to 01/11/2017 - practices be made at the No change beginning of 30/07/2018 Member of East of England Senate - √ - Direct Professional - Current any meeting Joint Clinical Lead for STP √ - - Direct Professional - Current

Vice Chair for STP Chairs Oversight Board √ - - Direct Professional - Current

Wife Dr K Gerlis – Advisor at Ross Practice & GP at - - √ Direct Personal - Current Stellar Healthcare & CCG advisor on dermatology

Stephen Lay Member - Sightsavers International :Trustee All: Verbal Signed King Governance declaration to 24/07/2018 4th July - √ - - Professional 2005 be made at the 2018 beginning of any meeting

Chair: IAPB Trading Ltd : Charity Trading arm of None charity, Internaional association for the Prevention of envisaged: Blindness www.iapb.org Organisation - - √ - Personal 2010 date mainly works in developing world. RNIB Pension Scheme: Trustee www.rnib.org.uk None - - √ - Personal 2016 date envisaged Chair, Stroke association www.stroke.org.uk Declare and recuse from any decisions related to 01/08/20 contracts or - - √ - Personal date 17 grants to the charity. Note conflict when discussing stroke matters. Harper Collins Executive Pension Scheme None 01/05/20 www.harpercollins.co.uk - - √ - Personal Date envisaged 18

10

Wife is volunteer at Aphasia Support group in To be declared Bishops Stortford at meetings when - - √ Indirect Personal 2012 date appropriate. No conflicts foreseen Terence Essex County Member - Essex County Council Verbal Signed Cutmore Council Rep - √ - Indirect Professional May-13 Current declaration to 01/02/2017 - Member - Rochford District Council be made at the confirmation - √ - Indirect Professional May-99 Current beginning of of no change any meeting 12/10/2017 Governor - Southend University Hospital Trust - √ - Indirect Professional Jun-14 Current Chairman - Castlepoint and Rochford Health and Wellbeing Board - √ - Indirect Professional May-13 Current

Member - Essex Health and Wellbeing Board - √ - Indirect Professional Apr-12 Current Toni Coles Director of No Interests declared Verbal Signed Transformation declaration to 01/06/2016 - be made at the No change beginning of confirmed ------any meeting 15/03/2017, 11/10/17 & 18/07/2018

11

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 3

Date of Meeting: 27th September 2018

Report title: Clinical Vice Chair appointment

Author: Ian Tompkins, Assistant Director of Corporate Services

Clinical lead (where appropriate): Presented by: Andrew Geldard, Chief Officer

Recommended actions / To complete appointment of Clinical Vice Chair of the next steps Board

The Board is asked to: Ratify the appointment of the Clinical Vice Chair of the Board

Executive summary This report states the outcome of the procedure to invite (maximum 500 word expressions of interest to become Clinical Vice Chair of limit) and purpose of the the Board following the appointment of six GP Board report: members in July 2018.

CCG Committees / CCG Board Groups previously consulted Equality Impact Analysis The process for recruitment of the six GP Board members (EIA) – state the and subsequent appointments of a Chair and Clinical outcomes and how will Vice Chair of the Board was carried out in accordance any detrimental impact with the CCG’s Constitution, based on NHS England’s be mitigated and constitution template. The Constitution sets out how the monitored or state where CCG will meet the public sector equality duty and the an EIA is not applicable arrangements in place to discharge this function. and why

Key issues and risks: None identified

Links to CCG All strategy/objectives

Checklist for completion with all reports:

Indicate implications for:

12

1. Patient and public N/A engagement 2. Resources This report does not seek any additional resources. The resource requirement to support the appointment of the GP Board members and chair/vice chair has been factored into this year’s budget. 3. Health outcomes N/A 4. Quality and N/A Performance

5. Information N/A Governance

6. Legal and/or The process carried out by the North & South Essex LMC Procurement issues and subsequent Board member appointments meet the requirements of the NHS (Clinical Commissioning Group) Regulations 2012. The statutory powers and duties of Clinical Commissioning Groups, and their Board, can be found in Parts 1 and 2A of the Health and Social Care Act 2012. 7. Conflict of interests No potential conflict of interest issues have been identified in relation to the appointment process.

8. Francis, Berwick and CCG Constitution and governance arrangements. Keogh recommendations

13

Appointment of Clinical Vice Chair to CCG Board

In compliance with paragraphs 6.6.4.2 and 6.6.4.3 of NHS West Essex CCG’s Constitution - the Chair and the Clinical Vice Chair of the Board are nominated from the six elected GP members to the executive body. This membership is equally represented across the three localities of West Essex

All GP elected members serve a term of no more than 3 years after which, each position is subject to re-appointment. Following elections conducted by North and South Essex LMC, and the subsequent appointment of six GPs to West Essex CCG’s Board in July 2018, the Chief Officer invited each of them to lodge an expression of interest by 19th July to become Chair and Clinical Vice Chair of the Board.

The Chair, Dr. Rob Gerlis, was subsequently appointed. However, the process for the Vice Chair position had to be re-run due to no expressions of interest being received by the due date.

A second process was run from 21st to 28th August. One expression of interest was then received from Dr Angus Henderson. The expression of interest was reviewed by a panel including the Chief Officer, Lay member for Governance and Lay member for Quality, who have confirmed that the individual meets the necessary criteria for the post.

The Board is therefore asked to ratify Dr Henderson’s appointment as Clinical Vice Chair.

A copy of the associated correspondence is attached as Appendix 1. The job description for the Clinical Vice Chair is attached as Appendix 2.

Appendix 1 - Appendix 2 - Vice associated correspondence.pdfChair job description.pdf

14

Minutes of West Essex Clinical Commissioning Group Board Meeting in Public held in the Conference Room, Harlow Health Resource Centre on Thursday 26th July 2018

Present: Andrew Geldard Chief Officer Bobbie Graham Lay Member, PPE Cllr Gagan Mohindra West Essex District Councils Representative Cllr Terry Cutmore Member of Essex County Council David McConnell Lay Member, Primary Care Dean Westcott Director of Finance, Contracting and Performance Dorothy Blundell Director of Corporate Services Dr Amik Aneja GP Board member Dr Jen West GP Board member Dr Rob Gerlis CCG Chair Dr Angus Henderson GP Board member Dr Christine Moss Chief Medical Officer David Wallace Interim Deputy Director of Nursing and Quality Maggie Pacini Consultant in Public Health Peter Boylan Lay Member, Quality Stephen King Lay Member, Governance and Deputy CCG Chair Tracy Manzi Assistant Director, Primary Care and Localities

In attendance: James Roach Programme Director, Integrated Care Liz Cutts Minutes Lance McCarthy Chief Executive, Princess Alexandra Hospital (for item 58/18 only) Prof Nancy Fontaine Chief Nurse, Princess Alexandra Hospital (for item 58/18 only)

Apologies: Dr Kamal Bishai Clinical Vice Chair Duncan Forsyth Secondary Care Consultant Jane Kinniburgh Director of Nursing and Quality Peter Wightman Director of Primary Care and Localities Toni Coles Director of Transformation

57/18 Declaration of Interest

The following declarations of interest were made by members of the Board in relation to the specific agenda items:  Cllr Gagan Mohindra advised the Board that he sits on the PAH Strategic Outline Case (SOC) Steering Group and on the Essex County Council Cabinet.

58/18 Princess Alexandra Hospital – Care Quality Commission Update 15

Professor Nancy Fontaine gave a presentation to the Board on the latest CQC rating for the Trust and the ongoing work to achieve an ‘outstanding’ rating.

She highlighted that, since last attending the CCG Board, the Trust have moved out of special measures and ‘inadequate’ and, following a further inspection by the CQC, have received a rating of ‘requires improvement’. Nancy highlighted that improvements have been made across the service ratings, with the Trust receiving a ‘good’ rating in well led, effective and caring services.

Nancy noted the key areas, which were highlighted as good or improved also included good incident reporting and learning from incidents, individual patient needs taken into account and committed to improving services. The areas of concern included mandatory training levels, the appraisal rate, nursing staffing levels, patient flow around discharges and the emergency department.

Nancy highlighted that the Trust have been successful in recruiting and have a healthy pipeline of new starters over the next few months, as part of the overall recruitment programme including local, national and international campaigns. She noted the Trust have focused on band 4 and trainee Nurse Associates, have developed clinical practitioner roles and have improved staffing in the emergency department, using a mix of different staff in the team. She also highlighted that 40 additional nurse posts have been added to the budget for 2018/19.

The refurbishment of the front door of the emergency department has received positive feedback from patients and improved the working environment for staff. Nancy highlighted this has been part of an overall piece of work on estates and capital undertaken by the Trust.

She advised that the Trust have a quality improvement plan, in which all the executive team have a role, and the plan is presented to the Executive Management Board, Quality and Safety Committee and the Board. To ensure the momentum continues, NHS Improvement chair a bi-monthly System Improvement Board, which is attended by system partners including the CCG, Healthwatch and the CQC, and undertakes detailed scrutiny of the quality improvement plan. The Trust also attend monthly scrutiny meetings with the CCG.

Nancy advised the Board that one of the criticisms of the CQC in 2016 was a lack of vision for the future and Lance McCarthy has clearly articulated future plans for the Trust, which are being developed with system partners. These include the five P’s programme, focusing on patients, people, performance, places and pounds, and the Trust’s 5 year plan to achieve an ‘outstanding’ CQC rating.

Dr Rob Gerlis thanked Nancy for her presentation.

James Roach noted the progress the Trust have made in relation to workforce issues and suggested that a system wide approach to retention and development of staff is required. Nancy agreed and suggested a system to allow future leaders to rotate through the system to understand other areas, such as CCGs and primary care, through a West Essex leadership programme.

Cllr Terry Cutmore asked whether, as part of the development of a new hospital in Harlow, there were plans for any specialisms. Nancy confirmed that Harlow will continue to be a District General Hospital, with joined up care for patients being provided through the sustainability and transformation partnership across West Essex and Hertfordshire.

Dr Christine Moss asked about progress in recruiting to the medical workforce. Nancy confirmed that the Trust have recruited a significant number of high calibre consultants across a number of recruited 13 consultants in 2018 and the areas which are proving challenging to recruit to are middle grade and junior doctors, where the Trust are aiming to develop innovative roles.

16

Dr Amik Aneja asked about flow through the hospital and failed discharges. Nancy confirmed that failed discharges are monitored from an incident perspective and are monitored closely. She highlighted that there is currently planning for additional capacity over the winter period to support flow.

Bobbie Graham asked about engagement with schools and colleges to support recruitment. Nancy confirmed that she spoke regularly at schools and colleges last year and the Trust offer work experience placements and apprenticeships through Harlow College.

Peter Boylan noted the improvement in the Trust’s well led rating and highlighted the amount of work, across the organisation and at all levels, that is required to achieve this. He noted that Nancy will be leaving the Trust and wished her well for her new role in Norfolk.

Cllr Gagan Mohindra asked how the Board could support the Trust to continue the improvement. Nancy highlighted the development of the ICP and areas of joint working, such as infection control and tissue viability, and support with patient flow and the increase in demand in accident and emergency services.

Lance McCarthy then gave a presentation to the Board on the development of a new hospital in Harlow. He highlighted the need for a new building, which will be fit for purpose to provide local people with a range of integrated services, including community and primary care.

Lance outlined the process commenced with the submission of a strategic outline case (SOC) to NHS England in July 2017. Following national changes to the assurance process, the next steps will include an assurance process through NHS England and NHS Improvement before being submitted for approval to the treasury and the Department of Health and Social Care. A pre- consultation business case (PCBC) is now required, which will be developed with the CCG, to be completed by the end of September. This will be taken to the Essex Health Overview and Scrutiny Committee in September, who will be approached for a view regarding formal public consultation. Engagement on the model of care will focus on the need for high quality District General Hospital services locally, including accident and emergency services.

Lance highlighted that the Trust are currently considering two new potential sites and the existing site for the development and will undertake a site selection process before jointly consulting with the local authority as part of the wider housing and associated infrastructure for the placement of the new hospital. This process will include looking at the implications on infrastructure and the potential patient population, the feasibility of the site, implications for patients and workforce and for ongoing revenue.

He noted that the next steps are to complete the PCBC and develop a detailed and high quality patient engagement plan, when sufficient detail is known. It was noted that the government have identified the need for ten new hospitals across the Country, and have confirmed that PAH are included in that group. Lance highlighted that support that has been received from local MPs, District Councils and the CCG, particularly noting the support of Robert Halfon, MP for Harlow.

Andrew Geldard confirmed that the development of the new hospital links closely to the development of the Integrated Care Partnership (ICP) in West Essex and gives it purpose for the next few years.

Rob thanked Lance and Nancy for their presentations and, on behalf of the Board, thanked Nancy for her work across the system and wished her well for her new role in Norfolk.

59/18 GP Board Member and Chair/Vice Chair Appointments

17

Andrew presented a paper to the Board, detailing the process undertaken to appoint 6 GP Board members, with two GPs each for Epping Forest, Harlow and Uttlesford localities respectively.

The Local Medical Committee (LMC) administered an appointment process for these roles and confirmed that applications were received from Dr Amik Aneja and Dr Rob Gerlis for Harlow, Dr Angus Henderson and Dr Jen West for Uttlesford and Dr Naveed Akhtar, Dr Kamal Bishai and Dr Ian Perry for Epping Forest. As three GPs responded in Epping Forest, the LMC held an election which resulted in Dr Kamal Bishai and Dr Ian Perry being elected.

Following completion of the LMC’s process, Andrew confirmed he wrote to the six GPs to invite them to express an interest in the roles of Chair and Vice Chair. Andrew updated that one expression of interest was received for the role of Chair, from Dr Rob Gerlis. A panel including Andrew, Stephen King and Peter Boylan reviewed and assessed the application against the requirements of the role and agreed that Rob should be re-appointed. No expressions of interest were received for the role of Clinical Vice Chair and a second process will therefore be run before the September Board meeting.

The Board ratified the appointment of Dr Amik Anjea, Dr Jen West, Dr Angus Henderson, Dr Kamal Bishai and Dr Ian Perry as GP Board members and the re-appointment of Dr Rob Gerlis as Chair.

60/18 Minutes of Meeting of the West Essex Clinical Commissioning Board on 31st May 2018

The minutes of the meeting of 31st May 2018 were agreed as a true and accurate record and signed by the Chair.

61/18 Matters Arising

45/18 – Workforce Reporting

David Wallace confirmed it is anticipated that updated workforce reporting will be available for the September Board meeting.

Cllr Gagan Mohindra left the meeting.

48/18 – Outcome – Learning Disabilities

Dorothy Blundell confirmed that the full detail of the operational plan outcome relating to learning disabilities – reliance on specialist IP - is included within the action log.

49/18 – Integrated Urgent Care Procurement

It was noted that the scenario and contingency planning for a change in provider over the winter period will be included in the mobilisation plan being presented to the Board in September.

62/18 Patient Stories

Bobbie Graham shared two patient stories with the Board.

18

The first story related to a child under the care of a Birmingham Children's Hospital specialist who had requested that the local GP prescribe growth hormones. Prescribing and monitoring of these hormones is outside the GP’s competency and they were unable to take clinical responsibility for overseeing this prescription. Birmingham Children’s Hospital was not able to fund the medication. With the help and negotiation of the CCG’s medicines management team, an agreement was reached for NHS England to fund the treatment and for Birmingham Children’s Hospital to prescribe, monitor and supply.

The second story related to a patient who had waited a long time to receive an appointment to see a neurologist at PAH. As a result, the patient felt she had no alternative but to arrange to see a consultant privately, therefore not requiring the appointment at PAH. The patient experienced difficulties in cancelling her appointment at PAH after many attempts but, with the help of the PALS Team at PAH, the appointment was eventually cancelled. The patient was left extremely frustrated, not only because of the wait for an appointment, but because it was so difficult to cancel it.

The Board discussed and noted the patient stories.

63/18 Chair’s Report

Dr Rob Gerlis advised the Board that he has completed appraisals and objective settings for Board members and the Chief Officer.

He noted that he attended a GP shutdown on 5th June, which focused on cancer services and had good representation from secondary care across the STP.

Rob highlighted that he met Sheila Salmon, Chair at Essex Partnership University Trust (EPUT) and they will be meeting again, with Andrew Geldard and Sally Morris, Chief Executive at EPUT, at the beginning of October.

Rob advised that he has attended a number of sessions arranged for the STP system to discuss the development of integrated care across the system and sat on the panel for interviews for the STP’s Director of Strategy. He also continues to attend a number of meetings as joint STP clinical lead including the Clinical Oversight Group.

Rob also highlighted there was a well received Board to Board session, with East and North Herts and Herts Valleys CCG Boards, on 21st June.

64/18 Chair’s Action

Rob advised the Board that he took a Chairman’s action on 12th June 2018 to approve the recommendation to award the contract for Specialist Healthcare Adult Learning Disabilities Services to Hertfordshire Partnership NHS Foundation Trust for a period of 7 years with the option to extend for a further 2 years.

The Board ratified the Chairman’s action.

65/18 Chief Officer Report

19

Andrew Geldard presented the Chief Officer’s report to the Board.

Andrew highlighted to the Board that the CCG received its annual assessment from NHS England for 2017/18 and was rated as ‘good’ for the second year. The CCG continues to aspire to receive an ‘outstanding’ rating and will continue to work towards this.

He noted that he has been linking with STP colleagues regarding the review undertaken by Carnall Farrar, focusing on progression towards an integrated care system and highlighted that the STP will be recruiting an independent Chair in the autumn.

Andrew advised the Board that he has also been meeting with groups of CCG staff and has been impressed with the feedback he has received, finding staff generally buoyant and motivated but keen to be clear on the future priorities for the STP and ICP.

Andrew noted he has been meeting with the Chief Executives of the three local District Councils and he and the Chair will be meeting with the leaders and Chief Executives to improve relationships and to continue to work together.

He noted that Duncan Forsyth has emailed regarding the workforce elements of the Chief Officer report, to ask that the Board are reminded of his previous comments regarding increasing pressures on the NHS and how these contradict with demography and that there will be future workforce challenges.

David Wallace reported that, for the year to date, there have been 2 cases of community acquired MRSA bloodstream infections for West Essex patients. PAH have had no hospital attributed cases and Barts Hospital have had 1 case.

Dr Christine Moss reported that the Hospital Standardised Mortality Ratio (HSMR) for PAH remains statistically ‘higher than expected’ for the 15th consecutive month of reporting. She noted that the diagnostic outliers are cancer of ovary, septicaemia and COPD and bronchiectasis. A new process for monitoring this is being introduced in August, which will include joint meetings with the CCG and Trust.

David noted that PAH have seen an increase in fill rates for day and night shifts for the second successive month and the overall registered nurse vacancy rate is 26%.

He highlighted that the CCG have recruited to a designate professional for safeguarding adults and therefore the pace and scope of assurance to the Board will increase.

Stephen King asked about system workforce planning and Andrew confirmed he has spoken to Lance McCarthy regarding rejuvenating the workforce elements of the ICP, to facilitate this across the system.

Dean Westcott reported that, at month 3, the CCG’s in year financial control total is break even. There are emerging pressures within CHC budgets which are being which, if continue through the year, would equate to a cost pressure of approximately £700k.

Dean noted that it would have been expected that the minimum levels of activity at acute Trusts would underperform more than they currently are, which is a trend being seen across the country.

Dean confirmed that PAH’s performance against the emergency department 4 hour 95% target is improving although July has been an extremely pressured month for the Trust. At month 3, the Trust’s performance against delayed transfers of care was good. The RTT target was missed following the national suspension of elective surgery in January but the Trust are

20

expected to achieve this target in July. PAH also failed to achieve the 62 day cancer standard, primarily as a result of the ongoing urology capacity issue.

Andrew shared the transformation report with the Board.

He highlighted that the integrated urgent care procurement is now live and will be coming back to the Board in due course. The system are working to simplify the front door into A&E at PAH and a new, integrated service will commence in August to bring together minor injuries and illnesses to ensure that only patients requiring acute emergency care go through to the emergency department. There is also a focus on flow through the hospital and a new admission and discharge standard operating procure has been implemented.

Tracy Manzi reported that the general practice extended access service is continuing to deliver an additional 4000 routine appointments per month in the evenings and at weekends. She noted that the Primary Care Commissioning Committee met on 20th June and discussed a number of areas including Angel Lane surgery temporary list closure and the impact on the neighbouring practice, John Tasker House in Great Dunmow. At their July meeting, the Committee reviewed evaluations of the first 9 months of the neighbourhood projects.

Dorothy Blundell advised the Board that the CCG held a celebration for the 70th birthday of the NHS, which was attended by the mayor of Epping.

The Board noted the Chief Officer’s report.

66/18 Quality Strategy

David Wallace presented the quality strategy and implementation plan to the Board.

He noted that the Executive Committee and Quality Committee have both reviewed and commented on the strategy, which sets out how the CCG will transform the way quality is considered and assured, so that it becomes the fundamental essence of all care pathways.

The strategy has been built around the CCG vision, building on the 5 year forward view for health and social care, the development of the ICP and the STP and delegated primary care commissioning.

David highlighted that the paper proposes an implementation plan for the strategy, which recommends that it is run as a project with leads from across the CCG and executive sponsorship.

James Roach supported the strategy and highlighted the need to embed it consistently in contracts and asked how patients would be involved in the process. David confirmed that the project would include patient engagement and patient activation. He noted that the implementation of the strategy would take a whole system approach.

Peter Boylan confirmed his support and noted this is the beginning of a different way of working, progressing integration across the system.

The Board approved the quality strategy and implementation plan.

67/18 Adult Mental Health Collaborative Commissioning Arrangements

Dean presented a paper, on behalf of Toni Coles, outlining the direction of travel for future adult mental health commissioning arrangements.

21

It was noted that the CCG are currently part of a North Essex consortium for adult mental health commissioning and North Essex CCG have served notice on this arrangement, following Mid and South East Essex CCG’s confirmation they wish to withdraw from the arrangement.

Dean highlighted that the existing arrangements would therefore cease on 31st March 2019 although it is expected that new arrangements will need to be put in place earlier than this. There are no options for establishing new collaborative arrangements within Essex and there are existing integrated commissioning arrangements across Hertfordshire.

It was noted that there are therefore 2 options available to consider:

 Option 1- bring the service in house and align functions with the internal CCG commissioning and contracting structures  Option 2 - work with the Hertfordshire integrated health and care commissioning team under a collaborative commissioning arrangement

It was recommended to the Board that the CCG continues to work with colleagues in Hertfordshire to develop proposals based on a new collaboration across the STP footprint and provide a comparator option for bringing the service in house. The CCG will aim to move to new commissioning and contract arrangements at the earliest opportunity, aiming for September 2018 and continue to work with Essex partners regarding transition arrangements. The Executive Committee will oversee the options, on behalf of the Board.

It was noted that a final proposal will be presented to the Board at their September meeting.

The Board approved the recommendations for developing a new adult mental health commissioning service.

68/18 Sustainability and Transformation Partnership (STP) Project Management Office (PMO) Hosting Arrangements

Dean advised the Board that there have been discussions within the STP regarding hosting of the STP and, following the Chief Executives decision that a CCG is best suited to host the STP PMO, West Essex CCG have agreed to take over responsibility from the current host, Hertfordshire Partnership University Foundation Trust.

Dean confirmed that the STP costs will be managed separately and there will be regular reporting to the Finance and Performance Committee and the Audit Committee as appropriate. The majority of staff within the STP PMO are seconded from partner organisations and will continue to be employed by them but, on occasion, there may be the need to recruit externally and these new staff will become employees of West Essex CCG on fixed term contracts. The CCG’s Remuneration Committee will agree the appointment of senior individuals.

Dean presented the draft governance framework agreement outlining the details of this arrangement and highlighted this has been discussed by the Executive Committee and the Audit Committee.

Andrew highlighted that there will be the need to develop this agreement further, as the host role develops, and noted that the STP holds funds of £2.5m therefore decision making must be clear and appropriate. He also highlighted that the CCG will be ensuring there are appropriate arrangements for secondments and the new HR function will be supporting this.

22

The Board approved the STP PMO hosting arrangements.

69/18 Caldicott Guardian Report

Christine presented the bi-annual report from the Caldicott Guardian to the Board. She highlighted that the report includes an update on the national data guardian for health and care’s review of data security, consent and opt-outs and the new data security and protection toolkit and noted that Peter Wightman is the CCG’s named executive member for data and cyber security.

Christine noted that data protection impact assessments need to be completed when a new project starts or if there is a need to change a system or process already implemented within the CCG. 10 assessments were completed in 2017/18 and 2 were completed in the first quarter of 2018/19, with no risks to privacy highlighted as part of the review.

The Board noted the report.

70/18 Annual Senior Information Risk Owner (SIRO) Report

Dean presented his annual SIRO report to the Board.

He noted that the CCG achieved level 2 against all the information governance requirements of the IG toolkit as at 31st March 2018. As part of the annual governance statement, the CCG is required to report on any serious incidents requiring investigation involving personal data reported to the Information Commissioner’s office and Dean confirmed that there were none reported.

Dean thanked Jane Marley, the Head of IG and Data Protection Officer for Essex CCGs, and her team for their hard work in supporting the CCG over the past year.

The Board approved the annual SIRO report.

71/18 Patient Safety and Serious Incident Report – 1st September 2017 to 31st March 2018

David highlighted the patient safety and serious incident report to the Board. He noted the report contains a summary of the serious incidents (SIs) reported to the CCG in quarters 3 and 4 of 2017/18, the findings of closed investigations and the associated learning and recommendations.

David noted that one of the key themes identified within the report is the quality of investigation reports at PAH and the quality team have spent time with providers to develop and improve the reporting, to provide the CCG with assurance.

Maggie Pacini noted that, as Chair of the Child Death Review Panel, the panel do not see the closures of SI actions. David confirmed that the quality team ensure that all actions relating to PAH SIs are closed and test that they have been embedded within the organisation.

The Board noted the report.

72/18 Infection Prevention and Control Annual Report 2017/18

David presented the annual infection prevention and control report to the Board.

23

He highlighted the areas to note include the change to the CCG’s strategic oversight following the ending of the MoU with Mid and North East Essex CCGs and that the CCG did not breach its annual ceiling for c-diff infections.

PAH breached its c-diff ceiling however after successful appeals its contractual outturn was below the ceiling threshold. PAH also reported no hospital MRSA bacteraemia cases. The Trust experienced an extended period of increased incidence of Norovirus affecting adult inpatient wards between January and March 2018 which affected 65 patients, 20 staff with a total of 91 bed days lost.

Barts Health breached its c-diff ceiling by 3, however has shown an overall reduction in Trust apportioned cases during the financial year. Addenbrookes reported 67 c-diff cases in total, which is above their trajectory of 49, however only 16 were attributed following appeal.

The Board noted the report.

73/18 Policy Summary Report

Dorothy Blundell presented the policy summary report to the Board, detailing the policies below which have been approved by Sub Committees of the Board:

 Lone Working policy

The Board noted the policy summary report.

74/18 Red Risk Report

Dorothy presented the red risk report to the Board, noting that the risk register has been reviewed by the Executive Committee, Quality Committee and Audit Committee.

The Board approved the red risk report.

75/18 Board Assurance Framework

Dorothy presented the Board Assurance Framework to the Board, noting that it has been reviewed by the Executive Committee and the Audit Committee. It was noted that the Audit Committee noted inconsistencies in the reporting of cancer risks and these are being work through.

The Board agreed the Board assurance framework.

76/18 Board Committee Reports

i. Finance and Performance Committee

The Board noted the report and minutes of the meetings held on 24th April and 29th May 2018.

ii. Quality Committee

The Board noted the report and minutes of the meeting held on 1st May 2018.

24

iii. Executive Health and Care Commissioning Committee

The Board noted the report and minutes of the meetings held 19th April and 17th May 2018.

iv. Audit Committee

The Board noted the report and minutes of the meeting held on 16th May 2018.

v. Primary Care Commissioning Committee

The Board noted the report and minutes of the meeting held on 16th May 2018.

77/18 Date & time of next meeting

The next meeting of the West Essex Clinical Commissioning Group Board will be held on Thursday 27th September 2018, from 9.30am, in the Conference Room, Harlow Health Resource Centre, Harlow.

25

Glossary

A&E: Accident and Emergency Department ACP: Accountable Care Partnership BCF: Better Care Fund C.Diff: Clostridium Difficile CHUFT: Colchester Hospital University Foundation Trust CIP: Cost Improvement Plan CQUIN: Commissioning for Quality and Innovation – a payment framework allowing commissioners to reward excellence CQC: Care Quality Commission CO: Chief Officer CSU: Commissioning Support Unit CUHFT: Cambridge University Hospital NHS Foundation Trust DoH: Department of Health EAU: Emergency Assessment Unit ECC: Essex County Council ED: Accident and Emergency Department EEAST: East of England Ambulance Service Trust EPR: Electronic Patient Record EPUT: Essex Partnership University NHS Foundation Trust – provider of community and mental health services for West Essex EWMHS: Emotional Wellbeing and Mental Health Service HOSC: Essex County Council’s Health Overview and Scrutiny Committee HSMR: Hospital Standardised Mortality Ratio - An indicator of healthcare quality that measures whether the death rate at a hospital is higher or lower than you would expect. IAPT: Improving Access to Psychological Therapies ICA: Integrated Care Alliance ICP: Integrated Care Partnership ICS: Integrated Care System IUC: Integrated urgent care KPI: Key Performance Indicator MEHT: Mid Essex Hospitals Trust, Chelmsford MDT: Multi-disciplinary team MOU: Memorandum of Understanding MRSA: Methicillin Resistant Strep Aureus NHSE: NHS England NHSI: NHS Improvement OD: Organisational Development PAH: Princess Alexandra Hospital NHS Trust, Harlow PCBC: Pre-consultation business case PPE: Patient and public engagement QIPP: Quality, Innovation, Productivity and Prevention RTT: Referral to treatment SHMI: Summary Hospital-level Mortality Indicator - A hospital-level indicator which reports mortality at Trust level SI: Serious Incident SLA: Service Level Agreement SOC: Strategic outline case STP: Sustainability and Transformation Partnership VTE: Venous thromboembolism (deep vein thrombosis and pulmonary embolism)

26

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 9

Date of Meeting: 27th September 2018

Report title: Chief Officer Report

Authors: Andrew Geldard, Chief Officer Jane Kinniburgh, Director of Nursing and Quality Dean Westcott, Director of Finance, Contracting and Performance Toni Coles, Director of Transformation Dr Christine Moss, Chief Medical Officer Peter Wightman, Director of Primary Care and Localities Dorothy Blundell, Director of Corporate Services Maggie Pacini, Consultant in Public Health

Clinical lead (where n/a appropriate): Presented by: Andrew Geldard, Chief Officer

Recommended actions / n/a next steps The Board is asked to: The Board is asked to note the report.

Executive summary This report provides the Board with an update on the key (maximum 500 word areas of work for the CCG. limit) and purpose of the report:  Patient safety and quality  Financial position  Contracting  Performance  System transformation  Integrated Commissioning

CCG Committees / Each of the areas within this paper reports through the Groups previously CCG’s governance structure into the appropriate consulted Committee to provide assurance to the Board.

Equality Impact Analysis n/a - this report is for information only.

Key issues and risks: Included within the report.

Links to CCG The report is shows the work of the organisation, linking to strategy/objectives each of the strategic objectives.

27

Purpose

The Board is asked to note the Chief Officer’s report, which provides an update on the key areas of work and performance and risk within West Essex CCG, linking to the five organisational strategic objectives.

1 To commission high quality and safe care

MRSA Blood Stream Infection (BSI) MRSA -The ceiling set by NHS England for 2018/19 remains 01/07/17-31/08/18 unchanged in line with Zero Tolerance.

Organisation YTD There was no change in the number of MRSA bloodstream West Essex CCG infections reported by PAH during July and August. 4

PAH Cumulative West Essex CCG has a total of 4 cases attributed for the Actual Cases 0 year to date. All community acquired with no single theme

or organisation.

Acute Trust and CCG ceilings for 2018-19 have been Clostridium difficile infection reduced by 1 case for each organisation which makes 01/07/17-31/08/18 achievement more challenging.

Organisation Annual YTD Princess Alexandra Hospital has reported a total of 6 cases ceiling against a ceiling of 9. At least 2 cases are pending appeal. West Essex CCG 48 28 WECCG has a total of 28 cases reported YTD against a PAH Cumulative trajectory of 48. Actual Cases 6

PAH Cumulative 6 Attributed Cases 9 (2 appeals pending)

Other Main Contracts Barts Health MRSA and C.difficile Cumulative rates 01/07/17-31/08/18 C-Difficile Year to date the trust has reported a total of 52 cases of C- Diff across the whole trust. Breakdown by trust site is not available for the months of July and August. Breakdown will be provided for the next Board report. Barts Health NHS Annual FT YTD MRSA Bacteraemia YTD 11/07/2018 Ceiling Trust wide data 81 Trust Wide Barts has reported a total of 8 MRSA Blood C.difficile (21 Whipps 52 stream infections year to date. The 1 trust attributed case cumulative Cross) was identified at Whipps Cross hospital and outcome of C-Diff investigation report is awaited. Cumulative 52 attributed cases Detailed breakdown by trust location will be provided for MRSA Attributed 0 1 the next board meeting.

All MRSA cases are subject to Post infection review to identify learning and actions. Where a case affects a West 28

Essex registered patient, the CCG will be informed by the Trust and would be noted on reports to Board.

Cambridge CUHFT University Hospital Annual C-Difficile YTD NHS FT (CHUFT) Ceiling For the year to date the Trust has reported 33 hospital onset cases of C-Difficile infection against an annual C.difficile ceiling of 48. 48 33 cumulative MRSA Attributed 0 1 MRSA No new cases of trust assigned MRSA have been reported during July or august.

1.2 Princess Alexandra Hospital

Details Update PAH Assurance - The CCG The Trust has reviewed and revised its QIP programme to focus continue to participate in on the must do and should do elements of the CQC inspection the on-going oversight of findings. PAH Quality Improvement Programme to address the The monthly Oversight Committee meetings (chaired by NHSI key themes that were undertaken during special measures) are now called the identified from the CQC System Improvement Board and will take place once every 2 inspection in 2016. months.

To close the assurance WECCG Continues to support and engage with the trust to process, the CCG are part monitor performance, quality and safety of services whilst it of the on-going continues work to deliver its plans to improve. Attached below programme of quality is a report from a recent quality assurance visit to an in-patient assurance visits where ward conducted jointly by Quality leads from West Essex and evidence of East and North Herts CCG’s. This gives a level of detail of areas implementation of actions reviewed during a QA visit and findings that are then shared is monitored and tested in back with the Trust. discussion with front line staff.

QA Visit.docx

There was no oversight meeting held in August, with the next formal Systems improvement board meeting is scheduled for 26th September.

PAH Mortality Update Mortality:

The CCG has not received the August/September position from the Trust and a verbal update will be given at Board.

 HSMR and SMR remain higher than expected for the

29

rolling 12 month period.  The statistical markers for mortality remain a significant concern.

1.3 Adult Mental Health Services: Essex Partnership University Trust

Detail Update CQC The report has now been published following the well-led and core service Inspection inspection undertaken by the CQC, between 30 April 2018-16 and May 2018. The report was published on 27 July 2018 and the provider received an overall rating of good.

A stakeholder feedback session was held on 31 July 2018 with presentations from the CQC Head of Inspections, Sally Morris Chief Executive for EPUT and NHSI. This was also attended by the Deputy Director of Nursing for west Essex CCG.

The CQC reported that under the ‘new’ system that there will be annual core service reviews and the timescales are based on the date of the report being published, rather than the date of the inspection.

During the event EPUT were praised for their Board to ward leadership with a positive organisational culture, since the two organisations merged. The staff were commended for their ability to adapt to the change and fully recognised that the organisation they worked for was EPUT. The presentation explained the ratings and why they had been awarded.

The outcomes of the inspection are as follows: The Trust has been given an overall rating of ‘Good’. For note Community Mental Health Services for people with a learning disability or autism was given a rating of ‘Outstanding’ for ‘Caring’.

30

Ratings for Mental Health Services

The CQC rated safe as requires improvement because:

 The trust’s system for the management of medicines was inconsistent. There were various examples of poor practice in relation to the rotation of stock, across the organisation.  There remained inconsistencies in the assessment of environmental risks at some locations. This included the identification and mitigation of ligatures and the use of appropriate furniture. However, it was evident that the trust had taken significant steps to address this issue. This included the removal of ligature anchor points and the introduction of ligature heat maps. 31

 Training compliance for services based in Luton and Bedford was poor. This was not helped by the recent closure of training facilities local to the service. Staff expressed concern at the distance and time to travel to training facilities in Essex.  Forensic staff did not adhere to the Mental Health Act code of practice in relation to seclusion. They found errors in paperwork. Staff working with children and adolescent patients on wards used seclusion, for the best interest of the patients, but the environment did not support this easily.  People accessing substance misuse treatment did not receive timely reviews of their medication.

However:  Leaders had oversight of safeguarding and incident reporting and shared lessons learnt. Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. Each service fed into the trusts governance meetings, which then led into board meetings.  Staffing levels were sufficient to meet the needs of the people using services. The trust used bank and agency staff to cover vacancies and unexpected absence. Where possible, managers booked staff familiar with services to ensure continuity of care. The trust was actively recruiting to vacant posts across the organisation.  Overall, staff managed and assessed risk well. Staff discussed risk at handovers and used standard risk assessments to assess and identify risk. Staff recorded ways to reduce and mitigate risk and updated assessments when risk changed.  The trust were working towards reducing restrictive interventions across their services. The trust had a reducing restrictive intervention group who supported services to review and assess restrictive interventions to improve patient experience.

The CQC has issued five requirement notices to the trust. EPUT must send the CQC a report on actions being taken to address

Bed Pressures The reduction in the use of out of area placements has been maintained with one Psychiatric intensive Care (PICU) patient out of area and 10 within South Essex beds.

1.4 Patient Experience

Patient Experience Complaints: The Patient Experience Team manages complaints, PALs queries and compliments from service users and members of the community. GP

practice staff can raise concerns and issues via the quality inbox. The team

also responds to requests from the Parliamentary Health Service Ombudsman for information relating to complaints the CCG have led on. In addition to this, the team responds to enquiries from MPs and the public.

A total of 19 complaints were received between 1 July and August 2018.

32

Organisation / Number of Summary Details Team Complaints General 3 Concerns regarding: Practitioner - the attitude of staff - delays in receiving test results - lack of response to concerns raised directly with the Practice Manager West Essex CCG 6 Concerns regarding: - the criteria for bariatric surgery funding. - The decision to reduce the amount of care a patient is receiving from CHC funding - The delays incurred with the CHC retrospective review process Arden-GEM 1 Concern regarding the retrospective (Continuing review service process Healthcare Retrospective Review Team) East of England 2 Concerns regarding booked transport Ambulance not turning up to take patient s to their Service appointments. Essex Partnership 2 Concerns regarding: University - Care received whilst a patient was at Foundation Trust Saffron Walden Hospital - The process of a CHC assessment Stellar 2 Concerns regarding Healthcare - Misleading information being provided to patient - Appointment being provided with a nurse and not a GP - Patient’s appointment at the hub being cancelled without them being informed. The Princess 3 Concerns regarding: Alexandra - Treatment received during breast Hospital NHS screening appointment Trust - The system for dermatology appointments. Patient has had to be re- referred by her GP for DNAing appointments that she was not aware of - A patient’s hearing aids that have not been returned following repair. Family experiencing difficulties in contacting the Audiology Department Total 19

There were no identified themes or trends in the reported complaints.

PALS: A total of 94 contacts were received between 1 July and 31 August 2018; 52 in July and 42 in August. In line with previous reports, the top PALS category continues to be requests for information and difficulties in obtaining appointments.

33

There has been a continued increase in contacts from patients about changes in medication prescribed from their GPs, in particular opioids and branded medication in response to recent changes in guidance. Concerns have also been raised in relation to restrictions in prescribing gluten free products.

Compliments:  Six compliments were received between 1 July and 31 August 2018.  Four compliments were for the good experiences patients had at their GP practice.  Two compliments were made to the Continuing Healthcare Team for their care and in placing patients and undertaking assessments.

GP Concerns: A total of 65 concerns were received from 17 GP practices between 1 July and 31 August 2018. This is in line with previously reporting periods. The main themes of GP concerns continue to be related to the quality of discharge summaries, the follow up of test results and the responsibility of making onward referrals.

The number of open concerns remains stable and the team continue to note improved and more efficient feedback from providers which has allowed for concerns to be resolved more quickly, however it is recognised that further improvement is still required.

1.5 Safe Staffing

PAH July Reporting Position: Staffing  For July August and September there are a predicted 13 RN starters, 12 pre- registration starters and a predicted 16 HCA starters.  June saw a small decrease in the fill rate for day shifts for both registered and unregistered staff along with a decrease for RN nights, but an increase for unregistered for night shifts (for the third successive month).

 Annual leave profiling for the Safer Staffing wards showed no wards exceeded 17%

for June.  Net gain of 6.7 WTE nurse starters to the Safer Staffing Wards.  There were a total of 16 (headcount) starters and 8 (headcount) leavers in June, giving a net gain of 7.07 WTE Trust wide.  The rolling 12 month position shows there is a net gain of 42.18 WTE registered nurses and midwives across the Trust.  Falls data for the Safer Staffing Wards showed a slight increase, with the level of harm remaining low.  Complaints increased to a total of 19  Pressure injuries decreased by 1 to 12 (all Grade 2)  The current vacancy position to 26.10%

Actions taken to mitigate risks associated with staffing levels below plan include:

 Roster scrutiny panels, chaired by the Chief Nurse. 34

 Health Group Matrons and non-ward based nurses providing direct patient clinical care, support and guidance at ward level.  The process of introducing 12 week rolling rosters for adult wards is ongoing. The aim is to increase the lead time for secondary staffing requests and improve retention of staff. Compliance remains variable with the 12 week rolling rotas but performance continues to be monitored and has shown some general improvement

 Incidents continue to be interrogated to identify levels of avoidable harm; currently the

quality and safety metrics indicate that there has been no significant avoidable harm.

The following table shows a breakdown of current vacancies by staff group for June against the May position (excluding medical staffing) reflecting the increase in funded establishment.

CCG-CHC Continuing HealthCare (CHC) Team Vacancies within the CHC team have improved significantly with no current registered Staffing nursing vacancies within the team. and Funded Contracted Vacancy update WTE WTE WTE

Nurses 9.30 9.30 0

Admin/ 13.50 11.50 2.00 Clerical

Progress is still being made with a reduction in the backlog of cases that are 28 days overdue with a high level of scrutiny still being maintained by NHSE for both of the 2 quality indicators. Improvements are being made in the way the team work with extended partners to both challenge business as usual and backlog reviews to

complete the work. Meetings have been arranged to discuss the Discharge to assess

pathways with acute providers to ensure that the 2nd Quality indicator is not breached Key Performance Indicators have been set for the provider arm and for the CHC team and are monitored weekly.

New training programmes have been devised by the Professional Lead for the Essex new/revised NHS Framework October 2018 and dates have been arranged with all Partnership system partners commencing the first week of September. University Trust Neighbourhood Teams

The table below shows a summary of workforce reporting alongside current

performance/quality issues for EPUT Community Teams:

Summary Vacancy Performance LT % 2018/19 Q1 Sickness by Turnover Training Indicator / Sickness Agency Q1 2018/19 Team KPI 35

Epping OT RTT 0% Integrated breaches 5.7% 4.0% 8.1% 14.6% 9.9% 83.3% Care Face-to-Face 38456 Team Contact

Harlow OT RTT 0% Integrated breaches 5.8% 2.2% 22.3% 17.0% 2.1% 87.2% Care Face-to-Face 30172 Team Contact Uttlesford OT RTT 0% Integrated breaches 5.0% 3.8% 2.9% 12.7% 0.0% 84.1% Care Face-to-Face 25072 Team Contact

Adult RTT 0% Speech & breaches Primary Language 2.3% 0.0% 11.4% 11.6% 0.0% 87.5% Care DNA – target Therapy - 3% Workforce 3% WE

Primary Care Workforce Update The CCG workforce priorities are:

 Developing relationships with key stake-holders and working together to develop the workforce- Achievements include Training Hub established and meeting regularly, meetings regularly with local universities, providers, local authority, STP

 Completion of a skills mix, and competency audit- completed for nurses and CPD

established to support

 Supporting competency development across both clinical and non- clinical roles to enable people to be working at the top of their licence- supported CPD, links with EPIC  Training Nurse Mentors and creating nurse forums and extending student nurse placements-- established and running local nurse forums  Promoting and supporting GP Fellowships to encourage and retain newly-qualified GPs- 2 national GP fellows commencing September, 2 local in recruitment process  Promote practice placements of Physician Associates and clinical pharmacists- started to place and promote both roles and other new roles especially paramedics  Champion leadership development and support for Practice Managers – PMs enrolled on Mary Seacole programmes  Developing a career pathway for non- medical staff working in Primary Care  Support International Recruitment- STP plan  Work with local schools, communities and HEIs to promote primary care as a career-

numerous fairs/events supported

Retention - New schemes and initiatives that enable GPs to stay in the workforce will be made possible through the new Local GP Retention Fund. Some £2.07 million of the national £7 million funding is being made available in Midlands and East during 2018/19 to promote new ways of working and offer additional support. Specifically, the fund will support the development of innovative local retention initiatives for GPs who are:

 Seriously considering leaving general practice or are considering changing their role or working hours;

 No longer clinically practicing in the NHS in England but remain on the National

Performers List (Medical); or

36

 Newly qualified or within their first five years of practice.

The fund builds on emerging best practice across the country, such as Great Yarmouth and Waveney CCG’s GP Career Plus pilot, which has created a scheme which seeks to retain experienced late-career GPs through pooled working.

International Recruitment – The programme to bring over doctors from Europe to work in practices has started as part of the national roll-out of international GP recruitment. The first interviews with potential recruits will be by Skype and these recruits must meet stringent criteria including a high standard of English (IELTS level 7). Those who pass this initial assessment stage will be invited to visit England and meet with prospective receiving practices in the STPs. Two companies which are highly experienced in international healthcare recruitment have been appointed for the region. Medacs Healthcare is supporting STPs in the West Midlands and North Midlands DCO areas, while the Central Midlands and East DCOs are being served by VPL Healthcare.

The STP has refreshed workforce plans to take account of new funding and the international GP recruitment allocation

Primary Care Networks - As the Next Steps on the NHS Five Year Forward View sets out, practices working together in networks is one of the key ways to achieve the longer- term transformational change needed in GP services. NHS England’s aim, as described in the 2018/19 planning guidance, is to “actively encourage every practice to be part of a local primary care network, so that there is complete geographically contiguous population coverage of primary care networks as far as possible by the end of 2018/19, serving populations of at least 30,000 to 50,000”.

Such local networks enable practices to work collaboratively and free up GP time to focus on patients with complex conditions by:  expanding diagnostic facilities;  sharing community nursing, mental health, and clinical pharmacy teams;  pooling responsibility for urgent care and extended access; and  sharing and acting on data to drive improvements in primary care. The primary

care network model is as relevant for practices in rural areas as in towns or cities,

since it does not require mergers or closures and does not necessarily depend on the physical co-location of services.

(N.B. These networks are the equivalent of the neighbourhood model which has been adopted within West Essex CCG ).

Data - In Midlands and East, 93 per cent of practices provided valid GP workforce data through the Primary Care Web Tool or HEE collection tools in March. This was a great improvement compared to the 85 per cent recorded in September 2015, but there is a need to achieve 100 per cent compliance if NHS England, STPs and CCGs are to have a true picture of the current workforce and what needs to be done to get it right for the future. We have undertaken significant work locally to build the accuracy of the workforce data base we hold and further BI support will help to provide analysis to enable targeted planning at Practice level.

Nurses - Through the GP nursing 10-point action plan, the aim is to grow the GPN workforce in the Midlands and East by 6.4 per cent by September 2020. This will result in 37

an extra 312 (full-time equivalent) nurses working in general practice, compared to September 2015 figures.

GPN funding is supporting a variety of work in the region during this financial year.

Initiatives to improve recruitment include the targeted development of a GPN

educator infrastructure to meet Nursing and Midwifery Council standards of access within each CCG; and a scoping project commissioned from the University of East Anglia to develop preceptorship for all nurses new to general practice, which will report in the autumn.

The West Essex Training Hub The West Essex Training hub has established quarterly meetings with the most recent meeting held on the 13th September. This was well attended and focused on an in- depth discussion about the paramedic role in general practice. Successful links have also been made with HEIs re training nurses, Physician Associates, Clinical Pharmacists

and Paramedics have been established and working continues with our colleagues in East and North Herts and Herts Valley on an STP footprint.

Nurse Forums Nurse Forums for all 3 localities are now successfully running, with good attendance. These are a platform to provide additional learning and discuss forthcoming events. Nurse conference will be held in February/March 2019 and an interlinked agenda will be discussed with our partner STP CCGs to ensure consistent approach. We have 2 Practice Managers attending the Mary Seacole Course.

On the retention front, a review of the Health Education England GPN Career

Framework, which has been commissioned nationally by NHS England, is consulting with GPs, local medical committees and other key stakeholders on issues such as the current variable employment terms and conditions for GPNs.

NHS England’s 10-point action plan for GP nursing aims through a five-year national programme to address the issues of rising demand and a decreasing workforce by:

 driving recruitment  aiding retention; and

 developing a high-caliber career pathway for general practice nurses.

Nationally some £15 million will be available over the five years of the programme and is separate to the GP Forward View investment.

Clinical Pharmacists – The General Practice Forward View (GPFV) committed to over £100m of investment to support an extra 1,500 clinical pharmacists to work in general practice by 2020/21. This is in addition to over 490 clinical pharmacists already working Adult across approximately 650 GP practices as part of a pilot, launched in July 2015. GPs Mental can continue to apply to NHS England through to February 2019 for funding to recruit, Health train and establish clinical pharmacists in their practices for the long term. Clinical Community Workforce pharmacists work as part of the general practice team to improve value and outcomes from medicines and consult with and treat patients directly. This includes providing extra help to manage long-term conditions, advice for those on multiple medicines and better access to health checks. The role is pivotal to improving the quality of care and ensuring patient safety. It also enables GPs to focus their skills where they are most needed, such as on diagnosing and treating patients with more complex conditions.

38

Both federations in West Essex have been successful in securing funding in previous waves of the scheme with 3 clinical pharmacists employed by Stellar Healthcare; only 2 remain and are based at The Limes Surgery and the Lister Medical Centre. Uttlesford Health is working with the regional implementation team to address recruitment issues for 3 clinical pharmacists.

The closing dates for further waves of the programme for bids to NHS England have now been confirmed and are as follows:

Wave 7 – 23rd November 2018 Wave 8 – 22nd February 2019

All submitted applications are assessed by a local NHS England panel using nationally prescribed criteria. Those shortlisted are then submitted for regional review before going to the NHS England national team for approval.

Following previous requests at Board information on the establishment and current community based mental health workforce has been requested directly via the Director of Nursing at EPUT. To date we have not yet received and have again followed up this request receiving assurance from EPUT that the information will be provided. This will be reported to the Board as soon as we have received.

2. Deliver sustainable health and care service transformation towards a more locally based integrated care service

2.1 Urgent Care

Urgent Care Performance update The improvement in performance against the 4 hour standard at PAH has been sustained, although there was a small dip in performance in July, as previously reported, which has been attributed to an increase in demand during the hot weather period and staff shortages in the emergency department at the end of doctors’ placements. Un- validated performance for August 2018 is 81% which is the first time performance has been over 80% for a full month since December 2015.

The diagram below shows accident and emergency (A&E) performance against A&E attendance numbers and indicates when key initiatives were implemented to demonstrate the overall impact of the urgent care transformation programme.

39

Staffing within the emergency department remains a concern, particularly overnight, as good performance during the day is regularly not replicated out of hours. PAH recruitment is now complete and additional staff expected to be in place by October 2018.

The system has continued to maintain the improvement in delayed transfers of care (DTOC) achieved below the national target of 3.5% each month this year (2018). The focus continues on the shifts to reducing the number of patients that are medically fit for transfer from 55-60 to 25 patients each day which will be achieved through delivery of the transfer of care model programme which was approved by Local Delivery Board (LDB) in August.

Urgent Care Transformation Update

Local Delivery Operations Group The new West Essex Operations Group, chaired by Phil Holland, Deputy Chief Operating Officer at PAH, is now fully functional and will meet on a fortnightly basis. With representation from all system partners the group provides the forum to agree system priorities, monitor progress and develop the urgent care transformation programme.

System Resilience

40

Work is underway across the STP to align winter plans and in particular daily OPEL system reporting. The East and North Herts CCG system resilience protocol will be adopted across the 3 CCGs.

West Essex winter plans have been drafted and will continue to be progress through the Local Delivery Board Operations Group before submitted to LDB for sign off in October.

It is expected that the new STP System Resilience Dashboard (SHREWD) will be operational within September and this will provide all partners with visibility over pressures across the system. This will be really helpful as we progress into winter as there will be the requirement for weekend reporting and the urgent care team is already working on new processes and a training pack for directors’ on-call.

Integrated Urgent Care (Incorporating GP Extended Access) Procurement The Invitation to Tender (ITT) for the new integrated urgent care service closed on 31st August 2018. A recommendation to award the contract will is a separate Board item in September.

An agreement is now in place with East and Norther Herts CCG for an integrated STP Directory of Services role (DOS) to support IUC and recruitment is underway.

NHS111 Online Phase 1 of NHS111 Online is now operational – this enables West Essex residents to go on line and seek NHS111 support. If self-help information is insufficient to meet an individual’s needs then they will call NHS111 for further support.

Phase 2 will be to link NHS111 online to the West Essex DOS however this cannot be progressed until the outcome of the IUC procurement is known as it requires significant investment by the incumbent provider.

PAH Emergency Department Integrated Front door At the front door of PAH’s emergency department the ICP initiative to integrated nurse streaming, minor injuries and minor illness with PAH as the lead provider is now fully operational and the Head of Service is in place. Work continues to capture the data required to evaluate impact of the service and to agree the financial and activity model required for the CCG to contract with PAH as the lead provider. Development of the model to operate 24/7 is dependent on agreement of the financial and activity model.

A&E Demand A repeat audit has been completed on appropriateness of ambulance conveyances and demonstrated sustained improvement.

41

Two new audits to help understand A&E demand are planned for September:  Review of GP referrals into the emergency department to understand the proportion of pre- attendance dialogue between primary care and acute, and to evaluate content of referrals to support front door streaming to the correct pathway first time.  Review of self-presenters on Mondays (peak attendance numbers) to understand if access to primary care over the weekend has been key contributing factor to attendance

Improving flow A business case was submitted to the Local Delivery Board in August that presented the West Essex vision for transfer of care clearly outlining the process and capacity improvements required to deliver national targets including 92% bed occupancy, < 12.5% stranded patients being Long Stays, < 3.5% DTOC and continuing healthcare, and to reduce on-going demand on continuing healthcare and social care by ensuring support plans are prepared in the right place at the right time.

Priorities for the next quarter are focused on a number of process improvements including:  Ward improvement plans to improve earlier discharge planning (reducing LOS by 24 hours for complex patients).  Better tracking of patients to increase visibility of issues along transfer of care pathways.  Agreed approach to assessment in the community, shifting resources if required from the acute trust to support. To be supported by a business case.  Further development of multi-disciplinary team approaches within neighbourhood teams.

Process improvement is an enabler to delivery of the national targets but cannot fully achieve without additional community capacity:  PAH have work underway to increase bed capacity by 27 by December with the additional of a modular ward.  CCG and ECC are leading on the development of a clinical and financial model to develop the currently vacant Sydenham House premises to increase community bed stock by 60 for quarter 4. Contingency plans are required in the event that the financial model is unsustainable.  ECC will increase access to available reablement at home capacity through robust contract management (5-6 discharges per day) expected no later than October 2018.

A full evaluation of the dedicated discharge vehicle pilot will be going to the Local Delivery Board in September, with a recommendation on the capacity required for Winter 2018/19 to ensure that transport issues are not contributing to discharge delays.

Therapy Review During July and August system partners reviewed 50 patients that had received therapy input during their inpatient spell at PAH to determine the level of involvement of 42

community therapy teams prior to and post hospital stay. The aim was to identify opportunities for integration of therapy teams that currently operate independently in PAH, EPUT and Essex social care. Early review has identified poor communication between teams resulting in duplication of activity and opportunities for ICP working. The full review will be shared with Local Delivery Operational Group in September.

2.2 Vulnerable Adults

Primary Care Psychological Talking Therapies (PCPT) The CCG currently contracts with Herts Partnership Trust (HPFT) to provide access to PCPT for 15% of local prevalence for 18/19. Based on performance to the end of quarter 1 2018/19 the current full year best estimate is 12.5%. The mental health five year forward view gives an obligation to deliver increased access to PCPT services of 19% in quarter 4 of 18/19 with a trajectory to 25% by quarter 4 of 2021. The last time the annual access target was achieved was 2015/16.

The Independent Service Review commissioned by North Essex CCGs and HPFT in 2017 highlighted the key issues behind poor performance were workforce recruitment and retention of accredited staff and low referrals into the service. Whilst a Contract Performance Notice (CPN) has been in place for some time we still have not seen the required improvement in performance.

A comprehensive paper was presented to the Executive Health and Care Commissioning Committee in August providing a detailed appraisal of current performance against the access standard and waits to second treatment. The paper presented a number of recommendations to improve performance against the commissioned 15% target and to commission additional capacity to support the increase in patients accessing PCPT to 19% in Q4 in line with the mental health five year forward view.

Recommendations agreed and being progressed are:  The CCG to continue to work with HPFT (Healthy Minds) to deliver a collaborative action plan to focus achievement of the core 15% access target in line with an agreed trajectory, focussing on improving capacity supported by a workforce plan and increasing referrals.  Develop a procurement process to commission additional short term capacity for the next 2 years to achieve as a minimum the quarter 4 18/19 access target of 4.75% (Annual 19%) and future targets to 2020. Procurement route through Any Qualified Provider (AQP) aligning with Hertfordshire to suppliment the existing contract with HPFT accessible through Clinical Triage Service (CTS). 43

 Continue to work with STP partners on longer term solutions for PCPT services

It should be noted that whilst there are concerns with the delivery of the national access targets and local targets for waits for second treatment the service is consistently achieving its recovery targets (quarter 1 54.18%), with good levels of reliable improvement (quarter 1 year to date 69.66%) being seen, and is also exceeding the national target for waits to 1st treatment. These metrics indicate that when patients do get into treatment – clinically they are doing well.

Dementia Diagnosis The national expectation for dementia diagnosis rates for people 65+ is 66.7% of prevalence. The CCG has continued to do well against this target with the month of July (M4) maintaining a position of 69%. Key areas of focus for the CCG in support of Dementia are:

 To review and enhance post diagnostic pathway- A clinical workshop is scheduled for 20th September - inclusive of primary and secondary care clinical leads  People with undiagnosed dementia in care homes – a service is currently being piloted funded under the iBCF until December 2018. A review is underway.  High number of dementia patients attending A&E- the specialist dementia liaison team in PAH has been commissioned for a further two months to allow sufficient data to be captured to review outcomes to help inform the future proposals for a CORE 24 service in PAH.

Out of area placements The CCG plans to deliver a 33% reduction in out of area placements compared to 2016/17 as part of our quality premium objectives for 2018/19. The CCG has performed above planned trajectory in the earlier part of the year, however, the opening of the new Assessment Unit in the Peter Bruff Ward has started to see a move to the elimination of out of area placements. In July West Essex had zero out of area placements.

EPUT contract performance EPUT continue to achieve all key contract KPIs (9) across community and inpatient services.

Service Transformation

Core 24/7 A&E Liaison Service The CCG with partners is producing a bid to access the second wave of the Core 24 Transformation Funds in October. This will provide adults and older people presenting with mental health crisis at the PAH emergency department access to 24/7 liaison mental health services. This will builds on the current service extending it to 24 hours a day. The service will support:  Reduction in inappropriate general hospital inpatient admissions  Improved discharge planning and coordination resulting in shorter lengths of stay and reduced general hospital re-admissions for adults and, particularly, older adults  An overall improved experience of services resulting from care provided by well-trained and knowledgeable general hospital staff who are not necessarily trained as mental health specialists but can more readily recognise mental health needs

The bid development is being taken forward by the newly formed Expert Oversight Group for mental health. The final bid will be presented to the Executive Health and Care Commissioning Committee for approval before submission.

44

Integrated Enhanced Primary/ Community Care As part of the STP an opportunity arose for system partners to bid for £300k of Big Lottery funding through the Innovation Unit to scale up the community based Lambeth Living Well Model. Work was progressed with the South Harlow Neighbourhood to develop an integrated enhanced primary/community mental health offer. Unfortunately the bid was unsuccessful but the programme of work continues with EPUT and the south Harlow neighbourhood.

Clinical Strategy Development The Mental Health and Learning Disabilities Steering Group has identified a number of priorities for mental health and learning disabilities for inclusion in the STP Clinical Strategy, these include:  The Integration of mental health with physical health  Developing a robust primary care mental health model to manage the year on year increasing demand for mental health services more effectively.  Make specialist services more accessible, such as eating disorders and personality disorders where provision, both local and specialist, is inadequate to meet demand and levels of morbidity  Improving access to psychological treatments  Improving services for severe mental Illness (psychosis)  Better coordination of alcohol and substance misuse

The detail of the strategy needs to be developed in particular the benefits, outcomes and local delivery models for West Essex.

Adult Mental Health Collaborative Commissioning Arrangements Since the last Board, work has continued with Hertfordshire colleagues and the Integrated Health and Care Commissioning Team (IHHCT) to develop a proposal for joint commissioning arrangements for adult mental health services with Herts Valley and East and North Herts CCG. A paper along with a proposed collaboration agreement is being presented to the Executive Committee on 3rd October for approval to transition to new arrangements during October when the current arrangements with North East Essex CCG cease. These arrangements cease on 30th September - this is an earlier timescale than reported at the July Board.

The arrangements being developed include a local and stronger mental health commissioning team in West Essex as part of a new collaborative led by the IHHCT. The arrangements being proposed will operate under clear principles that will safeguard local autonomy and decision making to develop and commission services that meet the priorities and needs of patients in West Essex.

The CCG has also been working with Essex CCGs on the transition of commissioning and contracting arrangements from North East Essex CCG to ensure a smooth handover of functions led by Director of Transformation and Director of Finance. The CCG is also working with key providers such as EPUT to agree new contract management and performance arrangements from October.

2.3 Adult Pathways

Programme Key Projects Points to Note

45

Diabetes NHS Diabetes The Multi-Disciplinary Foot Team and Diabetes Transformation Inpatient Specialist Nursing (DISN) Team across Fund PAH and EPUT have seen an ever increasing number of patients since the services mobilised in November 17. These services, supported by NHS England funding, are slightly behind plan in terms of numbers of patients seen and treated in Q1 of 1819, although they both demonstrate a noticeable improvement on Q4 performance of 1718. The DISN team provided care for 339 patients against a plan of 397 in Q1, whilst the MDFT saw 135 out and inpatients against a plan of 213 in Q1. Quarter 2 data will be ready next month.

Following the successful implementation of the Multi- Disciplinary Foot Care Team and Diabetes Inpatient Specialist Nursing Team, work is moving towards an evaluation of these services with the support of the re-launched Diabetes Expert Oversight Group (EOG). Peer review is booked for January 2019 supported by NHSE East of England Diabetes Clinical network

Overall, the Inpatient Specialist Nursing Team have provided care for over 731 patients living with diabetes, whilst the Multi-Disciplinary Foot Team have seen and treated over 281 patients; these services are good examples of integrated partnerships that provide much needed clinical expertise to those living with diabetes.

The Diabetes EOG will be looking to explore the role of Diabetes care within the community, working with a wide range of partners to provide optimum care for our residents across all services.

The National Diabetes Prevention Programme in West Essex has enabled many of our community to access good, evidence-based programmes that help minimise their risk of developing diabetes. This programme has been successfully introduced over the last year with good uptake by the majority of our practices making high numbers of direct referrals to the programme.

Respiratory 9 COPD High West Essex CCG has now launched the Locally Pathway Impact Enhanced Service through GP Practices. GP Interventions Practices are funded to provide the 9 COPD high delivered through impact interventions which have been developed General Practice by local respiratory clinical experts and, if patients receive all 9 within a year, will provide optimum 46

care to ensure patients experience fewer exacerbations and are able to manage their condition better.

Our focus since the last Board has been the development of a single contract for Respiratory care delivered by the ICP with plans to have agreed a proposal by the end of September for implementation in April 2019.

The 9 COPD high impact interventions include a gold standard classification process. Practices are now capturing this information and will help direct patients into the most appropriate service / course of action.

Musculoskeleta ICP MSK Following the development of an overarching l (MSK) Development MSK model by the MSK EOG, work has begun to pathway mobilise and deliver some of the priority pathways.

 First contact physios offer an alternative to seeing the GP for an MSK issue across five practices in North Uttlesford. Early findings tell us that the service is well subscribed and patient feedback is very positive. The service has been selected to represent the STP of NHSE high impact changes. There are also plans to extend this to the South Uttlesford practices.  The persistent Pain service has recruited a Head of Service, who is now working with the Transformation team to mobilise the service. Ambition is to see more patients in a community setting.  A Rheumatology pathway has been agreed and we hope to recruit a Rheumatology GPSI to bring less complex care into the community.

Along with ACP partners, the CCG continues to develop integrated ways of working for all these areas.

47

Cardiology British Heart The CCG have collaborated with STP colleagues Foundation (BHF) to submit a funding bid for additional hypertension detection provision within community pharmacists with the aim to deliver 5000 blood pressure tests across the STP over 2018/19 and 2019/20. The CCG was informed during August that we were successful and the transformation team are planning to support the implementation and delivery.

Heart failure nurse Education/training sessions will be provided by Essex Partnership University Trust (EPUT) via Heart Failure Specialist Nurses. Minimum 1 exercise session per week as well as dietary/lifestyle advice. Lead nurse joined during August after delays with recruitment. Future plans to integrate the rehab programme with respiratory. STP Palpitations Again, the CCG has collaborated with STP Pathway colleagues to develop a palpitations pathway to be delivered over 2018/2019. This pathway will provide patients with quicker, community based diagnostics to be managed by their GP, reducing the number of patients who need to wait to see a consultant. This pathway is planned to begin delivering from the end of October as this relies on PAH to set up the clinics ready to mobilise.

Atrial Fibrillation The STP has been successful with a funding application for 70 mobile ECG devices across the STP footprint to support quicker diagnosis of Atrial Fibrillation. This equates to 25 new machines and we were successful in obtaining 7 more. All machines have been allocated and are in use.

Dermatology Dermatology The Dermatology Programme is working towards the sustainability phase, with additional focus on the identification and management of skin lesions in the primary care setting in order to reduce the need for hospital referrals. Process underway to review the skill mix of primary care clinicians against national standards.

There is an additional STP focus on Dermatology for the year ahead, with which the CCG and clinicians are effectively engaged with.

Ophthalmolog Integrated Minor An Ophthalmology EOG has been established to y Eye Conditions review the final plans for the development of an Service integrated minor eye conditions service here in West Essex to ensure the proposed model for delivering this service through high street

48

optometrist can deliver the full scope of our needs. Service launch has been delayed from the initially proposed September. The Optometrists are completing clinical courses required to delivery this service and they are also completing the IG/NHS.net account training to make them ready. Further NHS Right Care Further scoping work is being undertaken Planning focussing on the following areas: . Dermatology . Hernia . Constipation and Liver Function Tests . Upper GI Bleeds . Glaucoma Intraocular Pressure . Cataracts . Diabetes

Using Right Care focus packs and local intelligence these are being reviewed by transformation leads and EOGs where will relevant.

Cancer

National key priorities for cancer remain unchanged. They are:

 62/7 wait  % of Cancers diagnosed as Stage 1&2  One Year Survival  Patient Experience

We are monitored at an STP level but within the STP the Trust levels are key to the overall position. The 62/7 target (patients taking not more than 62 days from referral to first treatment) performance determines the amount of transformation funding the STP receives (see detail below).

As a CCG our Quality Premium (QP) measures for Cancer attract up to £65,515 but if 62/7 target is missed at year end 50% of this Quality Indicator element is withheld. The QP indicator itself requires a 4% improvement in cancers diagnosed at Stages 1&2 compared with 2016 or over 60% whichever is the lower.

Current performance by the CCG and by STP in the national targets:

Cancer 62 Day standard

Organisation Standard Performance Trend (June 2018) PAH 85% 72.5% ↓ Addenbrookes 85% 78.7% ↓ Barts 85% 86.1% → ENH CCG 85% 73.3% ↓ HVCC 85% 77.7% ↓ WECCG 85% 74.2% ↓

49

STP 85% 75.4%

STP Funding for Cancer Transformation Herts and West Essex STP were successful in receiving funding for specific projects to support delivery of prostate and lung pathway in Quarter 4 last year. PAH received funding to train radiology staff in the use of mpMRI scanning for prostate cancer.

In 2018/19 we have been successful in bidding for both capital and revenue money. This will enable improvement in the National Priorities, creating and embedding optimal pathways for Breast, Lung, Colorectal and Prostate cancers and transformational work to develop services for Living with and Beyond Cancer and Transforming Cancer Care in the Community.

Capital Funding - Total £1,051,114 for the STP Princess Alexandra  £700,000 For new mpMRI scanner  £35,704.66 for FiT analyser and IT capability

Revenue Funding This has been awarded according to achievement of 62/7 target for the STP and the Alliance. We received 75% of our allocation in Quarters 1&2 (£979,701) and will receive 50% in Quarters 3&4. (£1,428,620). STP bids in total were – £1,308,051.

Specific funding for West Essex is as follows:

Project 1 - Lung Pathway PAH03 Molecular Co-ordinator 11,325.00 PAH PAH09 Develop Mesothelioma Service 20,000.00 PAH Project 2 - Prostate Pathway PAH04 CNS (x3) to support one-stop clinic 87,000.00 PAH Project 3 - Colorectal Pathway PAH11 CNS 27,083.33 PAH Project 6 Stratified Follow Up PAH08 Develop stratified follow-up 81,500.00 PAH tracking list

STP WIDE Programme:

Programme Management Employment of 8C (Programme 115,041.12 STP Manager), 8A (Early Diagnostics Manager) and 3 x Band 4 administrative posts to support programme and data collection for FIT Diagnostics Project 1 - Lung Pathway Training & Education 10,026.33 STP Project 2 - Prostate Pathway Training & Education 17,188.00 STP Project 3 - Colorectal Pathway Training & Education 17,188.00 STP Project 4 - FIT STP01 FIT in Primary Care / STP01 FIT 33,000.00 STP Equipment Training & Education 17,188.00 STP 50

Project 5 - Recovery Package & Stratified Follow up PROJECT 5 Recovery Package 146,887.00 STP Project 7 - CCC PROJECT 7 - CCC SUMMARY 47,188.00 STP

Delivering National Standards - 62/7 PAH has struggled to manage the 62/7 pathway target for urology in the last 6 months due to workforce issues. It is starting to improve but will not be sustaining till late in the year. Sustainable workforce will depend on recruiting or training CNS staff and this will take longer though transformation funds makes this possible. New capacity and capability in prostate scanning techniques are also important.

Stage 1&2 With regards Stage 1&2 disease improvement the key areas of work relate to colorectal cancers. The STP has funding to implement the FiT (Faecal immunochemical Test) available in general practice for patients with "low risk but not no risk symptoms". The test is very effective at eliminating those who do not have a cancer who therefore do not need to undergo further testing. Colonoscopy capacity is limited and so it is important to use the test for the right people. FiT is also likely to be available for patients with higher risk symptoms and also for those on long term monitoring.

There will be further work in supporting general practice with effective use of 2week wait processes and we will endorse the national Be Clear on Cancer programme to raise public awareness of cancer symptoms. Further work needs to be done to support earlier diagnosis of lung cancer. Work is ongoing to identify variation at GP Practice level for the uptake of the National Screening programmes.

Patient Experience Princess Alexandra have embarked on work to improve patient experience and have already run a stakeholder engagement event to understand from users what they might do to improve. Focused work to improve experience for men and for families will follow. The latest survey results will be published in the next few weeks. Improvements in Living with and Beyond Cancer especially the use of holistic needs assessments will receive funding.

2.4 Integrated Older People’s Programme

Key Projects Key Points Harlow Rapid Intervention Service provision in Harlow started in November 17 Neighbourhood and the aim of this service is to reduce A&E and non elective (NELs) Transformation admissions. From November to March, the service has had a net benefit of 11.6% reduction in NELs & reduction in A&E attendance by 0.7% when compared to 7.3% growth seen in neighbourhoods not able to access the service (Epping, Ongar and Waltham Abbey).

Positive feedback has been received by practices, care homes and domiciliary care providers who have used the service but widespread

51

verbal feedback suggests an out of hours alternative would be welcomed, particularly for care homes and domiciliary care providers.

The CCG’s Executive Health and Care Commissioning Committee in July approved recommendations to continue the service in Harlow and extend to Buckhurst Hill & Chigwell, Loughton and Waltham Abbey for 12 months. A commissioning plan for services for the whole of west Essex will be developed by January 2019.

Frailty STP West Essex is working with Herts Valley and East & North Herts as STP partners. Three frailty pathways have been signed off – Proactive identification of Frail patient in the community, Identification of Frailty and Acute urgent Emergency Frailty pathway. Two Falls Pathways also have been signed off – Proactive Management of person at Risk of Falls in the community and Falls Risk Identification in the community.

Next step - CCG to work with primary, acute and community providers to implement the three Frailty & two Falls pathways by identifying gaps and propose commissioning changes/ intentions for pathway implementation to go forward.

End of Life (EOL) STP The STP EoL Group is working on developing KPIs and measures which will be formally reported to the WECCG EOL Steering Group and the Frailty STP group going forward.

There is a piece of work underway looking at how EPUT and St Clare hospice community services work more effectively together.

A GP EoL LES has been ratified and circulated to practices and has been signed up to by all practices. The West Essex EoL Steering group will review outcomes from the first wave audit along with primary care to help support primary care and neighbourhoods to make the intended changes to improve outcomes for patients. Agenda item for meeting in May.

An EoL strategy is in development.

Care Navigation The care navigation team continues to engage with practices and all Partnership potential referrer routes to ensure increased access to the service for patients and is effectively supporting moderate frailty reviews and positive feedback on this service has been received as part of the moderate frailty evaluations. Fortnightly contract meetings continue to take place between the CCG and the care navigator service to ensure progress continues and capacity is fully utilised.

A full review of this service, and voluntary sector services in general, will be submitted to health and care in September 2018.

Grant Funding All 5 projects grant funded for 2018/19 have been running since April and contracts are in place.

52

In the meantime an approach to run a joint grant funding process with local partners for 19/20 is being worked up for review.

Alongside this we will be reviewing current allocations given to our local District Councils towards their Health and Wellbeing Boards to ensure there is parity across the system as currently allocations differ for each District Council. This appears to be purely historical.

2.5 Children, Young People and Maternity

Details Update Essex Child and Family Wellbeing Service The CQUIN report has now been reviewed and a series of Virgin Care’s CQUIN Report for Quarter 1 recommendations are being fed back to Virgin Care. was submitted to the CCG during August. A Service Level Agreement has now been drafted and A Service Level Agreement (SLA) is currently total costs have been estimated for the delivery of this being finalised, which will allow Virgin Care agreement. However, the number of staff requiring staff to gain access to patient record access to these systems has increased, having a systems hosted by Princess Alexandra significant impact on the projected cost. VC are now Hospital, including Pathweb, Cosmic and reviewing these numbers and taking steps to reduce the ICE. This will ensure that clinicians are able to number of licenses required by frontline staff to access access patient records when required, electronic patient records. A new estimate will be without encountering any restrictions. submitted to the CCG and PAH during the coming weeks.

Maternity Services WECCG’s maternity services have received the rating “Requires Improvement”. This relates to four indicators, Maternity Rating including Stillbirth & neonatal mortality rate, Women’s experience of maternity services, Choices in maternity The CCG have received their maternity services and Rate of maternal smoking at delivery. These rating from NHS England. This assessment is results were reviewed and discussed at the Maternity based on the relevant clinical indicators Quality Group meeting held on the 6th September. It has used in the overall CCG Improvement and been suggested that the CCG should write to NHSE to Assessment Framework for maternity. gain further information regarding their methodology for this research. It would also be useful to have sight of any recommendations arising from the assessment process. West Essex Complex Families Task Group The Children, Young People and Maternity Manager supported ECC’s Lead for Partnership Delivery with the This group reviews the resources that are design of a resource map, which provides an overview of available to families across west Essex who relevant services across west Essex. The document are receiving support from a number of includes contact details for community paediatricians, social care and health agencies. The group mental health practitioners, social care teams and develops strategies for coordinating child learning disability specialists. This resource is now being and adult teams in relation to issues such as shared with members of the public, GPs and other parental mental health and the transition relevant partners across the west Essex health and care from CAMHS to adult mental health services. system.

53

Epping Forest Start Well Action Group The group has now established the Family Hub Advisory Board. This provides a forum in which local The team are continuing to support the partners can receive updates on the activities of Virgin Epping Forest Start Well Action Group. The Care and Barnardo’s local Family Hubs. This group also EFSWA group meeting provides an provides an opportunity for the Healthy Family Teams to opportunity for the CYP&M team to receive receive constructive guidance and feedback from updates on local public health activities related agencies, whilst ensuring that the local funded and developed by the district community and families are engaged in the planning, council. It also presents opportunities for shaping, implementation and development of these partnership working. services.

2.6 Information Management and Technology

Scheme Issues Timescale IT Service Following a procurement process undertaken by all 7 Essex CCGS, Ongoing Procurement supported by NHS England’s Lead Provider Framework team, the successful bidder and future provider of IT services for the Essex CCGs and GP Practices is Arden & GEM Commissioning Support Unit.

Service commenced on the 1st July 2018 without issue. Business as usual has improved, especially with regard to the helpdesk service. Further work on infrastructure moves to happen in 2018, offering more options going forward for technology.

My Care MCR continues to deliver the brand across STP. A business case Record has been completed and is currently going through the 2018 governance process within the STP and its partnering organisations. My Care Record is being used at PAH and will soon be available to GPs in West Essex and East and North Herts CCG to access PAH hospital information. Access to the GP record is now being rolled out to East and North Herts Trust and West Hertfordshire Hospitals Trust and also Hertfordshire Partnership Trust via the MIG. This will be complete by October 2018 – following the completion of fair processing across the entire STP geography.

PAH continues to work with Essex County Council and EPUT to plan and scope for further data fields in the shared care record. In parallel to this, the wider activities of MCR continue – with a technical work-stream evaluating the best way forward for the overall technical solution, complying with national standards and minimising duplication.

Patient Roll-out commenced in April and completed in May 2018. After October Check-in mixed feedback, AGEM CSU has produced a report on the usage 2018 Screens and issues at the practices to include current status. The CCG are now being updated on a weekly basis as to progress and are systematically working through any issues with practices. The August position is much better generally but the project is yet to be signed off as complete.

E- The CCG have commissioned an evaluation for the delivery October 54

Consultation options for E Consultation. A project team are developing the 2018 requirements for this through consultation with Primary Care users and patients. In parallel a review of current approved software systems is underway. A presentation of the findings from the consultation together with recommendations was made to the CCG’s Primary Care Operating Group on 13th September.

It was noted there is widespread interest from practices for ways to enable self care and direction to appropriate alternatives, but there support amongst practices is variable for use of email consultation and video consultation. It was agreed: - a small working group would be set up to progress the agenda to the next stage, including 3 practices who would each trial implementation of e-consultation in their practices. - Ensure the e-consultation tools that enable signposting are integral to the support the CCG is commissioning for practices on this topic. - Health and As part of a new approach we are now procuring a Health and October Social Care Social Care Network, offering a more flexible option to enable a 2018 Network broader use of services and drive down cost. The HSCN project is (HSCN) led by EPUT with input by all Essex CCGs and partner organisations.

The EPUT Board has agreed to proceed to preferred bidder status following the conclusion of the Essex CoIN ITT. Therefore Updata has been appointed as the preferred supplier.

A workshop was recently attended to agre provision of back-up lines. For GP Practices we have agreed back-up lines (or an alternative) for all sites, as the low cost of implementation/upkeep is far outweighted by the disruption/lost productivity/system cost of an outage at a GP practice. Priority sites are now known and the implementation plan is being prepared.

2.7 Primary Care

GP Extended The General Practice Extended Access (GPEA) service continues April 18 to Access to deliver approximately an additional 4000 routine appointment March 19 per month in the evenings and at weekends and will continue to do so for the next financial year.

There are six operational sites delivering evening and weekend appointments to the whole registered population of West Essex CCG. Patient satisfaction with the service continues to remain

55

very high. The service is also used to redirect patients presenting at Princess Alexandra Hospitable Emergency Department who are more clinically suited to be seen in a primary care setting to a GP or Nurse Practitioner.

The CCG has also invested additional resources for Stellar Healthcare, the provider of the service, to supply additional capacity over all bank and public holidays when traditional GP practices are closed.

For 2018/19 a more integrated urgent care pathway is being commissioned incorporating GPEA, Out of Hours and 111 services. The procurement process is underway and the ITT is due to be published on 16th July 2018. This new service if successfully procured will commence in April 2019.

Primary care The next protected learning time events will focus on On-going protected Neighbourhood transformation and Population Health learning Management. The events will be locality based to enable rich locally based discussion and involvement of neighbourhood teams. The dates for each event are as follows:

 Tuesday 18th September Harlow Locality  Wednesday 19th September Uttlesford Locality  Thursday 20th September Epping Locality

Co- The Primary Care Commissioning Committee was held on Commissioning Wednesday 20th July 2018. The agenda items included:  An update on the General Practice Forward View focussing on Workforce and Access to Primary Care  Updates on recent practice closures and procurements  An update on the Care Quality Commission inspections of local practices and how the CCG supports practices through the process  The evaluation of projects running in neighbourhoods such as a physiotherapists in general practice and emergency care practitioners  Learning disabilities health checks progress report  An update on the plans to procure an integrated urgent care service to provide access to patients outside of normal working hours

Referral There are several initiatives within this programme which support On-going Support GPs to refer appropriately and manage demand for planned Programme secondary care:

a) GP referred 1st outpatient data – There is a data quality issue. Princess Alexandra Hospital have not fully coded the Outpatient Procedure activity, therefore the number of Outpatient Attendance is over inflated for M1.

b) External Peer Reviews – These took place in all three localities. Uttlesford had a presentation from Dr Ellen Auty and Dr Patsy

56

Fuller from the Essex Partnership University NHS Foundation Trust on Psychology. Harlow had their session on the Short Term Contract from Essex Cares and Epping welcomed NELFT and received a presentation on the Emotional Wellbeing Mental Health Service. These did not take place during the month of August 2018 as planned due to the holiday season. c) Inter Peer Reviews – This demand management tool has been included in the MOA for 2018/19. During July, 450 referrals were reviewed by 14 GP practices and 6 referrals were found to be unsuitable for secondary care. We will be encouraging more practices to engage with this element of the MOA. Those practices that have carried on with this element of the MOA have now incorporated the process of reviewing the referrals into their working day. d) GPs can access Advice and Guidance from hospital consultants through e-Referral. This referral support is one of the elements of the CQUIN where PAH are measured on performance. e) E-referral – Princess Alexandra Hospital have completed their paperless e-referral programme as planned. This is ahead of the National Paperless Programme deadline of October 2018. PAH are reporting 93% as at 14th June 2018 of GP referrals being received by e-referral. 100% of non-excluded specialties are available. The 7% difference accounts for anomalies, for example GPs are referring the patient for a 1st GP outpatient appointment instead of a follow up. PAH will liaise with primary care to highlight the practices that need assistance with their referrals and follow up appointments. f) Ardens – The second wave of practices have now completed their free trial and training package. They have now completed a short evaluation which confirms they are utilising Ardens effectively and have expressed a wish to keep using it.

Coverage - 21 of 22 practices are live now plus one GP Provider company. 10 remaining practices are on EMIS (9), Vision (1) or S1 internal solution (1). Ardens is used for 61 % of the West Essex population. 9 EMIS practices exploring move to SystmOne, if agreed to move within 9-12 months. Content - There are currently 25 pieces of local guidance and pathways embedded into the Ardens templates including the local drug formulary. Goal to load 10 pieces of local guidance and new pathways per month. National guidance is already embedded into the templates. Training - The training plan includes further sessions to embed current practice as well as identifying superusers to take the advancement of Ardens forward within each practice. Reporting functions to be further developed to enhance and 57

take the project forward.

2.8 Primary Care Estates

Brief Description of Delivery Project Title Scheme/Rationale for Status Comments Date Project

All Cohort 1 & 2 Estates projects The Fund is one of progressing with practices working several programmes alongside NHSE to agree milestones and Estates, Approval outlined in the process. The Limes are not proceeding Technology & for March General Practice with their scheme as WECCG are Transformatio schemes 2019 Forward View aimed exploring options with developers of the n Fund awarded. at supporting general North Weald project. We are hoping to practices. utilise these funds at Old Harlow Health Centre.

Land swap, relating to

developments in the Completion late 2018 with occupancy area, driven by Lister Medical Building in planned for October. October Harlow DC Centre progress Project commenced and progressing 2018 regeneration - as expected. delivery of new build

facility. Bid submitted to both STP and ETTF for scheme support. Awaiting update on funding availability from NHS England following slippage of another intended scheme. Options being considered by Options to Capacity issues due the practice to provide further Old Harlow be 2019 to population growth. capacity for known population growth considered. Options to consider are a full extension of the current infrastructure or a new site to develop. The Practice and CCG are in discussions currently with HDC with regard to availability of land. Successful submission to ETTF for double story extension to be delivered in 2018/19. Progressing to schedule with NHS England as part of ETTF Cohort 2. Double extension to Thaxted In Progress Building work commenced in the last 2019 premises. week of August and expected project term of 52 weeks. Huttons have been appointed as the primary contractor which NHS England have signed off on.

58

Discussions with NHS PS and HHCT with regard to further space being utilised Options to Church Capacity issues due within the current footprint. Potential be 2018 Langley to population growth. for three further consulting rooms. considered. Target date for the practice is November to take the extra space. Housing growth and population increase is now known, evidencing the requirement of the development of a larger facility centrally in Dunmow. This scheme is being registered with the STP agenda as critical. Individual meetings were held with practices in Potential strategic July with a joint workshop took place scheme due to in August to agree strategy. housing development - relocation of John For Linked in with UDC and developers of Great Tasker House with progression a site close to the centre of Dunmow 2019 Dunmow shared facilities with to business with an initial offer of space for a Angel Lane surgery case. facility of 1800sqm. Space and possibly requirement was provided to community providers developers in August. if required. Strategic work to agree best options for Dunmow generally is ongoing, with Practices and the CCG working together for agreement on infrastructure requirement. -

An offer by the Felsted Neighbourhood Plan Steering Group has now been made. They have confirmed a negotiation with the owner of the land to the West of Bury Farm which will provide both the land and a surgery building in exchange for the community’s support for a housing Felsted development. The surgery could (Branch to Possible scheme for OBC provide accommodation for 5 doctors 2018/19 John Tasker new build. required as well as additional consulting rooms Surgery) and administrative space.

The offer/intention is that the surgery and the land will be gifted to a new charity, The Felsted Community Trust, providing an asset and revenue stream for the community’s benefit. Discussions ongoing but a larger factility at Felsted would decrease the pressure at John Tasker House, whilst 59

plans for the larger Dunow capacity issue is addressed.

New GP practice as Full business case completed in Maynard FBC part of Ninefields September 2018. For submission to 2018 Court completed regeneration project. NHS England in September.

Options are being explored to develop the site of SWCH to include primary care. A workshop took place on the 9th July for all stakeholders. A project manager has now been appointed by NHS PS to move forward Developing the site of Feasibility a decision as to whether NHS PS will Saffron Saffron Walden being either progress a scheme themselves 2021 Walden Community Hospital prepared or allow a third party developer to progress. September decision is expected.

Crocus Practice now working with NHS England to agree space requirement.

2.9 Neighbourhood Teams

Neighbourhood teams The Primary Care Commissioning Committee (PCCC) has started to review the evaluations of the neighbourhood pilot projects and consider recommendations for ongoing commissioning arrangements beyond the 12mth project timescales.

July PCCC extended moderate frailty services for 3 neighbourhoods based on data submitted and 2 are required to submit more information. Extension also agreed for North Harlow’s primary care transformation project, subject to conditions.

Further evaluations will go to the Primary Care Commissioning Committee in September and monthly thereafter.

The GP shutdowns in September will be neighbourhood focused. The purpose of the shutdowns is to have dedicated time at locality level to:

 reach a common understanding of what the neighbourhoods have achieved so far  understand and agree future opportunities for neighbourhoods to 60

improve the care of specific patient groups using population health management approaches  have time for table discussions about how we are going to take forward the future opportunities in the neighbourhood

The sessions will be facilitated by the Locality GP leads and neighbourhood GP leads.

All GP practice staff in West Essex and wider neighbourhood team including EPUT, Social Care, Voluntary sector are being invited to attend.

Detailed data packs have been prepared to support the neighbourhoods to move towards a population health management approach which is about identifying cohorts of the population with current and/or future needs which are similar, and developing services around these needs. Elements of these packs have also been shared within the Integrated Care Partnership forums.

2.10 Financial Performance and Contracting

The report is included in within the finance, activity, contracting and transformation (FACT) report at appendix 1.

FACT Summary Sheets - SEPT 2018.xlsx

3. Ensure that local people are at the heart of all that we do

3.1 Communications and Engagement and Corporate Services

Comms & Engagement Strategy - A new communications and engagement strategy for the CCG has been drafted and will be brought to the November board meeting for approval.

The strategy sets out our main communications objectives, target audiences, key messages and specific activities. It includes refreshed vision and mission statements; a more succinct set of organisational values; a core narrative; and series of key deliverables.

Support for national campaigns - The communications and engagement team has worked to raise awareness of national health and care issues and promoted them across a variety of channels. These campaigns have included:

 National Suicide Prevention Day  Health awareness at festivals  Cervical Cancer screening  111

61

We will be focusing in the next couple of months on supporting the flu jab and ‘Help Us, Help You’ campaigns

Website - A critique of the website took place in August internally and some quick, immediate changes were made to some outdated content. These were specifically focused on the general public areas, such as ‘Get Involved’ and ‘About Us’.

A more detailed evaluation of the CCG’s website will now begin. We want to see what people think about the new layout and functionality of the site and make any refinements as needed. We are speaking with the CSU who host the site to talk through these refinements and talk about the future development over the next couple of years.

Social media A regular stream of communications has been put out via Twitter and Facebook on a variety of prevention messages, such as signposting to HealthHelpNow, NHS 111 and Know Your Numbers blood pressure checking. We have also shared information and updates on health and social care partners’ campaigns, e.g. the launch of My Care Record in West Herts and the shortlisting of the STP system-led Support for Carers project. Current numbers of followers on Twitter is 6910 and Facebook 265. Plans are in place to boost these over the coming months through a new comms and engagement strategy (see above)

Videos - A corporate video promoting the role, plans and activities of the CCG was completed and launched at the AGM on 26 July. Shorter vox pops will be available from next week on a number of key subjects identified in the video, which can be viewed on our YouTube channel. The comms team plans to make more use of videos over the coming months and will be working with internal teams and partners to identify subject matter and campaigns they are suitable for.

Annual Report - A summary version of the annual report, suitable for the general public was also launched at the AGM. The Key Achievements brochure includes the main achievements of the CCG over the past year as well as key messages and campaigns. Planning for next year’s annual report is underway.

Internal communications - We have commissioned a supplier to design and build a new staff intranet, which is due to be launched late October. An internal focus group has met and fed in ideas and an initial site layout or ‘wireframe’ and design will be received in the next week. The aim of the intranet is to reduce the high number of all staff emails and provide a secure space for internal documents and briefing resources.

We are also meeting with teams across the CCG to introduce the new and improved communications service. Individual members of the comms service are being assigned a couple of teams each to let them know what we do, how we can help and support their work and to link across the CCG to reduce duplication and overlap.

STP/ICP - The team remains in regular contact with the main leads from the STP, East and Norths Herts and Herts Valley.

Meetings are being arranged both at the CCG and at County Hall to re-engage ECC, Healthwatch Essex and the voluntary partners. Upcoming joint campaigns include an Open the Bag pharmacy campaign and working with Allied Health Professionals on a celebration day in October.

62

The West Essex CCG comms team is also leading on the development and delivery of a communications and engagement strategy for the local Integrated Care Partnership.

Events - The team has been out and about visiting key groups such as the voluntary sector, on 31 August at the Marketplace event in Epping Town Hall. A mapping exercise of all the key local events in the three areas and boundaries is underway to plan future activity.

The team continues to support the GP Shutdown events. At the September events the team is also conducting a short survey with GPs to get their opinion on how they want to receive information from the CCG.

Urgent Care - The comms team has been regularly promoting alternatives to A&E including images for Jayex Screens and social media messaging.

We are also attending national and local briefing sessions on the winter campaign (Help Us, Help You) ahead of a full campaign through October to January in liaison with the urgent care team.

Medicines Optimisation - Team members have attended the Medicines Champions meetings and are supporting the pharmacy team in the development of the Over the Bag campaign and the launch of the new Community Pain Management service.

Patient engagement - The team has continued to support the Harlow and Epping Forest patient forums over the last couple of months. The team also attended the Ongar forum where Hazel Angus and Dr Rob Gerlis gave presentations on behalf of the CCG.

A review of the CCG’s patient and public engagement is continuing and so far we have met with the chairs of the patient forums, the voluntary sector and local charities. The principal aim is to recruit a wider and more representative group of local residents. We also want to open up new methods of engagement and move away from solely relying on meetings.

Voluntary Sector - Efforts are continuing with the voluntary sector leads for Epping Forest, Harlow and Uttlesford to improve general engagement and involvement between us – namely what we can do for each other and how we can use our various networks to reach the many different local audience groups.

A number of ideas are being progressed including a discussion about the future of health and care with a group of young people, facilitated by the Livewire theatre company, and closer links with a newly-formed faith leaders and cultural forum.

Governance - The Good Governance Institute is continuing with its review of decision- making systems at the CCG. The review has taken a little longer to complete than originally expected and has been broadened to take account of the emerging integrated care landscape. A report will be brought to the November board meeting. In the meantime, the terms of reference for the board, audit, finance and performance committees are being reviewed and updated as necessary.

Emergency planning resilience and response - The CCG undertook its annual business continuity exercise in July, part of which included a live ‘lockdown’ of the buildings.

63

The designated Incident Coordination Centre in Building 1 is in the process of being moved to the Boardroom in Building 4.

Loggist training is planned for October and new recruits are being sought to assist incident managers during emergency incidents.

Declarations of Interest - A review of the CCG register has been successfully completed.

Health & Safety - A review of the risk assessments for offices and first aid, originally scheduled for July, is now being carried out in October to tie in with a reshuffle of desk arrangements in Building 4. This will be followed up with a campaign to remind staff to keep desk and floor space clean and tidy and clear of potential hazards.

New HR service - The new HR and organisational development service, provided by Herts Valley CCG from 1 August, has begun well. An HR business partner, Jeneva Allison, is based at the CCG four days a week and staff have welcomed the improved support.

A new suite of HR policies has been adopted by the CCG and workshops are being held with staff in October to make sure they are fully understood. Other HR improvements include the introduction of an employee assistance helpline for staff and their families, to provide free confidential advice and support on a range of subjects.

Staff training and development is also being improved.

A new appraisal scheme is being rolled out in November. This will provide better identification of training and development needs and talent mapping. Again, as series of workshops is being arranged to ensure everyone fully understands the new scheme and how links with the introduction nationally from 1 April next year of performance-related annual pay increments instead of the current automatic ones.

Staff training and development programme is also being overhauled to offer a much wider and more beneficial offer, linked to the new appraisal scheme. The programme will be heralded by a proposed CCG Training & Development Charter, stating the organisation’s ambition and commitment to staff development. The charter and accompanying programme are due to be launched in November.

Proposals are also being drawn up for a Healthy Workplace Charter for the CCG, similar to the one launched recently by the mayor of London. This will underpin a more proactive approach to staff wellbeing and reducing sickness.

This will continue to be provided by Serco.

Finally, the new HR service, together with representatives from the CCG’s corporate services and finance teams, have held a series of meetings with Serco to improve the operation of the payroll service. This includes smoother and more efficient systems and processes and putting more services, such as expense claims, online

4. Continue to develop as a leading commissioning organisation of quality health and care services

64

4.1 Essex Joint Health and Wellbeing Strategy

The Joint Health and Wellbeing Strategy (JHWS) is a statutory document under the Health and Social Care Act 2012 that sets out the priorities that partners in Essex will deliver together, working through the Board. The draft strategy has been widely circulated and discussed. Delivery of the strategy will require ownership and input from a wide range of partners and is far from the sole responsibility of healthcare partners. The CCG’s Executive Health and Care Commissioning Committee commented on an earlier draft in February 2018.

The Essex Health and Wellbeing Board approved the strategy on 18th July 2018. The full strategy can be found on the Essex County Council website at: https://cmis.essexcc.gov.uk/essexcmis5/CalendarofMeetings/tabid/73/ctl/ViewMeetingPu blic/mid/410/Meeting/4027/Committee/134/SelectedTab/Documents/Default.aspx

The four areas of focus for the strategy are:

1. Improving mental health and wellbeing 2. Addressing obesity, improving diet and increasing physical activity 3. Influencing conditions and behaviours linked to health inequalities 4. Enabling and supporting people with long-term conditions and disabilities

The proposed building blocks are:

(i) Developing health and social care assets (e.g. workforce and community) (ii) Applying digital and other technologies (iii) Place and community (e.g., planning and use of public spaces) (iv) Tackling social determinants (e.g. housing and employment). (v) System Leadership

There is still some ongoing work around the outcomes, especially for the mental health focus.

4.2 Hertfordshire and West Essex STP Quarter 1 2018 Assurance Review – 1st August 2018

Assurance reviews with NHS England are now held on an STP footprint, the latest of which took place on 1st August 2018. The system was congratulated on a positive 2017/18, which particular reference to CCG leadership and financial positions.

The development strategy for the Integrated Care System (ICS) was discussed in detail and it was recognised that regulator alignment between NHS England and NHS Improvement remains a challenge.

Clinical developments in respect of frailty, vulnerable and fragile services were recognised and a number of future deliverables discussed, notably the development of a Clinical Strategy and Model for the STP.

65

Establishment of the STP Local Delivery Board was noted as a strong step towards whole system working, with the focus now on the implementation of a single urgent and emergency care strategy and winter plan.

The full outcomes from the review are attached:

180318 HWE Q1_Assurance Meeting - Follow up Letter -v.Final.pdf

66

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 10

Date of Meeting: 27th September 2018

Report title: Addressing Social Isolation

Author: Mike Gogarty, Director Wellbeing, Public Health and Communities, Essex County Council Clinical lead N/A Presented by: Mike Gogarty, Director Wellbeing, Public Health and Communities, Essex County Council

Recommended actions / 1. To agree to a local approach to reducing social next steps isolation.

2. To work in partnership with local authorities, the wider NHS locally and the voluntary sector and communities to systematically identify and tackle social isolation.

3. To note the creation of the Loneliness and Isolation Forum across Essex to increase partnership working and note the update on the progress of the four main work streams which feed in to the Loneliness and Isolation Forum. The Board is asked to: To agree the priority afforded to this area and to oversee delivery of plans to address social isolation in the CCG area

Executive summary This paper details a proposed approach to tackling (maximum 500 word social isolation that is systematic, inclusive and limit) and purpose of the comprehensive. It focusses on identification of people report: who may be isolated and identified a key role for NHS partners including primary care in this. It then proposes a model to enable rapid signposting and a system to engage people with local support opportunities. The system will be further supported by a call to action campaign and will be supplemented by bespoke support for more vulnerable groups.

Groups previously Essex Health and Wellbeing board consulted Other Essex CCG Boards Equality Impact Analysis While people who are socially isolated may be (EIA) – state the anywhere and in any part of society, it is often more outcomes and how will common in those with protected characteristics. It is any detrimental impact likely then that any action in this area will address some be mitigated and of this inequality. monitored or state where There are however a numbers of particular groups who 67

an EIA is not applicable may be particularly be at risk of social isolation and for and why who a generic model will not be the best solution. It is therefore proposed that the wide systematic approach described here is enhanced through specific action to develop the support for people in identified vulnerable and high need groups.

Key issues and risks: 1The proposed developments should be an improvement over current dispersed systems.

2 There may be a risk around identified need exceeding capacity and we will need to continue to work with local VCS expertise to ensure w wide range of support is available and can be developed where gaps are identified

3 Given the conflicting demands on primary care and GPs, it is essential that the system is seen as of merit by this group and does not increase workload. It is to be hoped that appropriate use of this system will reduce call on GP appointments. CCGs will have a key role in ensuring GPs seek to identify people who may be socially isolated.

Links to CCG strategy/objectives

68

1. Summary

1.1 Social isolation can affect any age group including older people, young parents, carers and people who have mental health issues.

1.2 Recently the Essex Health and Wellbeing Board have developed the new Joint Health and Wellbeing Strategy. It is of note that the challenge and priority of social isolation was highlighted as a key issue in three of the four priority areas

1.4 Across Essex there are a breadth of interventions to tackle social isolation and/ or loneliness. At one end of the spectrum exist the structured, specialised commissioned services, and at the other exist more ad hoc and informal community based intervention. Both have an important role to play and all partners remain committed to making sure that any new response ensures that people who will benefit are identified and supported as required to access a range of opportunities that best meet their personal needs.

1.5 System partners have established and facilitated the Loneliness and Isolation Forum, which includes a large variety of partners. This Forum compliments groups that exist both locally and nationally to understand and address the issue, including the Essex Tackling Loneliness Forum which was until recently chaired by Age UK.

1.6 The Forum strives to drive a systemic change across Essex, and by bringing together partners across Essex have collectively agreed a set of ambitions for how as a system we will respond to the challenge of isolation and loneliness to achieve real change for people:

2. Work has progressed under the following workstreams

2.1 Identification of Social Isolation and Loneliness

2.1.1 This workstream considers how people who are lonely and/ or socially isolated can be best identified. There are a number of existing schemes in this area. Some both identify and then work with people to look at opportunities but is likely if we are to maximise penetrance of identification that we will need a wider group of people who are prepared and able to simply identify people who may be lonely and/ or socially isolated and then “hand off” to someone who can better, and has more time to, discuss with the person their needs.

2.1.2 It is felt that as most people will see their GP several times a year, an approach based in primary care, utilising as appropriate reception staff, GPs and practice nurses will be important. Other NHS opportunities include community nurse and in patient teams, as well as mental health providers, midwives, health visitors, community pharmacists, paramedics and A&E teams.

2.1.3 Within the wider system, social workers, county and district call centre and support staff, housing and leisure staff, trading standards staff, library and front line care staff, police and ECFRS staff have a role in identifying people who may be socially isolated.

2.1.4 There are also clear opportunities, increasingly being seized for the wider community to identify people they are in contact with or who they are aware of who may be socially isolated and to help them engage with support. These include people working with existing VCS groups, including CVS, housing associations and other housing related 69

support and private enterprises for personal services eg. toe-nail cutting; hairdressers; hoarding services; house clearance; gardening, handyman/trusted trader schemes. They also include people in the wider community. The approach will be supported and enabled in Essex through an awareness raising campaign (see below).

2.1.5. While all these approaches are important and will be developed. In order to ensure a systematic safety net to ascertainment, it is planned that Primary care be seen as a key player. CCG plans are being developed and are summarised below. Broadly similar systems are being put in place across CCGs working closely with local VCS leadership. It will be important to evaluate the services as they develop and roll out.

2.1.6 Particular concern was expressed by experts in sensory disability about the particular needs in this group, around both the high levels of social isolation suffered and the importance of identification and referral. Additionally there was a sense that often the best solution was around support, advice and guidance around the underlying cause related often to the sensory loss rather than isolation which may be a sequelae.

2.1.7 Each CCG has been working on how best they might operationalise a systematic approach locally. It is important that local mechanisms are effective but also best fit and meet local existing structures. The draft approach in each CCG is outlined in the Appendix “Primary care based action to identify people who are socially isolated” and the reader may wish to read these at this point in the paper.

2.2. Linking People to Services

2.2.1 When an individual has been identified as feeling lonely and/ or socially isolated they will need to understand what opportunities exist locally to support them. The system needs to include somebody who has the time and ability to understand how the person who feels isolated can best be supported, or helped to find their own solution and who is aware of the range of opportunities locally that might best suit that individual. It is likely that this role can in most cases best be performed by specialist “Care Navigators” who have a local knowledge of each area and specialist training to facilitate these conversations and effect change.

2.2.2. The proposal is to create a single, consistent, cross-County model, comprising a single point of access, the Lifestyle Service and a Care Navigation Service. While it is possible that some of the GP practice based solutions might enable a direct link to local services and support, in other CCG areas, the “hand off” would be to the central “care navigator” service. Additionally this model would work best for other NHS and partner workers who would not have direct access to someone who could discuss options with the person needing support. In thinking about people within the community who may be involved in identifying social isolation, it would be easier for them if they too could hand off to this service following identification.

2.2.3 The Care Navigation Service would be part of a wider offer pulling together community based support services, supporting a wide breadth of individuals with varying presenting needs, presenting a simple solution with a ‘no wrong door’ ethos. The wider group of current community based services that this might additionally embrace would include community agents, social prescription and mental health prescription (currently operating in Tendring only). There is also the opportunity to give consideration to other cohorts, including autism and dementia.

70

2.2.4 It is proposed that Provide, as part of the existing arrangements within the Lifestyle contract commissioned through Public Health, will continue to deliver this single point of access for Essex. The overarching ethos of the service is that there is no wrong door and service. Essentially this would include receipt of self-referrals as well as those from the groups above.

2.3. Community Capacity

2.3.1 There is a need for a choice of opportunities within local communities to support people who are social isolated. VCS colleagues have worked together to identify the range of existing service and are focusing on identifying where gaps exist and proposing actions to address them. The initial draft report of this group is appended as Appendix 1 and outlines findings and next steps. This will undergo further iteration.

2.3.2 In short while more work is needed to really understand what is available there is a sense that there are already a wide range of opportunities to help people be more socially connected right across Essex. It is proposed that the work to date be refined with an overlay of likely need in each area. We could look to locality based Google mapping of available services.

2.3.3 It is likely however that real feedback from Care Navigators, GP Care Advisors and others charged with ensuring people can access appropriate local support, on areas where they perceive real gaps in provision will be the best way to forensically understand what more needs to be made available. There will necessarily then be a degree of iteration in refining the community offer.

2.3.4 In addition to the groups identified we are working with local faith groups to ensure these are fully linked in to the work. Faith groups have been identified as key to supporting people who are isolated and additionally have clear potential to identify people who may benefit from support. We are also working with the Patient Participation Groups to explore how they can work to expand their role into this area.

2.3.5 It is clear too, that as well as identifying a bespoke response to social isolation, there is a need to pursue an Asset based approach around improving community connectedness and building social networks. The County Council Community team are working with existing place based social media groups across Essex to start to encourage their use in improving community cohesion by identifying local issues. These groups will enable small scale ‘micro-volunteering’ that can add another dimension to addressing the issue for individuals. A forum involving interested Facebook Administrators has been established. This approach links well with work in Essex by the Independent Living Collaborative, Rethink and Healthwatch which has shown how Increasingly IT literate local older people are.

2.3.6 The County are also preparing to re-procure befriending services. This work is informing thinking and, as recommended in the attached appendix from VCS colleagues, will be better linked to the wider community with opportunities for people needing social contact to better access activities such as volunteering, sports/clubs/community builder groups/demographic specific groups. It may for example be that someone would better benefit from transport to a group to enable social inclusion than from “befriending”. This approach will allow us to develop a more sustainable model supporting more people.

71

2.3.7 A key part of this will be to develop specific support to enable those who may have particular vulnerabilities and therefore be more likely to be isolated to best access support. These would include, but not be limited to, people who have a learning difficulty, people who have a sensory disability and people who are carers.

2.4 Local Campaign

2.4.1 We will seek to develop and deliver an external facing Social Marketing and Behaviour Change Campaign. We want to create a ripple effect across Essex to better understand the impact of loneliness and social isolation, and how we can all take small actions to help people in our community to connect to people, social networks and activity to live well. This will include raising awareness, encouraging people to seek support, encouraging people to offer support and reduce any stigma associated with feeling lonely or isolated. To include~

2.4.2 An external marketing campaign across all media channels some of which will require investment and some of which will maximise on cost neutral channels such as Social Media and connectivity with existing networks

2.4.3 We recognise the power of people’s voice in connecting communities to recognise and understand the impact of loneliness. We will work with a diverse range of people to shape and deliver this campaign.

2.4.3 The Campaign will involve a call to action and seek to create a social movement, much like the ‘green belt’ movement, that gives people the permission to get people helping people and generate significant and lasting behaviour change in communities in Essex. This will include opportunities for micro-volunteering and to become a recognised Community Connectors/ Friend. Establishing this movement and a bank of Community Connectors/Friends will require investment and a plan has been scoped around this

3. Resource Implications

3.1 These continue to be considered in the light of a better understanding of the existing resource in this area. Costs will include the further development of the Care Navigator model, specific developments around gaps in provision including around vulnerable and special need groups and largely non recurrent funding for the Campaign.

3.2 The key ask of CCG will be to ensure primary care teams and GPs are fully engaged and to work with providers to ensure the wider workforce including district nurses, community therapists and hospital wards also work to identify and refer/signpost people who may be isolated. It is hoped this may be undertaken within existing resources.

3.3 While more refinement is needed the indicative additional costs for these proposals across Essex will be around £500k for enhanced community support including the “care navigator” and support for vulnerable groups and around £200k non recurrent for the campaign.

Social Isolation and Loneliness Forum – Capacity Workstream

Background/Recap:

72

The Capacity workstream agreed to do the following in order to determine capacity across Essex to respond to social isolation and loneliness and recommend actions to be taken to ensure that there was a sufficient county wide effective, sustainable, and efficient capacity to tackle this issue:

1) Look at the current demographics across the county and needs – reports were submitted from the Essex Insight and Intelligence team showing that there are a few hotspots for social isolation and loneliness and outlining the key contributors to social isolation and loneliness (across ages and communities, not just older people); 2) Carry out a mapping exercise to attempt to see what interventions already exist across the county, where, what type, and how they are funded – this was done by the CVSs in partnership with RCCE, the Alliance, Healthwatch, and Essex Cares; 3) Attempt a gap analysis of existing capacity using 1) and 2), above; 4) Develop recommendations to stimulate and support capacity (e.g. via micro-grants, providing the infrastructure around volunteering, technical advice and guidance, etc.)

Analysis:

Looking at the data gathered in 1), above, we can see that every district has at least one high risk area of social isolation and loneliness, but when taken to a granular level of determining the contributors to isolation and loneliness, i.e. not speaking to someone at least weekly, the level of risk increases startlingly and covers the majority of the county. This shows that, when looking at capacity, we need to consider not just the delivery of services which directly tackle isolation but also services which are contributing to tackling some of the determinants.

The determinants to isolation have been agreed as: • Single pensioners. • Widowed. • Retired. • Unlikely to meet friends/family regularly. • Unlikely to interact with neighbours. • Poor health. • Suffering from depression. • Suffering from poor mobility. • Visually impaired. • Hard of hearing. • Struggling financially.

When looking, then, at 2), above, and the data received on activities already happening across Essex, it became clear that we need separately consider:

1) Relevant services which support the prevention (and identification) of social isolation/loneliness; 2) Direct delivery of services tackling isolation/loneliness.

It is important also to recognise that the data gathered is NOT cleaned – i.e. it has not been fully validated around quality and accuracy (some entries when looked at closely were found to be out of date or duplicated), and as no definition of the predetermined types of intervention (i.e. Formal Volunteering; Community Project) was given, people submitting the data have made personal decisions on what class of intervention each is. The data gathered before cleaning had 550 entries. After some focusing and deleting of

73

duplications, this still remained at 390. There is also limited information available about the funding of interventions and their sustainability.

A short exercise in cleaning the data to try to reduce duplications and to focus in on direct service delivery rather than outlying services was carried out.

After this exercise, the following conclusions can be drawn about the existing capacity across Essex:

1) All districts have some form of intervention available, but the type (i.e. formal or community) varies and some districts (i.e. Rayleigh) had very little showing – this could be because limited data was submitted or available, however, for this area.

2) There is a huge amount of activity occurring around isolation and loneliness across the county. Once data had a rudimentary cleaning, there were still 390 entries of activities which the group considered to be directly delivering services to tackle isolation and loneliness. BUT we cannot yet say with any certainty using this limited (and at this stage unreliable) data – - How these are funded and therefore how sustainable they are; - How long they are due to run for; - How many people they are currently reaching.

3) The original list of 550 interventions was seen to include what we can call ‘outlying’ services which in themselves are not set up to reduce isolation and loneliness but can clearly be seen to contribute to tackling it OR could help identify people who are isolated due to the social contact being made with individuals whilst carrying out the primary activity, for example: - Sports groups and clubs (that are not set up specifically for older members); - Faith groups; - CABs; - Mobility schemes; - Public services i.e. fire and safety (checks); - Equipment services; - Counselling; - Private enterprises for personal services i.e. toe-nail cutting; hairdressers; hoarding services; house clearance; gardening ; handyman/trusted trader schemes; - Volunteering; - Social prescription services; - Housing associations (which in some cases also operate their own schemes to reduce isolation of their residents).

It would therefore seem pertinent to be consider these in future plans and ensure that they are linked in in some way OR exploring targeted interventions with them as partners to encourage community action to develop sustainable models.

4) All demographic cohorts were served in some way, but the majority of services appear to focus on older people. The data does need further analysis, however, as many entries were indicated as Social Inclusion or Independent Living rather than identifying the client cohort and therefore when looking at detail are seen to work with people with a sensory impairment, young carers, etc and not just older people. We can also not easily determine without further analysis by geography areas and client cohort need , what is available and therefore where gaps exist– this will require further

74

cleaning and analysis of the data. At a glance, though, it shows that there are many groups which are condition/demographic specific.

5) There are some interesting and innovative approaches to reducing isolation which are sustainable but not county-wide: - Community run day nursery, supporting parents and acting as a social opportunity as well as looking after the children; - Community shops/cafes/libraries, where people are encouraged to gather and socialise and there is a sense of ownership; This could also be seen to include the social prescription shop model being piloted by MIND; - Foodbanks which run small cafes or ‘meet and greet’ when people come with their vouchers, which encourage interaction; - Community builder programmes which emphasise supporting the communities to develop sustainable social activities and interventions. These run alongside, but are not the same as, the Community Agent/Care Navigator/Social Prescribing programmes and are not county wide currently, but can be found in several districts in some form. They tend to be externally funded and therefore time limited, although whilst running the groups which are established are sustainable beyond the funding cycles.

6) We could not see any evidence of good neighbour informal schemes, but believe that they do exist. In many cases Neighbourhood Watches, faith groups, and Resident’s Associations carry out these activities or at the least encourage them.

Recommendations:

There appear to be 2 challenges to deal with when thinking of building capacity:

- The services available and how you can ensure that they are relevant, flexible, and reactive (as need will change); - The communities themselves and how you make them resilient and able to both be supportive to others within them and able as individuals to recognise and respond to their own situation.

Our recommendations for follow up work are:

1) The data gathered should, if to be used for decision making, be cleaned, analysed further, and if a focused and resourced piece of work (including data analysts) is carried out with more detail and focus on geography and client groups to more reliably inform future plans. Data we have received shows that the gaps in terms of type of intervention or type of group serviced vary from area to area and so this needs more focused and accurate work; 2) Where innovative and interesting but one off or small interventions are happening, it would be good to investigate them further and determine their efficacy and generalisability; 3) ‘Outlying’ services, which impact on social isolation but were not specifically developed for this purpose, should be considered in the bigger picture; 4) We know from local interventions and evidence that the following works in terms of focused services and should be explored more in terms of impact assessments and reach across the county: - The Asset Based Community Development Approach (community builders/connectors i.e.) - Social Prescription

Condition/demographic specific groups (i.e. autism, men, MS, parents etc);

75

Appendix - Primary care based action to identify people who are socially isolated

North East Essex CCG

The primary care based approach would have GPs with a key role in identifying people who may be isolated but with other primary care workers including receptionists and practice nurses playing a role.

GP care advisors have been funded across North East Essex through the IBCF with 15 in post (11.5 wte) embedded in Practices and working with VCS colleagues and other agencies (predominantly My Social Prescribing). Currently they have not been specifically engaged with people whose only issue is socially isolation but they are very well placed and have the capacity to do this. GPs who identify somebody as isolated who wishes to have support can access the adviser by sending a task through the system. Activity is recorded on System 1. The GPCA is then the conduit into other services and support for the person as appropriate. An intensive programme of care navigation training has already targeted over 150 reception staff in primary care, to better equip them to respond to social need. They are trained to social prescribe and connect with the wider voluntary and community sector through Connect Well. This programme could be replicated (dependent upon capacity) to GPCA and other connected workers in primary or secondary care.

The voluntary and community sector is embedded in specific primary care settings - i.e. Alzheimer's Society drop in sessions, social prescribers on outreach in surgeries and community settings. Additionally a range of other systems including Home from hospital services via Colchester 360 are trained to actively identify people who may be isolated. eg, volunteer drivers talk to people.

There are currently around 300 people trained around North East Essex who will also identify and signpost within the community. Work will also happen with A/E attenders as there is a high prevalence of loneliness identified in this group. Similarly care navigators working on the short stay and Frailty wards in Colchester hospital with play a key role in linking people into networks of support. These voluntary and community linking agencies would form another layer to the network to identify patients and solutions for them. A response such as befrienders network has also been developed across all disciplines, not just older people. The System Resilience Operational Group (SROG) will lead on delivery in NE Essex.

Mid Essex CCG

76

Mid Essex CCG have established 2 care navigators in every practice. These are frequently the receptionist and can identify people who they feel, through knowledge of their circumstances or because of their presentations might be isolated. GPs will also identify people who may be socially isolated and will refer to the care navigators.

It has been established that 60% of people with urgent presentations may be socially isolated and 60% of those attending A/E may have emotional issues. GP and receptionists are well placed to recognise and refer on people who may be isolated.

A number of practices are keen to start work in this area using a model based on that developed in the Mendips. This model is favoured as a systematic approach to recording information as needed on more vulnerable people. In addition, the CCG plan to utilise the De Jong screening tool to enable easier identification whether in the community, primary care or A/E. This means the CCG can also measure the impact of changes implemented.

This approach fits with the CCGs “Livewell” strategy and can be built into the intended approach to locality hubs, including physical, mental and social Care needs. The CCG are additionally looking to develop further social prescription.

An initial pilot was planned in three areas but wider implementation with ongoing evaluation is now proposed. They are also planning to use System 1 to identify people who may be at risk of social isolation

The CVSs are well placed to understand available opportunities and utilise Connect Well ME to collaborate and make these available to health and social care professionals and the wider community. Connect Well is an asset based, whole community approach to social prescribing and empowered signposting that has already trained receptionists and other staff in GP practices and will continue to link to the primary care system. Referrals can be made by anyone and there is an online self-refer option direct to a community activity or provider.

There are over 520 people already trained as Connect Well Champions, including staff in Leisure centres, local councils, pharmacies, colleges, social workers and libraries, to have a ‘Making Every Contact Count’ conversation with all ages of people and connect them with local activities. They are able to identify and refer on people who may be isolated across Mid Essex. Training is ongoing with regular updates and opportunities and every referral is tracked to ensure it is picked up by an activity/provider. Connect Well will support the CCG pilot to explore wider use of the identified screening tool to include trained Champions.

Connect Well works closely with Provide’s Essex Lifestyle Service, training the team the team as Champions so that ELS can offer a single access point for individuals requiring more than a simple referral to an activity or signposting; referrals are tracked through System 1 to quantify the impact of the service.

West Essex CCG

Within primary care, patients are identified opportunistically (via GPs, Nurses and/or receptionists) where a need is recognised, and holistic needs are also considered formally as part of the moderate frailty reviews which are now operational within West Essex neighbourhoods. Once identified hand off is to a Care Navigator Collaborative with a 77

single point of access operated through the Provide CIC, with access into Community Agents, Social Prescribing and Provide’s Essex Lifestyle services sitting underneath this access point.

The service focuses on a no wrong door approach and referrals are made using a single telephone number and email address to ensure simplicity of access into the Navigation Service.

The Provide Single Point of Access is operated via System 1 and ensures that NHS number can be collected to quantify impact of the service and where an individual has escalating needs, they can be handed back up into the appropriate clinical pathway ensuring Clinical Safety i.e. where an individual is experiencing a deterioration of a Mental Health Condition.

Following referral, the Provide Single Point of Access team make contact with the person being referred within 24 hours and undertake a guided conversation ascertain need. During this conversation the individual’s level of need will be identified and they may simply need linking with a local community offer or signposted to a community group. However, if a higher level of need is identified the individual is referred into the Care Navigator Collaborative for support.

Referrals can be made by: • GPs and practice staff • Self- Referrals • Other Health and Social Care Professionals NELFT, EPUT, PAH, IAPT, • System partners such as Essex Police • The EPUT Single Point of Access in West Essex (SPA)

A package of support is offered through the Care Navigator Collaborative and the individual is then handed off into the appropriate community support offer that best meets their needs. Importantly, where the originating referrer is on System 1, feedback and outcomes relating to an individual are sent back, this has helped to drive confidence in the Collaborative, particularly from a clinical perspective.

In West Essex there are 9.1 FTE within the Care Navigator Collaborative. In order to embed the service and to build relationships the Navigators are aligned to Neighbourhood Team Models and are assigned to a cluster of GP Practices where they attend multi-disciplinary team meetings (MDTs).

The Collaborative is operational across every GP practice in the CCG area.

Additionally, training has also been delivered with practice staff through EQUIP to help them to identify and signpost those who are socially isolated into the appropriate service.

In addition to Essex County Council funding, West Essex currently invests in the service as a CCG to enhance capacity to the value of 60K p.a. In addition South Uttlesford GPs using their own Primary Care development monies have also invested in some additional capacity to support the collaborative across their practices.

Basildon & Brentwood CCG

78

In Basildon and Brentwood it is recognised that GPs are far more likely to actively seek out people who may be isolated if there is a clearer sense of appropriate support being easily accessible. Initial thinking has suggested key roles for practice nurses and receptionists. Hand off in Basildon is to the same Care Navigator Collaborative operated through the Provide CIC that is used in West Essex.

Referrals can be made by: • GPs and practice staff • Self- Referrals • Other Health and Social Care Professionals – NELFT, EPUT, IAPT, BTUH, • System partners such as Essex Police

Across the CCG there are 9.8 FTE within the Care Navigator Collaborative. Again, as in West the Navigators are aligned to Neighbourhood Team Models and are assigned to a cluster of GP Practices where they attend multi-disciplinary team meetings (MDTs).

The Collaborative is operational across every GP practice in the Basildon and Brentwood CCG.

Additionally, training has also been delivered with practice staff through EQUIP to help them to identify and signpost those who are socially isolated into the appropriate service.

Castle Point and Rochford CCG

In CPR CCG, when a case presents in primary care there are essentially 3 x pathways options depending on individual context and circumstance. Receptionist navigator training is underway that will help facilitate these pathways.

The pathways are as follows:

1. Refer direct to ‘Befriending’ service commissioning by CCG and provided by CAVs 2. Refer (or encourage self-referral) to ‘Social Prescription’ service, “Ways to Wellness” also provide by CAVs 3. If wider health and care issues (alongside Isolation & Loneliness) refer to the ‘Care Coordination’ service which is a multi-agency team (including care-coordinators, GP lead, pharmacist, social worker and Age UK)

Through iBCF the CCG have invested in locality Navigator roles that enhance the Care Coordination offer and ensure appropriate ‘hand-off’.

All localities also now have weekly MDTs, led by Care Coordination team, used to discuss and plan care for moderate risk patients/clients.

The challenge for CPR CCG is identifying ‘socially isolated’ in first place. The key sources are primary care (as patients present) and the CCG’s Care Coordination Service (in receipt referrals from a range of sources). The latter keeps a register of ‘vulnerable’ patients (close to 3000 and rising) and the CCG are looking at the potential to actively interrogate this database to identify those at risk of being socially isolated. The CCG feel the communications campaign planned as part of this work could be valuable in helping 79

surface more unrecognised need. There is a strong ‘hand-off’ service already commissioned through CAVS (Castle Point Association of Voluntary Services)

CPR CCG have commissioned both their Social Prescription and Befriending services, the latter specifically targeted at the socially isolated. Patients presenting at practice with social isolation can be referred to either service. Practice staff have aids (including leaflets and cards) that are provided to enable speedy contact with these services. Patients are also supported to make the contact. Moving forward and linking with the CCG’s care coordination service, a care navigator collaborative model will be put in place in CP&R and this has been agreed by all partners to go live imminently.

80

Improved odds of Survival after Seven Years Social Relationships and Mortality Risk: A Meta-analytic Review Julianne Holt-Lunstad , Timothy B. Smith, J. Bradley Layton Published: July 27, 2010

81

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 11i

Date of Meeting: 27th September 2018

Report title: Proposed ICP Governance Model

Author: James Roach, Programme Director, Integrated Care Programme

Clinical lead (where Various leads across the Programme appropriate): Presented by: James Roach, Programme Director, Integrated Care Programme

Recommended actions /  Launch Delivery Plan for the rest of 2018/19 next steps  Hold all organisations to account for delivery  Finalise schemes of delegation of the ICP  Agree development of a Single Accountability Framework for the ICP

The Board is asked to: The Board is asked to;

 Approve the proposed ICP Governance Model to launch in Shadow form from the 1st November.  Support the transition from Shadow ICP Governance to full delegated authority in identified areas from 1st April 2018. Transition will include formalising the role of each forum, implementation in a timely way , gaining the relevant legal advice in relation to delegations and permissions and requesting Regulator support in relation to the proposed direction of travel  Endorse the development of a formal Alliance Agreement (in line with NHS England guidance) to underpin the ICP and its Governance model.

Executive summary This paper provides an outlined of the proposed Governance (maximum 500 word limit) Model for the West Essex ICP taking into consideration: and purpose of the report:  Recent discussions across the ICP in relation to the proposed governance model and how this links into individual provider governance  The need to reduce the duplication and ensure a more consistent model of system decision making  The development of a joint planning and contractual framework for the ICP and a Single Control total  The development of an underpinning Alliance Agreement which will bind the partnership in real terms  The potential future role of the CCG where the ICP is developed  Areas where delegated authority to act is required.

82

CCG Committees / Finance and Performance Committee Groups previously consulted Equality Impact Analysis No – but has been completed at individual scheme level (EIA) – state the outcomes and how will any detrimental impact be mitigated and monitored or state where an EIA is not applicable and why

Key issues and risks: Programme has a detailed risk register and is managed and monitored at the ICP programme Board.

Links to CCG Links to CCG strategic plan and STP Strategic Plan strategy/objectives Checklist for completion with all reports:

Indicate implications for:

9. Patient and public At various stages during the programme and as the paper engagement outlines a revised patient and public engagement strategy will be developed.

10. Resources Resources already allocated at scheme level

11. Health outcomes Population health focus will ensure appropriate targeting of clinical variation.

12. Quality and A number of schemes and pathways within the ICP are Performance focused on delivering improved service quality and performance.

13. Information IG implications are assessed at all times Governance 14. Legal and/or Not at this stage , relevant procurement and legal advice has Procurement been sought at key points of the programme issues 15. Conflict of N/A interests 16. Francis, Berwick N/A and Keogh recommendations

83

Developing an Integrated Governance Framework Proposal for the West Essex Integrated Care Partnership Section 1 - Introduction and Background The emerging ICP Governance model was developed following a mapping session held with system partners in July with the ICP Board in August approving the roll out of the model subject to  Each individual Partner Governing Body approving development of the proposed Governance Model

 Legal advice being sought in relation to the levels of delegated authority sort.

The aim would be to launch the ICP Governance Model from 1st November 2018 with delegation in identified areas being fully in place from 1st April 2019. The ultimate aim of the Proposed ICP Governance model is to reduce duplication and create single routes for system decision making and enhance these through associated schemes of delegation.

The CCG Governing Body is asked to;  Approve the proposed ICP Governance Model to launch in Shadow form from the 1st November.

 Support the transition from Shadow ICP Governance to full delegated authority in identified areas from 1st April 2018. Transition will include formalising the role of each forum, implementation in a timely way , gaining the relevant legal advice in relation to delegations and permissions and requesting Regulator support in relation to the proposed direction of travel

 Endorse the development of a formal Alliance Agreement ( in line with NHS England guidance ) to underpin the ICP and its Governance model

Section 2 - Key CCG strategic priorities and how the West Essex ICP Programme will enable delivery Strategic Priorities The ICP Programme will;

84

1.Collaboration Bind system organisations together to deliver key services under an Integration agreement. 2. Tackling Local variation Develop one consistent approach to identifying and addressing variation in our system according to local needs and operational realities. 3. Co –production and partnership Set the framework for co-production and oversee the implementation of integrated clinical pathways and services. 4. Deliver Ensure the system transacts initially in the 3 priority areas and jointly develops a pipeline for joint service development and identifies new clinical priorities for integration and capitation.

5. Adoption and spread of innovation Ensure that we develop a system wide platform for innovation through the Transformation Board and adopt and spread best practice.

6. Measure what matters Use data and evidence to identify system priorities underpinned by system wide population health and analysis.

7.Transparency  Developing a joint financial plan  Launch of an integrated performance dashboard  Sharing of data and intelligence

8.Accountability Develop a culture of holding each other to account for transformation and service change and ensure there is clarity on system wide roles and responsibilities.

9.Sustainability A joint focus on the future and ensuring we have a long term strategy for sustainable change through forums such as the System Transformation Board, System Finance Directors Group and the Strategic Estates Group.

85

10. System Leadership Ensuring a system wide implementation plain which delivers the key strategic objectives of the system underpinned by an effective pan system Organisational Development Plan.

It is intended that the Integrated Care Partnership covers all aspects of Health and Care in the West Essex area, specifically ✓ Public health ( defining strategic and tactical )

✓ Social care ( as above )

✓ Primary Care ( through the integrated Neighbourhood model )

✓ Community services

✓ Mental health services

✓ Acute services

✓ Specialised services ( this may well link to the development of the Integrated Care System across the current Herts and West Essex STP Footprint )

✓ Health education, innovation and R&D

✓ Governance, Assurance and regulation

✓ Resources and finance

✓ Capital and estate

✓ Information sharing and digital integration

86

✓ Workforce

✓ Communication and engagement

To enable effective ICP Governance the following enablers will be put in place across the system; ✓ Appropriate system wide governance and regulation

✓ Empowered System Leadership

✓ Delegation of resources in line with delegation of statutory functions ( role of CCGs where ICPs are established )

✓ Access to fiscal and regulatory levers that drives the improvement of health and wellbeing across the West Essex Health and Care System

✓ A shared strategic approach to capital and estates planning

✓ A shared strategic approach to communications and engagement

✓ A shared strategic approach to workforce planning (clinical and non-clinical )

✓ Development of new payment mechanisms

✓ Development of new information sharing system /process

Section 3- Key Governance Milestones  By October 10th 2018 – we will have approval to roll out the system wide governance model with system wide responsibilities and authority to instruct for legal clarification over where delegated authority can be implemented within the parameters of compliance.

 During October 2018 we will scope and agree a new single oversight and assurance framework for the ICP ( This we will scope in the System wide planning workshop on the 8th October )

87

 By November 2018 – Shadow capitated contract in place for the 3 priority areas

 By end of November 2018 we will agree an ICP Delivery Plan working as one in the key priority areas underpinned by a single contracting and assurance framework for the ICP. In particular we jointly publish set of ICP Delivery intentions for 2018/19

 By December 2018 we will have established the process and plan for the West Essex ICP Medium Term Financial Plan ( to launch formally on the 1st April 2019) and with it an approach for agreeing and monitoring investment decisions within the ICP

 By January 2018 we will have in place an ICP Alliance Agreement to bind the partnership in real terms providing the framework to work as one system to develop an integrated care partnership in West Essex.

 By November 2018, taking staff and public feedback into account we will refresh and rebrand the ICP from a communications and engagement perspective.

 By January 2018 determine the future role of the CCG in relation to strategic and tactical commissioning as the ICP becomes more established including putting in place system and place commissioning responsibilities.

Section 4 - Description of the Proposed Governance Model 4.1 Principles The revised Governance framework and the proposed West Essex ICP Alliance Agreement does not replace the legal framework or regulatory duties of our statutory organisations as they are currently constituted but instead sits alongside the defined framework to complement and enhance it

4.2 “Give and get “ The approach and subsequent agreements will include NHS England and NHS Improvement with the Alliance agreement being flexible enough (using NHS England template) to achieve the right level of delegated authority in areas such as  Financial

 Capacity

 Devolved freedoms and flexibilities

88

In return the intention would be to move away from a purely transactional approach to improved performance and transformation change

A trust based relationship With aligned goals With a relationship based or With projects providing professional  As the ICP is not yet a legal entity ( as defined by NHS England ) , Thecore ICP objectives Board through its governancenetworks process that and ensure delega tedhigh -quality authority will continue to engage closely and work in partnership with Boards , Governing Bodies and Councils throughoutjoined-up the care. development of the ICP

 The development of the ICP during 2018/19 will establish how individual organisations will be held to account for their contribution to the delivery of NHS Constitution and Mandate arrangements in full and remain part of the of the wider NHS system ICP. The ultimate aim is for the ICP to be assured once as a place for delivery of core local, regional and national priorities

The proposed Governance changes will ensure that we develop effectively as an ICP which will include collective decision making , governance and a single accountability framework to the delivery of the West Essex plan

4.3 The Proposed Governance Model What we are proposing is the development of collaborative ICP Governance (as outlined below) which recognises the statutory governance of member organisations but at the same times begins to accelerate the development of the ICP and bind it in real terms

89

 This model of system wide governance will remain in place between 2018 and 2020 and during this time it is intended that the West Essex ICP will work with Department of Health , NHS England and NHS Improvement to establish the governance model that will enable the system to develop into an independent fully functional ICP by 2020 ( the Current West Essex ICP vision )

 CCGs and Local Authorities will continue to receive their respective health and care funding and be statutorily responsible for their allocation.

 To act as an initial structure, it is proposed the Leadership and Management Team Terms of Reference, devised in Schedule 3 Part 1 on the NHS E template Alliance Agreement is used. These terms can be adapted, but provide a base. It is suggested that any recommendation surrounding delegation are made with the support of legal advice, as whilst the CCG and Trust will have statutory and regulatory duties, other collaborating members may also have terms defined by statutory or held within other constitutional documentation.

90

4.4 Summary of key meetings West Essex ICP Board The ICP Delivery Board will have system wide overview and accountability. It will develop an Alliance Agreement and a Terms of Reference for the Board to adopt; it will also lead the way in developing the Alliance Contract. It will ultimately oversee the delivery of all core programme objectives ensuring key issues addressed and any delegated authority is used appropriately in delivery terms.

The ICP Board has agreed that Primary Care should be represented on a locality basis. These will be specifically to represent the strengths and concerns of the Locality they represent from a general practice perspective though they should be also able to represent the wider Neighbourhood issues within their localities from a population health needs perspective. Board GPs as Locality leads is already understood and established.

The ICP Board will also have clinical/professional representation from other providers specifically PAH, EPUT, ECC and when appropriate from Hertfordshire.

Local Delivery Board It has been agreed that LDB is formally connected into ICP Governance Structure Formerly connecting the LDB into the ACP Governance structure, which covers Urgent Care, DTOC and winter planning. The ICP Delivery Board will also have overall delegated responsibility and sign off for decisions made by the LDB. This will establish the clinical pathway and single control total position for urgent care.

Existing Children’s and Mental Health Boards These will have a direct linkage to the ICP Delivery Board

Transformation Board This Board will take the lead for innovation and transformation across the system and focus on areas such as progress population health service alignment, delivery of core transformation priorities, and development of the ICP Workforce model. It will also take responsibility for aligning system efficiency plans.

The following key sub groups will link into the Transformation Board;

(a)Strategic estates group – maximise use of estate for current and future service needs.

91

(b)IT Interoperability – covering shared care record, interoperability and data sharing, it will also look to mainstream the integration of data, move towards single care record and align our analysis.

(C) Expert Oversight Groups – Joint clinical expert groups leading the development of Integrated Care Pathways in a range of clinical specialties

Operational Delivery Board The Board will oversee all programme delivery, performance management, financial leadership (Single Control Total and MTFP), development of new contracting and currency models and take responsibility for aligning CIP, QIPP and Cost improvement.

In the future it is hoped we will move all existing contracting and finance functions into one system Board meeting and develop a Single Accountability Framework for the ICP .There will also linkage into the work that is being undertaken at Neighbourhood and locality levels giving neighbourhoods a seat at the table and an opportunity to influence decision making across the ICP.

CCG Governance CCG Governing Bodies are required by statute to have 2 committees both of which should be chaired by lay members: 1. Audit Committee and

2. Remuneration Committee

3. In addition, the CCG has taken on delegated responsibility for primary care commissioning and has established a Primary Care Commissioning Committee.

4. Quality Committee

These committees would remain in place in the future for the CCG and all Provider Organisations.

Section 5- Future Roles of CCGs where ICP has been developed 5.1 – Key messages

92

Recent guidance from NHS England advised on the future role of CCGs where ICPs have been developed in the context of the Draft Integrated Care Provider Contract /Consultation package. This will be considered in more detail at the CCG Board Development Session in October, key messages are summarised below.  CCGs will continue to be responsible for the delivery of their functions, although it is recognised that they may also require through contract provisions an ICP to take action to support the function of certain CCG functions.

 CCGs functions can’t be delegated

 CCGs and ICPs should maximise opportunities for making shared use of administrative resources

 The establishment of ICPs will require providers to deploy integrated budgets flexibly. To enable this CCGs may wish to pool budgets with other commissioners

 The draft ICP contract developed by NHS England stipulates some requirements of ICPs which will subject to statutory constraints include

 Requirement to conduct a population health needs assessment and to develop strategies to improve health and wellbeing of the population

 The requirement to seek to address underlying health inequalities

 The need to put in place information systems and risk stratification

 Obligation to offer patient choice , including choice of primary care provider

5.2 – Future Opportunities Activity function CCG is responsible for Description How can ICP support delivery

93

Population needs assessment  CCGs are obliged to deliver JSNA  Join up assessment

 Local analysis of demand, population  Use data to determine future priorities needs and expectations and allocation of resource

 Needs analysis to deliver current and future contracture obligations

Commissioning Commission health services to meet needs of The ICP cannot directly commission services service but would be able to sub contract services within the scope of what it has been commissioned to provide

Managing and developing the supply chain for Stimulating the market to ensure there are a Yes the ICP should stimulate the market to services provided across the CCG ( including number of high quality options for patients ensure there are a number of high quality across the ICP ) available when commissioning service options available when it is sub-contracting services

Demand management across the CCG Putting in place actions across the CCG to Yes the ICP should create and manage control levels of demand on particular services demand management plans for their populations to enable patients to make appropriate choices

Engagement and consultation on service Section 142 – CCG Yes ICPs should develop new ways to involve change proposals their population in the design and use of services

94

Integrating the Provision of services across the CCG has a duty to exercise its functions with a ICP should lead on the development of CCG view to ensuring that health services are integrated provider pathways delivered in an integrated way where it ICP will hold responsibility for a wide range of considers that this would improve the quality of services itself , organisational barriers will be those services removed and the ICP will put in place smooth , seamless pathways between services provided by the ICP

Addressing health inequalities CCG obliged under Section 141 The Draft national ICP contract raises a specific obligation on the ICP to reduce health inequalities when performing its obligations

Planning and implementation of cost Yes Yes – ICPs are well placed to deliver these in improvement schemes a sustainable way Decision making relating to funding routes Yes Yes where service and contractually appropriate

Contract management for services within Yes in the normal ICP would be responsible for managing any outside of ICP scope contracts it has with sub-contractors. Quality monitoring Yes Yes quality monitoring of services being delivered through a sub contract should be carried out by an ICP

Oversight and management of system Taking responsibility as the system leader for ICP wide performance management of performance the overall performance of whole local health services it delivers and sub contracts system

Oversight of risk and reward mechanisms Using the contract to put in place mechanisms Not appropriate for ICP to have oversight of between CCG and ICP a reward mechanisms but can influence them through contract negotiations

95

Section 6 -Binding the partnership in real terms NHS England Alliance Agreement This emerging agreement ( when drafted ) will develop and embed the framework by which all partners will come together working as one in identified areas in 2019/20 to establish how we will develop as an integrated care partnership. We will agree together the delegated powers and new relationships we develop across organisations to deliver on this ambition and bind the partnership in real terms This alliance agreement will be developed in November. Section 7 -Proposed scheme of delegation The information below represents current thinking on proposed scheme of delegation for the ICP Programme, a more detailed proposal will be provided to the relevant Governing Bodies for sign off in September. Any suggestions below will be subject to receipt of external legal advice: Delegated to ICP Major Programme Decision Areas Remains with individual Boards Board Agreement to Overarching ICP Plan and investment requirements and underpinning Governance ✓ Agreement on formal ICP Board , levels of delegated authority and MOU ✓

Agreement on the assurance process ✓(CCG) Agreement of the decision to proceed with most capable lead providers approaches or proceed to competitive market procurement ✓(agree) Contract award recommendations for Governing Body Ratification ✓(agree ) ✓(Recommend )

Define the responsibilities and accountability of the Lead Provider ✓

96

Agreement on the mobilisation of resources required to deliver the programme and its objectives ✓ Day to day direction and leadership of the programme ✓ Recommendations and agreement on readiness to go live in April 2019 ✓(agree) ✓(Recommend )

Section 8 -Next steps /key decisions required The CCG Governing Body are asked to  Approve the proposed ICP Governance Model to launch in Shadow form from the 1st November

 Support the transition from Shadow ICP Governance to full delegated authority in identified areas from 1st April 2018. Transition will include formalising the role of each forum, implementation in a timely way , gaining the relevant legal advice in relation to delegation and permission and requesting Regulator support in relation to the proposed direction of travel

 Endorse the development of a formal Alliance Agreement ( in line with NHS England guidance ) to underpin the ICP and its Governance model

James Roach, ICP Programme Director

97

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 11ii

Date of Meeting: 27th September 2018

Report title: ICP Delivery Plan 1st August – 31st March 2019

Author: James Roach - Programme Director, Integrated Care Programme

Clinical lead (where Various leads across the Programme appropriate): Presented by: James Roach - Programme Director, Integrated Care Programme

Recommended actions /  Launch Delivery Plan for the rest of 2018/19 next steps  Hold all organisations to account for delivery  Finalise schemes of delegation of the ICP  Agree development of a Single Accountability Framework for the ICP

The Board is asked to: The Board is asked to  Agree the key actions outlined in the ICP Delivery Plan  Endorse direction of travel in relation to the development of schemes of delegation and ICP governance proposal  Agree that ICP Delivery Plan becomes a standing item at the CCG Board and Finance and Performance Committee for the rest of 2018/19.

Executive summary This paper provides a summary of the proposed ICP Delivery (maximum 500 word limit) Plan for the rest of 2018/19; the key actions are outlined and purpose of the below and will be overseen by the ICP Delivery Board with report: regular updates and areas for approval continuing to be presented to individual Governing Bodies at each key decision making stage. A more detailed action plan is held centrally by the Programme Team. This paper includes an overview of  Key strategic priorities  Key delivery actions  The proposed due diligence Process for MSK and COPD services  Proposed levels of delegated authority for the ICP Programme (this will form part of a more detailed Governance Proposal that will be submitted for approval at the September CCG Governing Body)

The Board are asked to review the proposed delivery plan and

98

endorse the key actions. At each Governing Body meeting, the Board will receive updates on key actions and progress on delivery of the ICP Delivery Plan. The Finance and Performance Committee will also receive updates at their monthly meetings.

CCG Committees / None at this stage Groups previously consulted Equality Impact Analysis No – but has been completed at individual scheme level (EIA) – state the outcomes and how will any detrimental impact be mitigated and monitored or state where an EIA is not applicable and why Key issues and risks: Programme has a detailed risk register and is managed and monitored at the ICP programme Board.

Links to CCG Links to CCG strategic plan and STP Strategic Plan strategy/objectives

Checklist for completion with all reports:

Indicate implications for:

17. Patient and public At various stages during the programme and as the paper engagement outlines a revised patient and public engagement strategy will be developed.

18. Resources Resources already allocated at scheme level

19. Health outcomes Population health focus will ensure appropriate targeting of clinical variation.

20. Quality and A number of schemes and pathways within the ICP are Performance focused on delivering improved service quality and performance.

21. Information IG implications are assessed at all times Governance 22. Legal and/or Not at this stage , relevant procurement and legal advice has Procurement issues been sought at key points of the programme 23. Conflict of interests N/A 24. Francis, Berwick and N/A Keogh recommendations

99

West Essex Integrated Care Programme Delivery Plan August 1st – 31st March 2019. Section 1 - Overview This paper provides a summary of the proposed ICP Delivery Plan for the rest of 2018/19; the key actions are outlined below and will be overseen by the ICP Delivery Board with regular updates and areas for approval continuing to be presented to individual Governing Bodies at each key decision making stage. A more detailed action plan is held centrally by the Programme Team. This paper includes an overview of  Key strategic priorities

 Key delivery actions

 The proposed due diligence Process for MSK and COPD services

 Proposed levels of delegated authority for the ICP Programme

Section 2- Key strategic priorities and how the ICP Programme will deliver. Strategic Priorities The ICP Programme will; 1.Collaboration Bind system organisations together to deliver key services under an Integration agreement/ MOU. 2. Tackling Local variation Develop one consistent approach to identifying and addressing variation in our system according to local needs and operational realities. 3. Co –production and partnership Set the framework for co-production and oversee the implementation of integrated clinical pathways and services. 4. Deliver Ensure the system transacts in the 3 priority areas and develops a pipeline for joint service development and identifies new clinical priorities for integration and capitation. 5. Adoption and spread of innovation Ensure that we develop a system wide platform for innovation through the Transformation Board and adopt and spread best practice and innovation. 6. Join up clinical and managerial leadership Develop a framework for system clinical leadership through the Senate and Expert Oversight Groups. Through the ICP Board develop a Joint Executive for the oversight and leadership of the ICP and wider system. 7.Measure what matters Use data and evidence to identify system priorities underpinned by system wide population health and analysis (such as the vital few).

100

8.Transparency Join up of financial position Transparent review of costs and spend Sharing data and intelligence 9.Accountability Develop a culture of holding each other to account for transformation and service change and ensure there is clarity on system wide roles and responsibilities. 10.Sustainability Look forward and ensure we have a long term strategy for sustainable change through forums such as the System Transformation Board, System Finance Directors Group and the Strategic Estates Group.

Section 3 - Delivery strategy

101

Section 4 - Action plan 2018/19 The information below is a summary of the key delivery actions that the ICP Programme will take forward for the rest of 2018/19

102

Reference Key area of focus Start date End Date On track 1 Pre mobilisation 1.1 Gain approval from ICP Board for service specifications 1st August 18th August Delivered ( COPD and MSK ) 1.2 Finalise legal and procurement position ( received ) 18th August 31st August Delivered 1.3 Commence ICP Provider Due diligence process for MSK 1st September 30thh October Starts 17/09/18 and COPD 1.4 1ST October 31st October 08/10/18 Draft Commissioning Intentions for ICP planning event 1.5 Establish and launch the Shadow Periods for MSK 1st November 31st March ,COPD and Urgent Care ( this will include completion of 2019 1.6 contractual variations and schedules and evaluation 1st April 2019 programme) 30th June 2019 Oversee the launch of the new service models and act as Strategic and Assurance Lead for the system Reference Key area of focus Start date End Date On track 2. Establish Programme Governance and Leadership 2.1 Sign off ICP governance model and with associated 24th July 1st September On track – item levels of delegated authority ( all aspects of the on Governing governance model ) Bodies 2.2 1st September 30th (PAH/EPUT/CCG) Governance model to be approved by individual September 2.3 Governing Bodies in September On track 1st September 31st October 2.4 Review /evaluation of ICP impact 1st August 30th Current contract review /take stock September On track 2.5 Draft Formal Integration Agreement (all partners) for date 1st January 19 effective launch of 1st April 2019. Potentially will need 31st March

103

Governing Body sign off in January and then shadow 2019 implementation to the end of March 2019 2.6 1st October Develop Communication and lead Stakeholder 31st March Work has Engagement Plan 2019 commenced 2.7 1st January 2019 Agree resources necessary for ICP Programme 31st March 2.8 mobilisation 2019/20 1st October 2019

Development of contracting intentions for the system 31st March Work has /ICP and develop and begin the implementation of ICP 2019 commenced( key 2.9 Intentions system meeting 1st October on 081018)

Development of the Medium Term Financial Plan for the 31st March 2.10 West Essex system and put in place a supporting 1ST October 2019 delivery and assurance mechanism 31st March Develop and Implement a Single Accountability 2019 Framework for the ICP

Reference Key area of focus Start date End Date On track 3. Launching local care models 3.1 Front Door Model ( Shadow with agreed MDS and 1st August 31st/3/2019 In negotiation payment terms ) 3.2 MSK service launch ( shadow with agreed MDS and 1st October 31st/3/2019 payment terms ) 3.3 1st October 31st /3/2019

104

COPD service launch ( Shadow with agreed MDS and payment terms ) 3.4 1st September 31st October Development of contractual mechanisms and relevant variations, associated legal frameworks with gain/risk 3.5 sharing agreement and financial incentives for impact 1st October 1st October from April 1st 2019 3.6 Transformation Board ( working in partnership with Expert Oversight Groups ) to recommend new clinical 1st October 1st November target areas for ICP 3.7 Develop an outline Clinical Strategy for the system and Ongoing 30th November Prioritise clinical work plans

3.8 Work with Professional Leaders Group and Clinical 1st December 31st March Senate to develop new areas for clinical integration and 2019 an Innovation Pipeline for 2019/20

Develop a ICP prospectus of future service delivery/commissioning intentions Market engagement in identified areas Reference Key area of focus Start date End Date On track 4. Developing the outcomes framework 4.1 Commence monitoring of revised outcome measures for 1st October 31 / 3/ 19 Outcomes MSK/COPD and Front Door Model drafted

4.2 Design and launch core system indicators and outcomes 1st September 1st November 4.3 Launch system wide Population Health Framework 1st October 31st October

4.4 1st August 1st October Undertake ICP needs analysis 5. Developing the contractual and financial framework

105

5.1 Define and agree via System FDS a detailed contracting 1st September 1st November strategy for 2019/20 and 2020/21 to include budget modelling, scenarios and the framework approach for risk 1st September 1st November 5.2 and gain share. Develop financial report and templates to support the revised contract model

Reference Key area of focus Start date End Date On track 6. Workforce and system development 6.1 Develop a workforce strategy following local needs 1st August 1st Nov analysis 6.2 Engaging OD support for the transformation model From 1st October 6.3 Launch Integrated Care System KLOE review September In progress 6.4 Confirm approaches in relation to strategic and tactical Board seminar commissioning October 7. Communications and engagement 7.1 Produce Patient Engagement Plan 3rd September Commenced 7.2 Produce Staff Engagement Plan 3rd September Commenced 7.3 Commence Public Engagement on ICP vision 1st November Approach approved at ICP Board on 100918

Section 5 – Next steps The CCG Governing Body are asked to  Agree the key actions outlined in the ICP Delivery Plan

 Endorse direction of travel in relation to the development of schemes of delegation and ICP governance proposal

 Agree that ICP Delivery Plan becomes a standing item on Boards and Finance and Performance Committees for the rest of 2018/19.

106

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 12

Date of Meeting: 27th September 2018

Report title: Emotional Wellbeing and Mental Health Service (EWMHS) update

Author: Jessica Thom, Assistant Director CAMHS Commissioning

Clinical lead (where appropriate): Presented by: Jessica Thom, Assistant Director CAMHS Commissioning

Recommended actions / N/A next steps The Board is asked to: The Board is asked to note the report.

Executive summary This report offers an update on the commissioned EWMH (maximum 500 word service and wider Children & Young People Mental limit) and purpose of the Health (CYPMH) Transformation Plan. Highlighting current report: service performance and activities to support the Southend, Essex & Thurrock (SET) Local Transformation Plan (LTP); Open Up, Reach Out.

CCG Committees / N/A Groups previously consulted Equality Impact Analysis N/A (EIA) – state the outcomes and how will any detrimental impact be mitigated and monitored or state where an EIA is not applicable and why Key issues and risks: N/A

Links to CCG CCG Commissioning intentions strategy/objectives SET LTP, Open up, Reach Out Five Year Forward Plan

Checklist for completion with all reports:

Indicate implications for:

25. Patient and public N/A

107

engagement 26. Resources N/A

27. Health outcomes Meeting and improving the mental health outcomes for Children and young people in West Essex CCG

28. Quality and N/A Performance 29. Information No Governance 30. Legal and/or The EWMHS contract is due for Procurement, with a new Procurement issues contract required by 1st November 2020

31. Conflict of interests N/A

32. Francis, Berwick and N/A Keogh recommendations

108

1. Background: The Essex service model

In November 2015, Essex launched a single integrated Children and Young People Mental Health (CYPMH) service (Tier 2 + Tier 3) delivered by a single provider, and commissioned in partnership across seven clinical commissioning groups (CCGs), Southend and Thurrock Unitary Authorities and Essex County Council. Commissioners have shifted from a fragmented tiered system to a single emotional wellbeing and mental health service.

The core service is delivered by seven teams based in each of the CCG localities with health and social care workers who specialise in mental health services for children and young people. They provide a full range of services from information, advice and support to specialist help for long-term and serious mental health problems. The seven localities teams each have a base, that mainly work out in local communities with children, young people and their families at home, in local schools, children’s centres, in GP practices and other familiar and convenient places. The introduction of the Essex Single Point of Access (SPA) has provided an open access route for all professionals, schools, Children and young people (CYP), parent/carers, including self-referral, allowing contact with mental health services directly through a single telephone number and email address.

2. The CYPMH offer:

 Community EWMH service  24hr Crisis Service covering A&E’s across Southend, Essex and Thurrock  Dedicated Eating Disorder Service  EWMHS Learning Disability Service  Digital mental health support service

3. Current CYPMH statistics

During 2018/19 there continues to be an increase in referrals to EWMH services, the current acceptance rate for the CYP referred and accepted for a service is 97% against, a national average of 75%. To support this demand commissioners have piloted a digital offer via Kooth and continue to work with the EWMHS provider; North East London Foundation Trust (NELFT) to understand and plan for the demand and capacity. NHSE national target for CYP access to mental health services for 2018/19 is 32% commissioners are working to support meeting this target while managing the demand and waits for mental health provision.

3.1 EWMHS service:

As of June 2018 (snapshot) Indicator WECCG Total Service Pan Essex Referrals in 163 1140 Referrals accepted 162 1123 Total contacts 882 6760 Crisis team total contacts 58 511 Eating Disorder contacts 3 377

109

Referral to Treatment seen 90.17% 91.57%

3.2 Online Counselling: Kooth, Snapshot August 2018

The online digital offer is receiving an average of 2000 logins and 400 CYP per month, with the average age between 15-17years using the service outside of 9-5 working hours.

4. Achievements/ improvements in 2018/19

In-line with the Open Up Reach Out CYP Local Mental Health Transformation plan Priorities the commissioning collaborative have been planning, proposing and investing in priority areas to meet the plans objectives.

Priority Offer Achievement/ improvement Digital service Online Counselling offer for More than 10,000 CYP 11-19 yrs (Kooth) have logged in Q1 18/19

Crisis service Re-modelling the current New model will offer a Crisis offer rapid response, intense support and longer home treatment offer

110

CYP engagement Mental health school More than 700CYP campaigns delivered by engaged per campaign Reprezent Professional support: Embedding the Schools Health professionals will be Schools offer (NEFLT) & extending able to access the self- the Schools self-harm harm toolkit electronically. toolkit to Health Schools reporting professionals Transitions Pilot a Transitions offer for Agreement to pilot due to CYP 16-25yrs begin Dec 2018

EWMH Learning Difficulty Additional investment to Investment to support service expand the EWMHS learning difficulty clinicians learning difficulty service to support Care Education across Southend Essex & & Treatment Reviews Thurrock and increase the age to 18years.

4.1 Remodelled Crisis service: Community Response & Intensive Intervention Service, from December 2018

Graphic representation of Community Response and Intensive Intervention Service within EWMHS. Main access to pathways via SPA, Hub, A&E or T4 as part of discharge

4.2 CYP Engagement: Reprezent

111

Reprezent are commissioned to deliver a communication and engagement service to children and young people throughout Southend, Essex and Thurrock via radio media.

Passmores Academy, Saffron Walden County High and King Harold Academy Schools, with over 700 pupils exploring stress and how to deal with it. Video clip of the school’s Campaign https://vimeo.com/247041718

5. Next steps

The next steps for Children and Young People’s Mental Health in West Essex CCG and the Essex collaborative will be to:

 Implement the NHSE national Schools Green paper trailblazer Pilot for; mental health teams in Schools and a 4 week wait for treatment- Pending bid approval by NHSE  Evaluate the current EWMH service and strategic commissioning arrangement to inform future procurement and commissioning of CYP mental health services  Oversee and monitor the Crisis re-modelling and Transitions pilot  Implement the Infant mental health service  Roll-out the self-harm toolkit  Strengthen and widen CYP engagement

6. Further information is available from the SET LTP: https://westessexccg.nhs.uk/news/docs/cyp-ltp

112

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 13i

Date of Meeting: 27th September 2018

Report title: Hertfordshire and West Essex STP Estates Plan

Author: STP Estates and Capital Workstream

Clinical lead (where N/A appropriate): Presented by: Peter Wightman, Director of Primary Care and Localities

Recommended actions / next steps The Board is asked to: The Board is asked to approve the STP estates plan

Executive summary The STP estates plan was completed for submission in (maximum 500 word draft to NHS England in July 2018. A standard template limit) and purpose of the was provided with mandated data collection. report:

HWE STP Estates workbook V1.2 16th July - Boards.pdf

The workbook template reflected the priorities set out within the Governments response to the Naylor Review of NHS Estates – “NHS property and estates; why the estate matters for patients’.

www.gov.uk/government/publications/naylor-review- government-response

The plan sets out the scale of the estates challenge across the STP and the key role that estate transformation needs to contribute to the overall service transformation strategy of the STP. It identifies a series of estate improvement metrics that the STP needs to deliver over the next three to five years and sets out actions that need to be taken collectively across the STP partner organisations as well as actions to be taken by individual constituent organisations. These are summarised in section A8: critical decisions and road map.

One of the key requirements of the process was the identification and prioritisation of a future pipeline of

113

capital projects across the STP, together with a pipeline of future disposal opportunities (with sale proceeds contributing to the cost of delivering identified priorities). All organisations submitted a list of future capital schemes; providers also submitted details about current capital schemes funded via internal capital allocations. The total estimated capital requirement for the STP equates to between £1.7 and £2.1 bn – the range reflecting upper and lower range costs of the two major acute redevelopments at West Hertfordshire Hospitals NHS Trust and Princess Alexandra Hospital, Harlow.

The STP FD led the prioritisation process on behalf of STP organisations; the key focus of the prioritisation process was the identification of schemes that the STP wished to put forward for capital funding via the STP ‘wave 4’ capital bidding process. There were 2 linked but separate submissions for projects / bids with a value of >£100m and projects / bids with a value of <£100m. The STP undertook a full evaluation of a long list of projects submitted by STP member organisations to identify a short list of projects for submission to the national bidding round. Bid evaluation criteria were set out nationally and the local prioritisation process used the same criteria to evaluate submissions from STP organisations.

Following the prioritisation process the HWE STP submitted bids to the national review process for the major acute redevelopment programmes at West Hertfordshire Hospitals NHS Trust and Princess Alexandra Hospital, Harlow. In addition the following 7<£100m estate relate bids were submitted:

1. Additional Bed Capacity PAH 2. WHHT Emergency Care Transformation WGH 3. ENHT Creation of Herts and West Essex Vascular Hub 4. ENH Luton and Dunstable Renal Dialysis Unit Relocation 5. WHHT Planned Care Transformation (Phase 1) 6. PAH Transformation of Day Case Services 7. ENH Satellite Radiotherapy - North Herts & Stevenage

The wave 4 bidding process also allowed for IT bids to be submitted – at the request of NHS Improvement a bid was also submitted for £7m capital funding to address ongoing issues with the implementation / functionality of the Lorenzo EPR (electronic patient record) at East and North Herts NHS Trust.

114

Sections A4 to A7 and section B of the workbook set out the project and disposals pipeline in more detail.

The plan / workbook and project pipeline will need to be regularly up dated and mechanisms put in place to track progress against KPI and action delivery. It is anticipated that the workbook will be updated on an annual basis and that the project pipeline and prioritisation will be regularly reviewed. Future waves of capital funding are expected to be released at a national level although this has not yet been confirmed. The STP estates and capital group will co-ordinate work over the next six months to ensure that the STP is well positioned to bid against any future capital bidding processes.

The overall programme will be overseen by the estates and capital group, working closely with the STP FDs group. Governance arrangements are set out in section A of the workbook.

CCG Committees / STP Chief Executives, Directors of Finance and Estates Groups previously and Capital Group. consulted

Equality Impact Analysis An EIA will be completed as part of the premises (EIA) – state the development programme. outcomes and how will any detrimental impact be mitigated and monitored or state where an EIA is not applicable and why

Key issues and risks: Ensure WECCG estate development plans are known at STP level, and therefore within any potential approval and funding criteria Links to CCG Continue to develop as a leading commissioning strategy/objectives organisation of quality health and care services. Linked to WECCG estates strategy.

Checklist for completion with all reports:

Indicate implications for:

1. Patient and public Patients and public will be engaged as part of the engagement Estates Strategy process.

115

2. Resources Resource is supplied from the current West Essex CCG staff

3. Health outcomes Adequate facilities to provide primary care are essential for high quality outcomes

4. Quality and Patients should continue to receive the same standard Performance of Primary Medical Services 5. Information N/A Governance

6. Legal and/or NHS England Premises Directions will need to be followed Procurement issues in granting capital / s106 and business cases for increased rent reimbursement. Procurement rules apply depending on type of developments 7. Conflict of interests Processes need to take into account any conflict of interest with regard to GP practice and investment in their premises 8. Francis, Berwick and Premises are a key enabler to service quality Keogh recommendations

116

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 13ii

Date of Meeting: 27th September 2018

Report title: STP Update Report

Author: STP Project Management Office

Clinical lead (where Dr Rob Gerlis, Chair and STP Clinical Lead appropriate): Presented by: Andrew Geldard, Chief Officer

Recommended actions / next steps The Board is asked to: The Board is asked to note the report.

Executive summary This is the first of a regular update report that will be produced (maximum 500 word limit) by the STP transition team. and purpose of the report: The report provides an update on the key work areas for the work stream and will ensure that STP member organisations Boards and Governing Bodies are up to date with developments.

The externally commissioned report on the transition to an Integrated Care System details the challenges and national context for the STP. The report generated recommendations for development of both ICS and ICAs. These recommendations are supported by the CEO Board and the STP team are developing an action plan.

The STP recently attended a Regional Review with NHSE and NHSI. There was positive feedback as well a clear steer on the need to focus on the STP’s medium term financial plan and clinical strategy.

Work continues to develop the STP’s medium term financial plan. It will be completed by the end of October 2018.

The STP is developing a system wide clinical strategy. An engagement event is taking place on 4th October 2018, and the strategy will be available for wider consultation during November and December 2018.

CCG Committees / Executive Committee and Executive Health and Care Groups previously Commissioning Committee. consulted

117

Equality Impact Analysis Has an EIA screening been conducted? If not please outline (EIA) – state the why. If it has what was the outcome of this analysis – how will outcomes and how will any detrimental impact be mitigated and monitored – n/a any detrimental impact be mitigated and monitored or state where an EIA is not applicable and why

Key issues and risks:

Links to CCG strategy/objectives

Checklist for completion with all reports:

Indicate implications for:

33. Patient and public Confirmation of the STP’s patient and public engagement engagement plans are included in the report.

34. Resources Detail on the medium term financial plan is included in the report. 35. Health outcomes Health outcomes are incorporated within the STP clinical strategy.

36. Quality and Quality is incorporated within the STP clinical strategy. Performance

37. Information n/a Governance

38. Legal and/or n/a Procurement issues 39. Conflict of n/a interests 40. Francis, Berwick Detail incorporated within the STP clinical strategy. and Keogh recommendations

118

STP Update

September 2018

1. Introduction

This paper provides an update from Hertfordshire and west Essex STP to be discussed at STP member organisations Board or Governing Body meetings. This report is the first of these reports which will be provided on a regular basis by the STP transition team and will include information on key work areas.

This report provides an update on:  Final report from Carnall Farrar on the transition to an Integrated Care System.  Recent regional review meeting held with NHSE.  STP medium term financial plan.  Development of STP wide clinical strategy.

2. Hertfordshire and west Essex STP – transition to an Integrated Care System.

2.1 In March 2018, organisations in the Hertfordshire and west Essex (HWE) STP agreed to embark upon an ambitious programme that would include transitioning to an Integrated Care System (ICS), underpinned by Integrated Care Alliances (ICAs). The STP’s ambition is to be recognised as an ICS by NHS England from April 2019. Carnall Farrar (CF) was commissioned to facilitate the leadership of the STP to co- develop the scope and functions of both the ICS and associated ICAs. The twelve week period of support took an interview and workshop based approach, supported by a wider system opinion survey and benchmarking. This report outlines progress to date on the co-development tasks the STP set itself. It offers recommendations to accelerate progress towards being recognised as an ICS.

2.2 HWE faces a number of challenges that can only be resolved by working at scale across the system. The population will grow by 150,000 by 2024 and those aged over 65 will increase by 12% by 2025, further increasing demand on an already stretched system. In 2017/18 the 4 hour A&E waiting time target was breached by all HWE NHS providers, and A&E activity has risen at the three acute providers between 2-6% from 2015/16 to 2017/18. HWE faces unique workforce challenges. Accessibility to London (with higher wages) and Cambridgeshire (with perceived better experience) make it more difficult to recruit and retain staff. A further specific challenge for HWE is the condition of the acute trust estates which require up to £1bn of investment for major renovation.

2.3 An ICS acts as a strategic commissioner for the health and care needs of a whole population and aligns the system in terms of strategy, commissioning and delivery. It commissions care from ICAs that focus on care needs for specific population cohorts. To become an ICS, HWE STP will have to meet the five criteria set out by NHS England: strong leadership; strong financial management; track record of delivery; a coherent and defined population; and compelling plans to integrate primary care, mental health, social care and hospital services. An Integrated Care System (ICS) for HWE will improve population health outcomes and ensure system sustainability. By commissioning strategically at scale, resources can be pooled and targeted where

119

most needed, addressing the specific challenges faced in HWE, such as urgent and emergency care performance and estate requirements. The potential for access to national transformational funding is also increased by moving towards a recognised ICS rather than maintaining the status quo as an STP.

2.4 The organisations included in the HWE ICS will reflect those in the STP, and an initial governance structure is proposed in the report. The future commissioning form could be based on a Joint Committee of CCGs including NHS England, with budget pooling across health and social care supported by section 75 agreements. Further work is needed to agree specifically which functions will be commissioned at different levels e.g. ICS, ICA and at locality/neighbourhood level. There are seven recommendations for HWE to progress the work on transitioning to an ICS, detailed below:

ICS recommendations

Recommendation 1: Create a clinically-led health and care system strategy for HWE To realise benefits of joint working, HWE should set out system-wide strategy, to include a firm focus on population health and place-based care. This should comprise a compelling case for change with priorities for action and a clear proposition for sustainable health and care delivery, starting with an assessment of the population’s needs. The scope should include prevention, health and care (clinical and non-clinical). Other concrete proposals should be developed in this strategy for urgent and emergency care, primary care transformation, planned care and the approach to population health management and place based provision. A sustainable proposition for the NHS and local government should be the core, but it needs to recognise the link to wider public and voluntary services. The strategy should be underpinned by the medium term financial strategy (including delivery of a single financial control total and any investment requirements to deliver the strategy) and a system workforce strategy. A phased implementation plan with near, medium and long term objectives should be included with stated aspirations to reduce activity across points of delivery within the acute trusts.

Recommendation 2: Develop collaborative governance The STP needs to further develop a collaborative governance structure for the ICS which can facilitate strategic commissioning and enable leaders to be held to account. This should provide clarity on the authority for joint decision making and the processes entailed. An independent chair should be appointed to facilitate collaboration, forge consensus, hold individuals to account and provide robust challenge as the STP transitions towards an ICS. A system clinical lead and respective workstream clinical leads should also be appointed. The STP leaders should discuss and agree the leadership model for the ICS, including the potential role of a chair within the ICS. Organisations within the STP should work together to commit to whole system working and define a set of principles about what this means in practice that is in line with the overarching governance structure.

Recommendation 3: Develop joint commissioning arrangements HWE commissioners should map out current organisational arrangements and understand current resources. Decisions that need to be made across HWE

120

versus at individual CCG level need to be defined, building on recent work undertaken between the three CCG boards. Movement to Joint Committees for joint decisions should be undertaken, starting with oversight of the system strategy. Joint commissioning arrangements should include NHS England as decisions about population health management are likely to involve care for people who receive specialised interventions commissioned at the national level. CCG Governing Body engagement should continue on a joint basis to accelerate this.

Recommendation 4: Develop system leadership The HWE STP should develop system leadership across the STP, ensuring there is a clear mandate to deliver the vision and strategy developed for transition to an ICS. There should be clearly defined leadership roles supported by resources commensurate to the task. STP workstream SROs should be drawn from the chief executive cohort, supported by an agreed clinical lead. Each workstream SRO should be given a clear remit, a set of responsibilities and be held to account for delivery. Any gaps in system leadership capacity should be quickly identified and filled. The organisations within the STP need to commit to supporting the leaders in developing in and transitioning towards an ICS, and should provide resource for double running as required. The overarching governance structure should align with and reinforce system leadership.

Recommendation 5: Accelerate information sharing To improve strategic and operational decision making for HWE, information flows need to improve. An information sharing agreement should be set up with an information governance architecture. This should be used to accelerate development of an integrated dataset across HWE for use by organisations and frontline staff to improve decision making.

Recommendation 6: Link the medium term financial strategy with resourcing requirements To support the development of a population health management approach, resources will be required throughout planning and implementation. This will include pump priming and double running costs. Investment requirements should be scoped and determined by September 2018 in order to enable system leadership (see recommendation 4). The medium term financial strategy should take into account resource requirements for the emerging ICS as a key part of the overall system financial plan. Further work needs to be done to factor in the impact of the recently announced funding settlement for the NHS and understand how this might be best used at a system level.

Recommendation 7: Improve UEC performance as an exemplar of joint working The HWE STP needs to deliver on national requirements for planned care, mental health, cancer and other programmes. However, there is an opportunity to focus efforts on accelerating UEC further this year. This will also support the establishment of a recognised track record of delivery across HWE. A plan is needed to deliver required improvements for the 2018/19 winter period against national planning guidance. This should detail short term and system-wide aspirations to reduce non-elective admissions and bed days. A current state and future demand and capacity plan should be included. HWE

121

Chief Executives, including all acute trust leads, should continue to meet jointly to determine the direction and collectively hold each other to account for delivery against an agreed shared plan. Progress should be jointly reported by HWE STP organisations to regulators and feedback sought to the STP as a whole, as opposed to individual organisations. In parallel, the STP leaders need to put thought into how to move other national priorities forwards so that UEC is not progressed at the expense of any other area and so that radical approaches to transforming can remain a core component of the system’s agenda.

2.5 The HWE STP has also committed to supporting the development of Integrated Care Alliances (ICAs). Integrated Care Alliances (ICAs) are alliances of NHS and other care providers that work together to deliver care by agreeing to collaborate rather than compete. These providers include hospitals, community services, mental health services and primary care. Social care, independent and third sector providers may also be involved. ICAs coordinate care delivery at locality and neighbourhood levels between multiple providers, reducing barriers between organisations and enabling the delivery of population health. They enable a shift in focus from a traditional disease or pathway-based approach to a holistic and individual value-based approach. It is easier to assemble multi-disciplinary teams (MDTs) within an ICA and incentives for staff from different organisations can be more effectively aligned towards a common goal. In HWE, the financial impact estimations range from a conservative level of ambition that could deliver £53m net savings to a stretch level of ambition that could deliver up to £265m net savings by 2022/23.

2.6 To begin the design of the ICAs, a population segmentation assessing resource consumption by cohorts with similar needs within HWE was carried out. It determined that 12% of the HWE population consumes 43% of current resources. This 12% comprises three cohort groups that would benefit from integrated care (frail adults and older people with complex needs or ‘frailty’; children with complex needs; specialist mental health). Momentum has been built for starting by establishing three ICAs focused on adults and older people with complex needs. Recent discussions across the HWE STP have leaned towards a lead provider form that allows one provider to coordinate the activities of others for the relevant priority cohort. To ensure the successful delivery of the interventions through the ICAs, four critical enablers (workforce, estate, payment, and information) have been identified for further development. There are four recommendations for HWE to progress the work on transitioning to an ICA, detailed below:

ICA Recommendations

Recommendation 1: Accelerate development of neighbourhood models HWE should leverage existing local best practice and roll out neighbourhood level delivery models for 30-50k sized populations across a wider footprint. This should be driven by a priority cohort approach to designing interventions. Lessons learnt from schemes that have been running for a while (e.g. the care home Vanguard) should be reviewed and adopted. It should be recognised that the role of primary care will be pivotal to the successful delivery of population health at a local neighbourhood level (e.g. primary care

122

involvement in MDTs) – and without the involvement of primary care, the evidence suggests that ICAs will fail.

Recommendation 2: Set commissioning budgets and required outcomes HWE commissioners should review current contracts and spend to identify defined budgets for ICAs based on population need by October 2018. To set the budget for specific population cohorts under a population health management approach, a full financial segmentation is required which will only be possible to do if an integrated dataset is put in place. This should be accompanied with the development of clearly defined outcomes expected to be delivered by ICAs that will be used to support future payment models. Resetting commissioning budgets in this way will enable a shift towards outcomes-based funding and away from activity-based funding, changing the way that providers are incentivised to deliver care. The principle of population based funding should be supported across the STP.

Recommendation 3: The number and scope of ICAs needs to be clearly defined and formally agreed by executives in the STP The HWE STP should start by focusing on the development of three ICAs for the adults and elderly with complex needs cohorts. This should be set out in a formal document that commissioners and providers sign up to, including Local Authorities. Chief executives should be responsible for ensuring board-level agreement to this at their respective organisations. Following the agreement of the specific scope of the individual ICAs, lead provider arrangements should be created for each respective ICA. Each ICA needs to agree its lead provider and member providers. The arrangements should formalise payment mechanisms and risk and gain share within the ICA. ICAs should aim to move to shadow form for the first cohort by October 2018. However, in progressing the three, it should be recognised that this could be part of a phased approach to broader development of ICAs. The HWE STP leaders should discuss the timetable for other population segments coming on-stream (e.g. specialist mental health).

Recommendation 4: Agree and put in place resource to establish ICAs Each ICA should agree leadership requirements to drive the development work forwards. To do this successfully, resources will be required in order to establish the ICAs (or build on work completed to date to move towards full establishment), and the STP should ensure these are provided. Dedicated management capacity will be needed to support delivery, supported through a the crystallisation of a model which delegates sufficient authority to ICAs at the neighbourhood level to run themselves in a way which best meets the needs of their local populations.

2.7 The CEO Board and Chairs Oversight Group has received the final report and supported the recommendations.

2.8 A high-level roadmap with key milestones has been developed to outline the work programme for development of the ICS. By coming together and working towards

123

becoming an ICS, HWE organisations will be better placed to respond to health and care challenges, and harness the opportunities to better serve the health and care needs of the HWE population.

3. Regional Review

3.1 The STP had a regional review meeting on 8th August 2018 with Paul Watson, Regional Director (Midlands and East) from NHSE Elliot Howard-Jones, Director of Commissioning Operations (Central Midlands from NHSE, Jeff Worrall, Delivery and Improvement Director (NHSI) and Verena Stocker, Deputy Director, National Transformation Team. The STP was represented by Deborah Fielding, STP Leader, Sally Morris, CEO EPUT, Lance McCarthy, CEO, PAH, Chris Lawrence, Chair, HPFT, Kathryn Magson, CEO HVCCG and Jonathan Wise, interim STP Finance lead.

3.2 At the meeting the STP gave an update on the progress that is being made with transformation, development of the medium term financial plan and the transition to an Integrated Care System.

3.3 NHSE recognised that there had been a lot of progress, but that more is needed for the system to work as a full collective. An example they gave was the remaining disparity between forecast out-turns in parts of the patch and the fact that you are still operating a largely unmoderated PbR system would indicate that there is progress still to be made. The meeting also discussed opportunities to improve the maturity of the system in relation to working in different ways around system transformation to avoid the negative effects of procurements and penalties

3.4 It was recognised that a key milestone will be the production of a clear medium-term financial plan that describes how the system will return to recurrent financial balance. It was noted that the financial plan will need to incorporate the changes that you are planning and also describe how you will approach the 2019/20 planning round as a collective and reflect this in contractual agreements.

3.5 The work underway as part of the urgent care and frailty work streams was explored. It was agreed that they looked very promising and the STP were encouraged to ensure that we had SMART objectives.

3.6 The STP was cautioned not to be too fixed on ICS status as an end in itself. The journey to ICS status will need the STP to have in place a clear service and financial plan and some evidence of beginning to implement such a plan; this must be the key focus for the coming months. It was agreed that the conclusions reached by the recent work on ICS and ICA development were sensible and will provide the basis for future work.

3.7 It was noted that the STP is in the process of appointing an independent chair through a national process and NHS England are involved in the recruitment process.

3.8 The next regional review is scheduled for the 7th November 2018.

4. Medium Term Financial Plan

124

4.1 The STP is committed to having a Medium Term Financial Plan. The overall approach to, and objectives of, an STP wide medium term sustainability plan are set out below:

4.2 Objectives of the plan are: a) Understanding of the drivers of the underlying position (including ‘Do Nothing’ position) and a clear and robust trajectory to achieve underlying recurrent balance (‘Do Something’ position), including an understanding of the working capital and cash requirements in the interim period. b) Financial and activity projections underpinned by clinical strategy, transformational changes and benchmarked evidence. c) STP wide collective principles developed for the 19/20 planning round, including ways of working, approach to single control total, contracting/payment arrangements etc. d) Draft Finance, activity and workforce plan for 19/20 (with clear timeline and process to finalise and to then be effectively used to measure system wide delivery (using KPIs) with risks and opportunities also fully articulated/understood). e) Clear alignment across the STP (one ‘integrated’ plan), that all organisations have reviewed and agreed, and that is consistent with all internal plans, and all submissions to NHSE/I. f) Confirmation of timeline for further internal assurance that both the medium term and draft 19/20 plans are deliverable, including robust implementation plans. g) Risk assessment (including understanding of the downsides) and mitigation plans regarding these.

Please note that these are all subject to national guidance anticipated September 2018, with further details November 2018

4.3 The overall approach to the modelling and both do nothing and do something modelling are:

 To use 2017/18 outturn as an anchor point  2018/19 describes the do something interventions as per operating plans  2019/20 onwards will include: . Pre SOC interventions, with scenarios

125

. SOC impacts

Note: ICS/ICA assumed to be required as an enabler in the Do Something to underpin delivery.

126

4.4 The principles of the Do Nothing modelling approach are taken from the NHS 5YFV both in terms of the structure below and in terms of quantifying the impacts (as per appendix 1), together with local inputs (e.g. additional capital costs required in the Do Nothing, etc) which were applied to the 17/18 outturn.

4.5 The proposed Do Something inputs were discussed and agreed at the CEO Board on 1st May 2018, and are detailed below:

Service Transformation - reduce Collaborative Productivity - reduce unit demand, service change: cost of delivering services by working • Urgent and Emergency Care (including together: Frailty, impact of mental health • Estates workstream etc) • Procurement • Out of hospital (including Primary Care • Clinical Support Services and Prevention) • Workforce • Planned Care (inc Fragile Services,POLCE) Enablers: Business as usual: • Place Based Care • CCG • Technology • Continuing Care QIPP • Prescribing QIPP • Trusts • CIPs (deliverable by Organisations working alone)

Collaborative Structures: Strategic Financial Enablers: • Organsational form/ function • STF requirements • Payment reform/ aligned incentives • Single Control total • Reduced Transaction costs • Capital and revenue investment to support • Capitated budgets transformation

4.6 The work over recent months has been steered and overseen by the STP wide FDs group, with regular updates to the STP CEO group and the timeframe going forward is for a paper to be discussed and agreed by the CEO group on 16 October, with consideration by all organisations in late October/early November.

127

5. STP Clinical Strategy – Integrated care for a healthier future

5.1 The health and care system wide clinical strategy will be a sustainable NHS and local government proposition that will be developed to focus on population health and place based care which will have the following overarching aims to:

 set out our future health & wellbeing ambitions for people in Herts & west Essex, building on existing strategies  provide a framework for patient/user focused, clinically led & high achieving healthcare services  ensure a sustainable approach which addresses the health & wellbeing gap, the care & quality gap, affordability & efficiency gap  improve clinical outcomes  reduce unwarranted variation, ensure evidence based standardised approaches and to ensure full & effective clinical engagement in the design, development & delivery of our clinical strategy

The STP CEO board have explored and recognised that the development of the clinical strategy will require a set of delivery components and these could include:

 An assessment of the population needs  Population health management and place based care provision  Heath and care prevention that is clinical and non clinical  Wider public and voluntary sector services linkage  Urgent care , emergency care , primary care and planned care transformation

This additional intention of this strategy is that it will provide the supportive architecture over the development of an aligned medium term financial and workforce strategy.

It is also recognised that at the heart of the strategic development there will be a requirement to hold to a set of agreed principles which may include the following:

 Enabling Communities with an emphasis on self-help/prevention  Population based commissioning system  One place, one system, at the levels of 30-50,000, 100,000, 500,000 & 1.5 million  Transforming integrated care with a cohorted approach to complex older people (frailty), children & mental health  Reducing variation & standardising care to best practice  Developing enablers at scale & pace  Engaged clinicians and professional who demonstrate awareness & commitment to the clinical strategy  Clinically co-designed strategy based on best practice & evidence review of successful approaches nationally  Robust clinical networking & strong relationships across the system  Effective clinical & professional engagement for both health & social care  Shared commitment to improved outcomes for patients/users

128

The approach to designing the strategy will additionally require consideration of the clinical service offers for the future at ICS, ICA, locality and neighbourhood population levels as exemplified as follows:

Working Core Clinical Services offered Clinical services Together across services at three at a larger scale that would the STP to district general to a require a range hospitals eg improve Clinical geographical of tailored & A & E, outcomes e.g. population varied maternity, Specialist rather than a interventions services integrated frailty Appendix 1 provides a samplepathways of the for planning approachcohorted that could be takenfrom tomultiple start toincluding define the programme of work required to progresspopulation the development eg alongsideorganisations the cancer, acute adults & older following milestones: older people urgent care aimed at trust fragile with complex centre, diabetic individuals eg services like

needs. Plus care, joined up

30-50,000 Pop Size 1,520,000 500,000 100-150,000 ICS ICA Localities Neighbourhoods

 Utilise launch of Professional Clinical Leaders Group on 4th October 2018 as clinical engagement event  Clinical strategy ready for wider consultation & agreement in December 2018, with implementation plan (timescales TBC)

Recommendations

 Clinical Programme approach led by CEOs and Clinical Leads  Each CEO to lead development of appropriate chapter using their current portfolio lead & workgroup  Extended STP clinical oversight group (COG) taking a lead role in aligning organisational strategies so they are in line with the overall STP / ICS strategy.  COG to advise & lead clinical pathway development with the support of the STP senior transition team.  STP to “hold the ring” on co-ordinating & managing development and ensuring “golden thread” on behalf of COG and Directors of Finance.

129

130

6. Next Steps

6.1 Below is a table that summarises the next steps.

Date Meeting Action 7.9.18 Clinical Oversight Group Clinical Strategy Planning Sessions 18.9.18 Joint Chairs and CEOs  Update on Medium Term Financial Plan (MTFP).  Update on Clinical Strategy. 21.9.18 Finance Director meeting Sign off of MTFP 2.10.18 CEO Board Sign off of MTFP 4.10.18 Clinical Leaders Group  Clinical engagement event  Draft clinical strategy to be agreed by clinicians 16.10.18 CEO Board Sign off of paper to go to STP members Boards, detailing draft MTFP and Clinical Strategy 31.10.18 Submit draft MTFP to NHS England 22.10.18-8.11.18 Paper to be received and approved by STP member boards or finance committee 7.11.18 Regional review with NHSE MTFP and Clinical Strategy to be presented and discussed. 21.11.18 Essex Health and Wellbeing Engagement with wider stakeholders Board 19.12.18 Hertfordshire Health and Engagement with wider stakeholders Wellbeing Board Nov and Dec STP stakeholder Wider consultation with stakeholders 2018 regarding clinical strategy

6.2 Please note that early engagement with HealthWatch and patient representative group will be built into the above timetable.

6.3 STP members to continue their commitment to the STP and ensure that they support their clinicians and staff in engaging the contributing to transformation work streams.

131

APPENDIX 1

132

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 14

Date of Meeting: 27th September 2018

Report title: Safeguarding Children and Adults Annual Report 2017-18

Author: Christine Muirden - Designated Nurse Safeguarding and Looked After Children Anita Root - Designated Nurse Safeguarding and Looked After Children Phillippa Uren - Designated Professional Lead Safeguarding Adults

Clinical lead (where Jane Kinniburgh, Director of Nursing & Quality appropriate): Presented by: Christine Muirden - Designated Nurse Safeguarding and Looked After Children Phillippa Uren - Designated Professional Lead Safeguarding Adults

Recommended actions / Annual report - No specific recommendations/ actions have next steps been identified within this report

The Board is asked to: The Board is requested to note this report.

Executive summary The purpose of this report is to provide assurance to the (maximum 500 word limit) Board that West Essex Clinical Commissioning Group and purpose of the (WECCG) has robust and effective safeguarding processes in report: place that reflect local and National Guidance. This report presents evidence of the CCGs Safeguarding Team achievements’ and continued commitment to safety, protection and prevention of harm to our local population within west Essex.

This annual report reviews the work across the year and gives update that the CCG has discharged its children and adult safeguarding responsibilities across the health services it commissions.

The annual report provides a brief overview of the legislative framework for safeguarding children and adults at national level, and how this informs collaborative arrangements across Essex to ensure the CCG fulfils its statutory duties.

The report includes leaning from national and countywide safeguarding audits, inspections (CQC and Ofsted), Serious Case Reviews and Domestic Homicide Reviews, and how these have informed local protocols and practice.

133

It also appraises the committee on CCG’s legal duty to safeguard adults as described in Mental Capacity Act 2005; and the Law Commission’s final recommendations on Deprivation of Liberty Safeguard.

Finally the annual report provides an update of the CCGs activities, and outlines the key priorities and the work plan for 2018/19.

CCG Committees / Quality Committee 4th September 2018 Groups previously consulted Equality Impact Analysis The CCG works with partner agencies and health (EIA) – state the organisations to ensure that services and processes are in outcomes and how will place to respond to children and adults who are at risk or who any detrimental impact be have been harmed, including delivering improved outcomes mitigated and monitored and life chances for the most vulnerable, regardless of race, or state where an EIA is age, gender reassignment, ethnic background, culture, sex, not applicable and why sexual orientation, marriage and civil partnership, pregnancy and maternity status, religion or belief or mental status.

Key issues and risks: Risk/Issue Details Mitigation/Recovery Safeguarding The CCG Oversight of children Safeguarding progress is through processes Children team the PAH Contract and training continue to support Meeting and CCG were the PAH team to Quality Assurance identified improve Oversight Group. within the safeguarding Announced and CQC report processes, facilitate unannounced as requires supervision and safeguarding visits improvement embed learning continue, with for Princess from incidents. constructive Alexandra feedback offered and Hospital outcomes monitored. (PAH).

Links to CCG Strengthens the quality framework for commissioned services. strategy/objectives Meet Statutory Requirements for Adult and Children’s Safeguarding.

Checklist for completion with all reports:

Indicate implications for:

41. Patient and public No direct views have been taken from service users. All engagement actions taken reflect statutory guidance to improve safeguarding for children in West Essex.

134

42. Resources None

43. Health outcomes The CCGs seeks to work with partner agencies and health organisations to ensure that services and processes are in place to respond to children and adults who are at risk or who have been harmed, including delivering improved outcomes and life chances for the most vulnerable.

44. Quality and The continued high performance by the CCG in relation to Performance safeguarding children and adults will have a positive impact on the quality of health services provided to west Essex service users.

45. Information Any information sharing will comply with the General Data Governance Protection Regulations 2018; Mental Capacity Act 2005; Mental Capacity Code of Practice 2015 and CCG’s Information Sharing Policies and Procedures.

46. Legal and/or None Procurement Issues 47. Conflict of None interests 48. Francis, Berwick F-1,2, B -1,3,5 K-8 Implementing the Recommendations and Keogh Putting the Patients first recommendations • F-109,117 K-3 Ensuring robust, transparent systems in place to support the process, complainants, staff and organisation to ensure that learning is embedded • F-124, 125, 133 Duty to require and monitor delivery of fundamental standards Responsibility for requiring and monitoring delivery of enhanced standards Roles of commissioners in complaints • F142 Unambiguous lines of referral and information flows

135

West Essex Clinical Commissioning Groups Safeguarding Children and Adults Annual Report 2017/18

August 2018

Purpose of the Report The purpose of this report is to provide assurance to the Board that West Essex Clinical Commissioning Group (WECCG) has robust and effective safeguarding processes in place which reflect national legislation and statutory guidance, and demonstrate the commitment of the organisation to embed safeguarding both internally and within its commissioning functions.

This report presents evidence of the CCGs Safeguarding Children and Adult team achievements and continued commitment to the safety, protection and prevention of harm to our local population within west Essex.

1. National Context

1.1 Safeguarding Framework

The definition of safeguarding children is necessarily broad, reflective of the spectrum of need, and is defined within Working Together (2015) as:  Protecting children from maltreatment;  Preventing impairment of children’s health or development;  Ensuring that children grow up in circumstances consistent with the provision of safe and effective care; and  Taking action to enable all children to have the best outcomes.

As an NHS organisation and a commissioner of services, the CCG is required, under Section 11 of the Children Act (2004), ‘to ensure that its functions are discharged having due regard to safeguard and promote the welfare of children’. This likewise applies to any services the CCG commissions.

The key safeguarding legislation in relation to children and adults includes:  Children Act 1989;  Children Act 2004;  The Care Act 2014;  Children and Families Act 2014;  Children and Social Work Act 2017;  Mental Capacity Act 2005;  Counter Terrorism and Security Act 2015.

136

Whilst the pertinent safeguarding statutory guidance is as outlined below:  Working Together to Safeguard Children 2015; to be updated in 2018  Promoting the Health and Wellbeing of Looked-after Children Statutory guidance for local authorities, clinical commissioning groups and NHS England. DfE/ DH March 2015.

Safeguarding roles and respective competencies required for all staff working within a healthcare setting are further prescribed within the guidance:  Safeguarding Children & Young People: Roles and Competences for Health Care Staff. Intercollegiate Document (RCPCH 2014).  Looked-after Children Knowledge, skills and competencies of healthcare staff. Intercollegiate Role Framework (RCPCH/ RCN, 2015).  Female Genital Mutilation: Standards for training healthcare professionals. NHS England 2018.  Prevent Training and Competency Framework. NHS England 2017.

1.2 The NHS England (2015) “Accountability and Assurance Framework The implications of the statutory requirements are further clarified within the NHS England (2015) “Accountability and Assurance Framework: Safeguarding Vulnerable People in the Reformed NHS” which sets out with greater clarity the responsibilities of each part of the system and key individuals who work within it.

Implications of the document for the CCG:

 Stipulates that NHS England, CCGs, Designated Professionals and local providers should ensure appropriate representation on the Local Safeguarding Children Board (LSCB) and Safeguarding Adult Boards (SAB).  Distinguishes between providers’ responsibilities to provide safe and high quality care and support, and commissioners’ responsibilities to assure themselves of the safety and effectiveness of the services they have commissioned.  Requires CCGs, as a member of the Safeguarding Adult Board to have a Designated Adult Safeguarding Manager (DASM) and Mental Capacity Act (MCA) Lead.  Requires CCGs, under delegated arrangements, to be responsible for ensuring that the commissioned General Practitioner (GP) services have effective safeguarding arrangements and are compliant with the MCA.

1.3 Safeguarding Children Statutory Guidance

Although Working Together to Safeguard Children (2015) remains the key statutory guidance for inter-agency working to safeguard and promote the welfare of children, the Children and Social Work Act 2017, which came into effect from May 2017, will require a revision of current guidance. A new version of Working Together is anticipated in early 2018. Key recommendations include:  New safeguarding partnerships led by local authorities, the chief officers of police and CCGs to make arrangements to work together to safeguard and promote the welfare of local children including identifying and responding to their needs.  A new Child Safeguarding Practice Review Panel to review serious child safeguarding cases and develop a repository of learning.

137

 Introduces ‘Child Death Review Partners’ consisting of the local authority and clinical commissioning groups for the area, replacing the LSCB function. Child death review partners to make arrangements to review child deaths resident in their locality.

2. County Context

2.1 Multi-Agency Safeguarding Arrangements CCGs have a statutory duty to be members of the Local Safeguarding Children Board (LSCB), working in partnership with local authorities to fulfil their safeguarding responsibilities. The Essex Safeguarding Children Board (ESCB) works in close partnership with the Southend and Thurrock LSCBs to encourage seamless working and minimise unnecessary duplication of work.

A collaborative approach is adopted across Essex with the Accountable Officer for Castle Point and Rochford representing the 5 CCGs at the ESCB Executive Board. The Mid Essex Designated Nurse and the Designated Doctor for North Essex act as the expert advisors to the Board. The Director of Nursing for WECCG attends the Health Executive Forum (HEF), a sub- group of the Board, and the Designated Nurse for Safeguarding and Looked-after Children is a member of the ESCB Strategic Child Death Overview Panel. In anticipation of changes outlined within the Children and Social Act (2017), a review of the structure of the ESCB has been undertaken, placing greater emphasis on the contribution of the local Stay Safe groups to enhance the interface between front-line services and the strategic safeguarding agenda. The Designated Nurse now chairs the West Essex Stay Safe Group, and is working actively with partners to progress the priorities outlined within the ESCB Business Plan 2017-19. The ESCB Effective Support for Children and Families in Essex document was updated in 2017 to reflect the complexity of the new challenges and emerging themes within the safeguarding arena, e.g. child exploitation and gangs, radicalisation and modern slavery. The document outlines the thresholds for intervention from universal to specialist services i.e. Local Authority Children Social Care, in-patient Child and Adolescent Mental Health Services, Youth Offending Service (level 4). Greater emphasis continues to be placed on early intervention and the lead professional approach at Additional and Intensive levels (2 and 3), facilitating a ‘team around the child and family’ model of support. 3. Inspections and Audits

3.1 Care Quality Commission (CQC) Although the CCG safeguarding children and adult provision has not received a CQC safeguarding inspection since 2014, Princess Alexandra Hospital (PAH), the substantive acute provider, was rated inadequate by the CQC in July 2016. Specific concerns were raised regarding children’s safeguarding processes, reporting and investigations. Similarly, concerns were identified in relation to safeguarding adults and the inconsistent knowledge of staff regarding mental capacity assessments. Action plans outlining improvements implemented to address deficits have been monitored by the CCG, and further triangulated during safeguarding focused unannounced visits in April and September 2017. Progress has been scrutinised during both the PAH Oversight Forum and Patient Safety and Quality Review contract meetings. Key themes identified included access to safeguarding supervision within maternity services, exercising professional curiosity, ensuring the voice of the child is evident within practice, lack of governance and internal scrutiny of

138

safeguarding adults’ processes, poor knowledge of Mental Capacity Act and poor safeguarding training compliance. A CQC report published on 21st March 2018 following a review inspection in December 2017, increased the overall rating to ‘requires improvement’, although still noted challenges within safeguarding children training compliance. The CCG Quality Assurance Oversight Group (QAOG), established in November 2016, provides a further forum for scrutiny and monitoring of progress, using the CQC Key Lines of Enquiry as the framework. 3.2 Joint Area Targeted Inspections (JTAI) In January 2018, the CQC, Ofsted and Her Majesties Inspectorate of Constabulary and Fire & Rescue Services published Guidance on Joint Targeted Agency Inspection on the theme: Child sexual exploitation, children associated with gangs and at risk of exploitation and children missing from care, home or education. In preparation for an inspection, work plans have been developed reflecting the core lines of enquiry. These have been shared with the main providers and the Named GPs in preparation, should west Essex be targeted. 3.3 Ofsted Inspection Essex County Council participated in a pilot Ofsted Inspection in July 2017 receiving a good overall and outstanding with regards to leadership across the county’s children’s services. A full inspection is expected in 2018. 3.4 Serious Case Reviews (SCR) Serious Case Review A

A Consideration Panel was convened on 29th January 2018 following a referral by the Safeguarding Team to the Essex Safeguarding Children Board (ESCB) in relation to the death of a 7 month old infant from west Essex. The Panel has concluded that the case meets the criteria for a SCR. The Essex SCR Panel is to meet in early June 2018 to establish Terms of Reference for the review.

Serious Case Review SL

The SCR Overview Report and recommendations are awaited regarding a south-west Essex case following the deaths of both a mother and her baby. The case had significant involvement by west Essex providers. A Practitioner event is planned for early July 2018 to review the final document before it is published.

Thematic Review of Teenage Suicides in Essex

A Thematic Review of Teenage Suicides in Essex has been facilitated by the Essex Safeguarding Children Board (ESCB) following a significant increase in cases since April 2017. Themes and learning identified by the review will be shared across the county in due course. A Task and Finish group is being established to facilitate this, with a strategic learning event planned for June 2018.

3.5 Multi-agency Case Audits (MACA)

139

Themed Multi-agency Case Audits (MACA) have continued to be coordinated across Essex by the ESCB. These are statutory mechanisms which bring together representatives of partner agencies and professionals responsible for promoting the welfare and safety of children and young people. The forums consider how different services and professional groups co-operate to safeguarding children and make arrangements to work effectively to promote the outcomes for children. Cases reviewed have included those where concerns were identified in relation to Fabricated and Induced Illness, an area presenting increasingly complex and challenging demands on services. 3.6 Independent Inquiry into Child Sexual Abuse (IICSA) The IICSA continues to investigate whether public bodies and other non-state institutions in England and Wales have taken seriously their responsibility to protect children from sexual abuse, and make meaningful recommendations for change in the future. A particular focus for 2017 has been The Truth Project, enabling survivors’ of CSA to share their experiences within a safe and confidential environment. The CCG and main providers have completed a work plan incorporating the IICSA checklist prepared by Verita, to provide assurance re: specific information governance and safeguarding procedures. A further work plan regarding the Lampard recommendations from the Savile investigation has also been completed by the CCG and providers to seek assurance and oversight of safer recruitment processes, the management of volunteers and managing allegations against staff. 3.7 Safeguarding Adult Review (SAR): - There has been no change to the Care Act (2014) in regards to safeguarding (Sections 42-46) and the statutory guidance supporting this remains the same. Section 44 of the Care Act stipulates that Local Safeguarding Adults Board continues to have 3 main duties one of which is to “conduct any safeguarding adults review (SAR) in accordance with Section 44 of the Act” (Department of Health 2016). Over the past 12 months West Essex CCG has not been asked to contribute to any review for a West Essex resident. 3.8 Domestic Homicide Review (DHR) These reviews were introduced by section 9 of the Domestic Violence, Crime and Victims Act (2004). They are multi-agency reviews of the circumstances in which the death of a person aged 16 and over has resulted from, or appears to have resulted from, domestic abuse. Over the past 12 months there has been 1 request for participation in a DHR. This was commissioned by Braintree Community Safety Partnership. A review of care has been completed and submitted. This DHR has not yet been completed and all relevant learning will be shared in due course. 4. CCG Safeguarding Responsibilities 4.1 Safeguarding Audit: Section 11 Requirements & Safeguarding Assurance Tool (SAT) Section 11: The ESCB has reduced the frequency of the requirement for all agencies to complete a Section 11 self-audit tool to bi-yearly. West Essex CCG Section 11 audit has been completed for submission to the ESCB in May 2018. Most of the criteria are fully met; outstanding areas include an audit of the robustness of CCG induction process, and an audit of how the CCG shares information. These have been allocated to relevant individuals to complete. NHS England Safeguarding Assurance Tool: Following the publication of Safeguarding Vulnerable People – Accountability and Assurance Framework for the NHS (2015), NHS Midlands and East region developed an electronic

140

Safeguarding Assurance Tool (SAT). The SAT enables CCGs to rate their Safeguarding services against multiple quality assurance criteria aligned to nine key themes:  Leadership and Accountability  Governance & Commissioning  Training  Safer Recruitment  Inter-agency working  Lessons Learnt  Policy & Implementation  Patient Engagement  Supervision

The SAT Tool has been updated to include Looked-after Children provision, and was re-submitted to NHS England on 31st October 2017. Six of the nine domains are considered green; the three remaining amber, with concurrent work plans in place. Feedback from NHS England has been positive, with recommendations for the capacity of the Designated Dr for Safeguarding Children function to be increased in accordance with the Intercollegiate Guidance (2014).

4.2 Safeguarding Clinical Network (SCN) The Safeguarding Clinical Network provides a robust organisational model through which safeguarding health professionals and organisations across Southend, Essex and Thurrock come together to ensure effective, collaborative working and strategic vision. The governance structure ensures outcomes and risks are escalated to the Health Executive Forum. Each CCG is allocated lead responsibilities for specific areas of focus, ensuring consistency of practice and guidance across the health economy. Lead responsibilities for west Essex include the Child Death Review process, the Emotional Well-being and Mental Health Service and Early Intervention. 5. Local context

5.1 Leadership and Accountability Leadership and responsibility for safeguarding at Governing Board level is achieved through the Director of Nursing and Quality. Clinical expertise within the CCG is provided through the Designated Doctor and Nurse roles for safeguarding children and adults and Looked-after Children, as well as the Named GPs. In addition, there is a commissioned post of Designated Doctor for Unexpected Child Deaths, to provide clinical expertise for west Essex. This role is currently fulfilled by the Named Doctor for Safeguarding Children at Princess Alexandra Hospital. Following a review of the Designated Nurse role for west Essex CCG in late 2016, a combined post of 1.75 WTE Designated Nurse for Safeguarding and Looked-after Children has been adopted. The post of Professional Lead for Safeguarding Adults became vacant in early February 2018. As a consequence, there has been a reduction in proactive safeguarding activity, with urgent matters escalated within the Nursing and Quality team for action as required. The post is actively being recruited to, with the likelihood of the successful candidate being in post by July 2018. 5.2 Named GP The Named GPs continue to work proactively with the Designated Nurses to enhance safeguarding processes within GP practices. A programme of safeguarding core training and themed sessions are offered to all GP Practices in west Essex, facilitated by the Safeguarding Team. In addition, the monthly CCG GP Newsletter is utilised to provide updates

141

on relevant safeguarding hot topics, e.g. learning from serious incidents, changes to legislation etc. 5.3 West Essex CCG The Safeguarding team proactively influence the commissioners’ responsibilities to assure themselves of the safety and effectiveness of the services they have commissioned. The team are actively involved in the commissioning cycle, as evidenced within the Virgin Care Pre-birth – 19 Service contract, which came into effect on 1st April 2017 and the Integrated Urgent Care procurement. WECCG Commissioning health economy is very diverse, as outlined below, highlighting some of the challenges and complexities for both service users and partners navigation of the systems.

5.4 Safeguarding Contracts Schedule The Safeguarding Contacts Schedule was updated in 2017/18 to reflect changes to legislation and guidance. This is now embedded within all CCG contracts and incorporates both Section 11 requirements and the NHS England Accountability and Assurance Framework. This has also been incorporated within the CCG Quality Assurance and Oversight Group (QAOG) framework to provide a baseline to inform the assessment of safeguarding compliance. 5.5 Essex Child and Family Well-being Service (Virgin Care Pre-birth – 19 services)

The Essex Child and Family Well-being Service was launched on 1st October 2017. A new structure for safeguarding and look-after children provision has been implemented for each quadrant in Essex, to meet the staffing recommendations as outlined within the Intercollegiate Document (2014). The CCG Safeguarding Team continues to oversee the west Essex provision, both for assurance purposes and also to support the provider team development.

5.6 Emotional Wellbeing and Mental Health Service (EWMHS)

The Safeguarding Team have supported the EWMHS Commissioners to embed safeguarding requirements and assurance processes within the contract. A new quality indicator to ensure the emotional well-being and mental health needs of looked-after children referred to the

142

service are assessed within agreed timescales is due to be introduced from 1st April 2018. Oversight of progress implementing the new arrangements will be monitored via the provider contracts meeting.

5.7 Princess Alexandra Hospital (PAH) Princess Alexandra Hospital continued to fall below trajectory for safeguarding children training level 3 compliance during 2017/18. As mentioned, this was highlighted within the March 2018 CQC report, with particular regard to specialist areas e.g. surgery and orthopaedics. The organisation appears committed to improving compliance, with senior management support, however the on-going staffing shortfalls provide significant challenges to enabling practitioners to attend. Safeguarding supervision provides a further challenge for PAH with compliance again well below trajectory. This is partially a result of insufficient trained supervisors within the organisation. The CCG are currently supporting PAH with this function, with the expectation that staff are up-skilled in 2018/19. Princess Alexandra Hospital (PAH) have been involved with NHS Digital to progress actions to implement the CP-IS system (Child Protection - Information Sharing). The hospital is also amongst the first cohort of providers to implement the Female Genital Mutilation (FGM) Information Sharing system (FGM-IS). The FGM-IS is now live and the CP-IS in the final stages of going live. The later will ensure that all children and unborn subject to child protection plans or looked-after by the local authority are identified when accessing urgent care services at PAH. The social care team is automatically notified that the child has attended. 5.8 Safeguarding Adults Assurance from Providers Assurance regarding adult safeguarding within Essex Partnership University NHS Foundation Trust (EPUT) and Princess Alexandra Hospital (PAH) are currently limited to safeguarding training figures for each organisation and via serious incidents which may be reported over time. The Designated Professional for Adult Safeguarding is working to review all safeguarding referrals made in the last 12 months from each organisation so themes can be understood and support given to ensure learning from incidents is embedded. Attendance, by the CCG, at the adult safeguarding steering groups and scrutiny committees is currently being refreshed. Joint working with Essex Social Care has been established and joint reviews taking place to support providers. Care Homes Woodland Grove Care Home has now had a suspension notice in place for several months due to organisational safeguarding concerns. Support has been offered to the home in respect to the safeguarding with specialist training from EPUT speech and language team regarding specialist diets and thickened fluids for their clients. Local Authority has also supported an improvement programme of Mental Capacity Assessments and Deprivation of Liberty Safeguard applications and record keeping. The home remains under review pending re-assessment by local authority. 5.9 West Essex Strategic Leads Safeguarding Forum Following a series of professional disagreements regarding safeguarding cases within West Essex, a quarterly forum has been established for senior managers with strategic oversight of safeguarding children within their organisation. The intention of the meeting is to build closer effective working relationships and a shared understanding of the complexity within health and social care in west Essex, and how they contribute to the overarching safeguarding agenda. The platform should also provide oversight of some of the current challenges facing each agency. 5.10 Serious Incidents (SI)

143

There has been no new safeguarding children SIs from the acute provider in 2017/18.

6. Safeguarding Themes

6.1 Child Death Review Process (CDR) The Southend, Essex and Thurrock (SET) Procedures for Responding to Child Death were updated in 2017 to incorporate recommendations from the Royal College of Pathologists and The Royal College of Paediatrics and Child Health. Essex adopted a Nurse-led Rapid Response Team model in 2015, to respond to unexpected child deaths across the county. This has resulted in a consistent and quality assured service, with a particular focus on supporting families. The contract has been extended until 2020, including uplift in capacity to facilitate a simultaneous review of child deaths meeting the Learning Disability and Mortality Review Programme (LeDeR), which commenced on 1st September 2017.

There were 15 child deaths in west Essex in 2017/18, of which 7 were unexpected. This is an increase from 2016/17.

Age at time of death Cause of death Congental Cardiac 10 9 Prematurity 8 2 3 Infection 6 1 Genetic 4 3 3 2 Disorder 3 Metabolic 2 Abnormality 4 0 Cause Under 1 year 1-5 years Teenage Unknown

 Following a multi-faceted campaign by the ESCB in 2016/17, the number of sudden unexplained deaths in infancy reduced across Essex in 2017/18. Nonetheless, safer sleeping remains high on the agenda. Awareness raising strategies continue to be implemented across Essex including making every contact count and the provision of safer sleeping literature.  In response to a rise in the number of suicides of under 18s across Essex in 2016/17, a thematic review was completed by the ESCB. Learning from the review will inform on-going work streams to support young people more effectively. There were no suicides in west Essex during this period.  A further theme emerging from the reviews is with regards to sepsis and early recognition. The Strategic Child Death Overview committee has been working with the Designated professionals to develop an A5 traffic light tool for parents and carers, to help recognise signs of deterioration, and when and where to seek medical advice.  An East of England Child Death Overview Forum has been established to share themes and learning across the region.

144

 As of 1st September 2017, the deaths of all children from 4 years with a diagnosis of learning disability have been reviewed for the Learning Disability Mortality Review Programme to identify any specific themes and inform service provision.

6.2 Looked-after Children The statutory guidance Promoting the Health and well-being of Looked-after Children (2015) states that CCGs and NHS England have a duty to cooperate with requests from local authorities to undertake health assessments for looked-after children and ensure support and services are provided without undue delay. Local authorities, CCGs, NHS England and Public Health England must cooperate to commission health services for all children in their area. Highlights  The number of children in care in Essex on 31/03/18 was 1020, of which about 100 were Unaccompanied Asylum Seeking Children (UASC), an overall slight increase from the previous year but remaining an outlier to the national picture.  On 31/03/18, west Essex CCG was responsible for 226 looked-after children, with a further 213 children placed within the locality from other Essex CCGs or other counties.  West Essex has a higher number of UASC placed in the locality than other Essex CCGs, due to a clustering of semi-independent accommodation in Harlow.  A Standard Approach letter has been cascaded by NHS England to all CCGs and Providers regarding invoice arrangements for looked-after children health assessments, when they are placed outside their originating area. It is anticipated this will ensure a more timely assessment and reduce complexity within the system.  Challenges have arisen regarding the capacity of providers to complete health assessments for looked- after children placed out of county. Contingency measures have been initiated where appropriate, and concerns escalated to NHS England.  Work continues with the local authority to improve the timeliness and quality of paperwork to initiate the statutory health assessments, with oversight at the Children in Care Partnership Board.  The CCG were successful in an application to NHS England for a non-recurrent grant to develop resources and training for Primary Care across Essex with regards to the health needs of Unaccompanied Asylum Seeking Children (UASC).

6.3 Missing and Child Exploitation (MACE) The west Essex MACE Group, a multi-agency forum which reports to the SET Child Sexual Exploitation Strategic Group, continues to meet bi-monthly to consider patterns of absence and to identify issues relating to exploitation, trafficking, gangs and offending behaviour. The group has been proactive in targeting ‘hot spots’ from local intelligence, and to implement preventative work with young people to reduce risks. Learning is shared at the Local Operational Group and Named Professional meeting, and incorporated within safeguarding training. 6.4 Mental Capacity Act (MCA) (2005) and Deprivation of Liberty Safeguards (DoLS) There is currently no update regarding the review of the above. However, it has been proposed that Deprivation of Liberty Safeguards be replaced by Liberty protection Safeguards. It is likely that there will be further guidance around this in coming months. An internal audit has been carried out by MAZARS to review the processes with regard to the management of DoLS and section 117 aftercare. Following the audit, work is underway to ensure the below findings are resolved:

145

 The DoLS procedures were not fit for purpose – ACTION: Review of procedure and Deprivation of Liberty Policy to be written;  The SLA between the CCG and Kennedys solicitors does not clearly define the role of the Solicitors or the CCG in the event of an appeal – ACTION: Review of SLA to be completed;  Service users who have been assessed as having capacity should be re-assessed annually – ACTION: Mental Capacity Policy to be written.  The CCG does not receive any detailed information regarding section 117 service users who are assessed and monitored by the Individual Placement Team (IPT) – ACTION: WECCG has discussed and agreed revised reporting from IPT to include information provided in respect of each person in receipt of S117 Aftercare to ensure 100% compliance with use of MCA, and clear understanding of status of caseload on an ongoing basis.  Management information received from the IPT regarding other activity undertaken on behalf of the CCG is limited – ACTION: The IPT Team have amended their risk and exceptions report to include a quarterly report for the attention of each Essex CCG:  Relevant staff were not aware of on-going litigation – ACTION: Communication protocol to be agreed and implemented with the CCG Governance Team.

Areas of good practice were as follows:  Mental Capacity Assessments had been completed for all cases tested.  From the cases tested all relevant forms for Court of Protection had been completed with all relevant documentation retained.

As there is currently no assurance that these processes are robust it has been requested that this risk be placed on the risk register. 6.5 Preventing Radicalisation The Prevent strategy, published by the Government in 2011, is part of our overall counter- terrorism strategy, CONTEST. The aim of the Prevent strategy is to reduce the threat to the UK from terrorism by stopping people becoming terrorists or supporting terrorism (HM Government, 2015). As a CCG it is expected that the contracts with provider services have PREVENT embedded into their services, policies and training. PAH currently have 77.4% of staff that are complaint with both Basic Prevent training and Workshop to Raise Awareness of Prevent (WRAP) with this. EPUT training levels are at 93% and 94.9% respectively. Training figures for WECCG in relation to this are not available currently and a Training Needs analysis is currently being undertaken. The Prevent Lead attends the Chanel Panel (a programme that supports people at an early stage that have been identified as being vulnerable to be drawn into terrorism). This multi- agency panel offers support by:  Identifying individuals at risk;  Assessing the nature and extent of that risk;  Developing the most appropriate support plan for the individuals concerned.

7. Safeguarding training A full programme of safeguarding training levels 1-3 and updates on topical issues is offered by the safeguarding team to GPs, practice staff and CCG workforce in west Essex. Topics have included bruising in non-mobile children, information sharing and consent, learning from

146

child deaths, child exploitation and the health needs of looked-after children. Training content is informed by the national and local agenda, and learning from all safeguarding reviews. For adult safeguarding within WECCG there is currently no formal guidance to knowledge and competencies expected from training. Currently all staff are expected to attend Level 1 awareness, while clinical staff are expected to attend a Level 2 training which is designed around case discussions. WECCG compliance for adult safeguarding training was 74% for Level 1 on 31st March 2018. ACTION: CCG Adult Safeguarding Competencies to be reviewed when the new Intercollegiate Document re training competencies is published later this year and agree training trajectory to ensure that WECCG are complaint with all necessary training. 8. Safeguarding Consultations The Safeguarding children team received approximately 120 telephone consultations from a range of professionals in 2017/18. Some of the consultations were complex and required multiple contacts. One of the recurrent themes is with regards to Fabricated and Induced Illness. Although the number of cases is comparatively small, the complexity and level of challenge for all professionals working with the families is considerable. Learning from the cases has been shared anonymously within updates, with a particular focus on process and the governance with regards to information sharing within these circumstances.

Consultations came from

60 49 50

40

30 19 20 14 11 11 9 10 4 0 GP PAH VirginCare Other WECCG Social Other CCGs Care

147

Consultation Themes

Domestic Violence 4 8 6 Physical Abuse Concerns 6 7 4 Consent/PR queries 5 Referral queries & concerns 7 LAC RHA delays 26 Fii

9. Key Priorities and Work Plan for 2018/19  Continue to critically evaluate and influence the effectiveness of safeguarding arrangements within all services commissioned by WECCG through the oversight of contractual arrangements.  Ensure the CCG has robust policies and processes in place to meet its statutory safeguarding duties and that all CCG employees’ attend safeguarding training appropriate to their roles and responsibilities.  Safeguarding designated nurses to be integral to procurement arrangements for all new providers.  Support and facilitate safeguarding arrangements within Primary Care.  Continue to strengthen relationships with provider services through both formal and informal communication pathways.  Work with statutory partners to respond to the national and local safeguarding agenda, identifying key work streams in relation to child exploitation, domestic abuse, neglect, radicalisation and modern slavery.  Act as a resource of expert advice and support to the CCG through the transition to the new safeguarding arrangements as outlined within Working Together to Safeguard Children (2018) when published.  Work proactively with the CCG, ESCB and Strategic Child Death Overview Panel to implement the changes outlined within Working Together to Safeguard Children (2018) and the Child Death Review Statutory Guidance when published

10. Conclusion West Essex CCG continues to work in partnership with the Essex Safeguarding Children Board, Essex Safeguarding Adults Board, NHS England and other statutory agencies to ensure robust safeguarding arrangements are in place within all organisations and commissioned services. Changes to the landscape of the healthcare economy, the introduction of Sustainable Transformation Partnerships and Accountable Care Organisations are likely to provide future challenges, however the focus on safeguarding for both children and adults must remain paramount if we are to promote and safeguard the well-being of our service users. WECCG aims to promote and maintain the best safeguarding practice across West Essex in accordance with national and local policies, ensuring these are implemented in a robust and effective manner. This will take account of both the Essex facing safeguarding agenda and the Sustainability and Transformation Plan (STP). Every opportunity will be used to raise

148

awareness about safeguarding and to contribute to multiagency work, including contributing to the Local Safeguarding Adult Boards. CCG’s vision is to commission health services that promote and protect individual’s human rights, independence and wellbeing, also that those individuals are effectively safeguarded against abuse; neglect; discrimination and poor treatment; are treated with dignity and respect; and enjoy a good quality of life.

References Children Act 1989. http://www.legislation.gov.uk

Children Act 2004. http://www.legislation.gov.uk

Children and Families Act (2014) http://www.legislation.gov.uk/ukpga/2014/6/contents/enacted

Children and Social Work Act (2017) www.legislation.gov.uk/ukpga/2017/16/contents

Department of Education (2015) Working Together to Safeguard Children: A Guide to interagency Working to Safeguard and Promote the Welfare of Children London: https://www.gov.uk/government/publications/working-together-to-safeguard-children--2

DHR statutory guidance: https://www.gov.uk/government/publications/revised-statutory-guidance-for- the-conduct-of-domestic-homicide-reviews

HM Government (2015) Promoting the health and well-being of looked-after children Statutory guidance for local authorities, clinical commissioning groups and NHS England: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/413368/Promoting_the_ health_and_well-being_of_looked-after_children.pdf

RCPCH (2014) ‘Safeguarding Children and Young People: Roles and Competencies for Health Care Staff’ (Intercollegiate Document). https://www.rcpch.ac.uk/sites/default/files/page/Safeguarding%20Children%20- %20Roles%20and%20Competences%20for%20Healthcare%20Staff%20%2002%200%20%20%20%20(3)_0. pdf

RCPCH/RCN (2015) Looked after children: knowledge, skills and competence of health care staff Intercollegiate Role Framework, RCN, RCPCH May 2012 https://www.rcpch.ac.uk/system/files/protected/page/Looked%20After%20Children%202015_0.pdf

The Care Act (2014): http://www.legislation.gov.uk/ukpga/2014/23/contents/enacted

The Mental Capacity Act 2005 https://www.legislation.gov.uk/ukpga/2005/9/contents

149

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 15

Date of Meeting: 27th September 2018

Report title: Emergency Planning, Resilience and Response (EPRR) NHS England Core Standards Author: Jackie King, Essex CCGs Head of Emergency Planning Clinical lead (where Not applicable appropriate): Presented by: Dorothy Blundell, Director of Corporate Services Recommended actions Please see immediately below: / next steps The Board is asked to:  Note the results of the EPRR self-assessment.  Endorse the compliance rating for the EPRR core standards as reported to NHS England  Note the level of the deep dive compliance achieved for command and control Executive summary This report provides information with regard to the NHS England (maximum 500 word EPRR Annual Assurance process 2018-19 and assesses the CCG’s limit) and purpose of the compliance against the NHS England EPRR Core Standards and report: the Command and Control ‘deep dive’. The report also details to the Board any incidents in Q1 and Q2 that have involved action being taken by the CCG and the Emergency Planning Team.

There is now a requirement with NHS England to outline recent incidents and provide a section on maintaining compliance in relation to communications, training, LHRP attendance and exercising within the report.

The Board paper and self-assessment was signed off by our Accountable Officer and sent to NHS England by the 31st August 2018 deadline.

The ‘deep dive’ standard 2 will be fully compliant once the Incident Coordination Centre is moved is moved on 21st September 2018, although as it stands it does not affect our overall full compliance rating. CCG Committees / Executive Committee (September 2018) and Audit Committee Groups previously (September 2018). consulted Equality Impact Analysis As this is a performance report an EIA is not required.

Key issues and risks: None identified.

Links to CCG Specifically strategic objective number 4 – that the CCG will

150

strategy/objectives continue to develop as a leading commissioning organisation of quality health and care services.

Checklist for completion with all reports:

Indicate implications for:

49. Patient and public Not applicable as this this is an internal report. engagement 50. Resources No financial resources are directly required as this is a report.

51. Health outcomes This report has no direct impact on any health outcomes.

52. Quality and Compliance with the core standards will provide a positive Performance impact in respect of staff, premises and other CCG stakeholders emergency planning, resilience and response safety.

53. Information No information governance implications have been identified. Governance 54. Legal issues No legal implications have been identified.

55. Conflict of No potential conflict of interest issues have been identified. interests 56. Francis, Keogh This report will support development and achievement of a and Berwick whole systems approach to open and transparent patient Report centred leadership. recommendations

151

EMERGENCY PLANNING RESILIENCE AND RESPONSE (EPRR) NHS ENGLAND CORE STANDARDS

Purpose

This report provides information in regard to the NHS England EPRR Annual Assurance process 2018-19 and assesses the Clinical Commissioning Group’s compliance against the NHS England EPRR Core Standards and the Command and Control ‘deep dive’. The report also details to the board any incidents in Q1 and Q2 that have involved action being taken by the CCG and the Emergency Planning Team.

Background

As part of the NHS England Emergency Preparedness, Resilience and Response (EPRR) Framework, providers and commissioners of NHS funded services must show they can effectively respond to major, critical and business continuity incidents whilst maintaining services to patients. The NHS England Core Standards for EPRR set out the minimum requirements expected of providers of NHS funded services in respect of EPRR.

NHS England has an annual statutory requirement to formally assure its own, and the NHS in England’s, EPRR readiness. To do this, NHS England asks commissioners and providers of NHS funded care to complete an EPRR annual assurance process. This process incorporates four stages: 1. EPRR Self-assessment 2. Local Health Resilience Partnership (LHRP) confirm and challenge 3. NHS England regional EPRR team confirm and challenge 4. NHS England national EPRR team confirm and challenge

The NHS England Core Standards for EPRR have been reviewed this year. Changes include:  Expanded focus on Business Continuity  Revised formatting  Removal of the CBRN (decontamination) equipment list

This year’s annual ‘deep dive’ is Command and Control.

Stage 1 - CCG Self-Assessment and Compliance

The EPRR Core Standards self–assessment has been undertaken by the Essex CCGs Emergency Planning Team (EPT) who is now hosted by the Mid and South Essex Joint Commissioning Team in partnership with the CCG.

The EPT with the CCG has undertaken a self-assessment against each individual core standard relevant to the organisation, and rated the compliance for each. A compliance criterion is as follows:-

152

There are 43 Core Standards in total applicable to the CCG. The CCG has been assessed as green – fully compliant - across all the applicable core standards. A copy of the assessment spread sheet is attached (Appendix 1).

The CCG has an overall organisational assurance rating FULLY COMPLIANT as the CCG has achieved 100% compliance across all the core standards they are expected to achieve. Fully compliant in addition requires the CCG board to agree with the position statement

Therefore The CCG Board is asked to endorse West Essex CCG’’s declaration of FULLY COMPLIANT against the EPRR Core Standard and is asked to note that the self- assessment has been reviewed by the CCGs Emergency Accountable Officer.

Deep Dive

The 2018-2019 EPRR annual assurance deep dive focusses on ‘Command and Control’. The self-assessment of these deep dive statements does not contribute to the CCGs’ overall EPRR assurance rating, and these are reported separately.

The self-assessment against the ‘Command and Control’ deep dive standards has concluded that West CCG is fully complaint in 7 out of 8 standards. The CCG has partial compliance in standard 2 - incident coordination centre (ICC) resilience as it has been agreed following recent training and exercising that the ICC will be moved a new ICC location within the CCG office site to allow easier communication flow and more resilience out of hour’s access. Actions are detailed on the self-assessment document (Appendix 1)

Stage 2 Local Health Resilience Partnership (LHRP) confirm and challenge

NHS England Midlands and East (East) in conjunction with the LHRP will host a ‘confirm and challenge’ process to review and consider the organisation’s EPRR self-assessment return.

The NHS England Midlands & East (East) EPRR Team, along with the support of the CCG Emergency Planning leads, will undertake some validation of the self-assessment

153

process including planned visits to discuss provider’s responses, to view evidence and, where required, to request further information. These sessions will take place between the 3rd- 21st September.

NHS England Midlands & East-East EPRR Team will produce a draft LHRP summary report to be signed off by the Strategic LHRPs throughout October, prior to submission to the NHS England regional team.

Maintaining Compliance

The CCG Emergency Planning Team has a work plan in place to assist in ensuring that a full level of compliance is maintained.

To maintain full compliance it is essential that the CCGs’ Accountable Emergency Officer continue to support the Emergency Planning Team in the following key areas in particular:-

1. Full participation in the Strategic Local Health Resilience Partnership. 2. Continued development of resilient communication 3. Training of tactical and strategic commanders and loggists and completion of wider awareness raising for CCG staff as outlined in the Local Health Resilience Partnership (LHRP) training needs analysis. o The Emergency Planning team have commenced a refresher training schedule for all West CCG loggists and have a training session in place at West Essex CCG on the 30th October to increase loggist numbers. o On Call Training - The West Essex CCG currently have 10 (50%) on call staff that have not attended strategic training and these staff has been encouraged to attend the next training day on the 9th October 2018. This is due to a number of new staff new to on call. The Emergency Planning Team have undertaken on call refresher training on the 7th June in conjunction with the Transformation/Urgent Care Team and continue to provide on call training to new on call staff.. o The Emergency Planning Team will be providing familiarisation training to a wider CCG audience during 2018. o Media training has been arranged during October and November for on call staff 4. Participation of key CCG staff in the on-going exercise programme both within the CCG and with multiagency partners o The CCG has undertaken the following exercises during 2018 :- . CCG communications exercise Feb 2018, . NHS England Exercise starlight communications Exercise May 2018. . Live lockdown and Business Continuity July 2018 o Planned Exercises include:- . Essex cyber-attack exercise 19th September,

Incident Reporting

154

It is now a requirement that at least annually the Emergency Planning Team provide in a report to the board details of any incidents affecting any of the 7 Essex CCGs. Below is the incidents that the Emergency Planning team have been made aware of and have assisted in as required during Q1 and Q2

 Business continuity incident - disruption of reablement service – April 2018  Business continuity incident - acute provider IT failure resulting in disrupted access to Pathology Link by GP practices – April 2018  Business continuity - mortuary capacity issues across Essex over winter period due to coroner related issues – December 2017 to April 2018  Business continuity incident – disruption of Patient Transport Services (PTS) - June 2018  Business continuity incident – disruption of PTS following loss of server - June 2018  Business continuity incident – disruption of Out of Hours service following IT failure  Business Continuity incident – disruption of community services following loss of telephony and IT systems – June 2018  Security incident - delivery of suspicious packages to a number Trusts nationally - August 2018

Recommendations

The CCG Board/Governing Body is asked to:

 Note the results of the EPRR self-assessment;  Endorse the compliance rating for the core EPRR standards as reported to NHS England;  Note the level of deep dive compliance achieved for command and control;

Appendices

Appendix 1 - CCG Self-assessment August 2018

Core Standards self assessment - West Essex CCG.xlsb

Jackie King CCG Head of Emergency Planning August 2018

Signed AEO (………………. CCG) ……………………………….

155

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 17

Date of Meeting: 27th September 2018

Report title: Red Risk Report Author: Grainne Stephenson, Governance and Risk Manager Clinical lead (where Not applicable appropriate): Presented by: Dorothy Blundell, Director of Corporate Services Recommended actions / next To inform the Board of the red risks for the CCG as steps escalated by the Executive Committee. The Board is asked to: The Board is asked to approve the report and advise if there are any other mitigating actions that should be taken or any other risks that should be noted. Executive summary (maximum This report contains the high level red risks from the CCG 500 word limit) and purpose of Operational Risk Register. The latest updates and the report: amendments for September 2018 are indicated in red text. There are currently nine red risks.

The report contents are as follows:

 Red Risk Progress Indicator  Red Risk Report  Risk Matrix CCG Committees / Groups Executive Committee, Quality Committee (quality and previously consulted nursing, clinical and maternity risks only) and Audit Committee. Equality Impact Analysis Not applicable to this report as each risk will have a risk owner who will, where appropriate, undertake an equality impact assessment. Key issues and risks: As presented and described in the attached report. Links to CCG By identifying risks and corresponding mitigating actions strategy/objectives that can be put in place, the CCG is able to control and manage the risks to achieving it’s strategic and operational objectives.

Checklist for completion with all reports:

Indicate implications for:

Patient and public PPE implications have not been assessed as this is a engagement (PPE) performance report so the views of patients, carers and the public have not been sought. Resources This report does not seek any resource. Health outcomes This report has no direct impact on any health outcomes. Quality and Performance This report seeks to provide a review of the internal risk management system the CCG employs to assure the

156

Executive Committee, the Audit Committee and CCG Board that governance arrangements and overall levels of control within the CCG are robust. Information Governance No information governance implications have been identified.

Legal issues There are no identified legal implications. Conflict of interests No potential conflict of interest issues have been identified.

Francis, Berwick and Keogh This report will support achievement of a whole systems recommendations approach to open and transparent patient centred leadership.

RISK SCORING MATRIX (Extract Risk Management Policy)

Consequence/severity

Insignificant Likelihood of Risk Minor (2) (1) Moderate (3) Major (4) Catastrophic (5)

Rare (1) 1 2 3 4 5

Unlikely (2) 2 4 6 8 10

Possible (3) 3 6 9 12 15

Likely (4) 4 8 12 16 20

Almost Certain (5) 5 10 15 20 25

157

CONSEQUENCE SCORING

When the following Consequence and Likelihood are multiplied together, the scores give a risk rating of between 1 and 25 on matrix.

LIKELIHOOD OF OCCURRENCE

Likelihood Rating Definition

Rare 1 extremely unlikely or virtually impossible (0 -5% chance)

Unlikely 2 low possibility but not impossible (6 - 20% chance)

Possible 3 fairly likely to occur (21 - 50% chance)

Consequence Rating Description Insignificant 1 Minor impact injury which did not affect the person. Reduced organisational performance for <1 week. Minor 2 Minor injury, first aid required. Reduced organisational performance, between 1 week and 1 month. Moderate 3 Semi-permanent injury/damage lasting up to 1 year. An over 7 day staff injury reportable under RIDDOR. Litigation cost of £50,000 to £500,000. Reduced performance up to one month. Major 4 Significant or permanent injury (loss of/use of limb) major injury, reportable under RIDDOR. High environmental implication. Litigation cost of £500,000 to £1million. Temporary service closure. Low key national media coverage Catastrophic 5 Unexpected death of a patient or member of staff. Significant national adverse publicity. Severe loss of confidence in the organisation. Extended service closure. Litigation cost greater than £1 million. Adverse high profile national media coverage. Likely 4 more likely to occur than not (51 - 80% chance)

Almost Certain 5 almost certainly will occur (81 - 100% chance)

158

Red risk scores shown with asterisks (for example *16*) indicate those that have a red rating for at least the previous two month period. Risk Risk Risk Target Sept Oct 2017 Nov Dec Jan 2018 Feb March April May June July August Sept Ref: level: Owner 2017 2017 2017 2018 2018 2018 2018 2018 2018 2018 2018 Risk: W125 Performance Failure: DW 12 *20↔* *20↔* *20↔* *20↔* *20↔* *20↔* *20↔* *20↔* *20↔* *20↔* *20↔* *20↔* *20↔* A&E 4 hour standard W103 Non-achievement of MB 8 20↔ *20↔* *20↔* *20↔* *20↔* *20↔* *20↔* *20↔* *20↔* To be 20 20↔ To be 95% of patients seen, advised advised treated and admitted or discharged within 4 hours of arriving at A&E with an increased risk of mortality in ED W215 Transformation savings TC 4 16↑ 16↔ *16↔* *16↔* *16↔* *16↔* *16↔* *16↔* To be To be 16 16↔ *16↔* from service elements of advised advised the 2018-19 transformation programme including: Adults, CHC, Medicines & Older People may not be delivered. W221 Lack of assurance of CM 4 16↔ 16↔ *16↔* *16↔* *16↔* *16↔* *16↔* *16↔* *16↔* *16↔* *16↔ *16↔* *16↔* safe care at Princess * Alexandra Hospital with overall HSMR rates higher than expected. W212 Delay in SH/ 4 6↔ 16↑ 16↔ *16↔* *16↔* *16↔* *16↔* *16↔* *16↔* To be 16 16↔ To be procurement of IUC TC advised advised model

W230 Ambulance response LH 9 New 12↑ 12↔ 12↔ 12↔ 16↑ 16↔ *16↔* To be 16 16↔ To be times affected by 9 advised advised ARP and PAH handover performance W126 Performance Failure: DW 6 *15↔* *15↔* *15↔* *15↔* *15↔* *15↔* *15↔* *15↔* *15↔* *15↔* *15↔ *15↔* *15↔*

159

Ambulance response * time W166 All trusts abilities to CM 3 6↔ 6↔ 6↔ 6↔ 6↔ 6↔ 6↔ 6↔ 9↑ 15↑ 15↔ *15↔* *15↔* meet cancer targets, particularly the 62 day wait.

160

Risk Risk Risk Target Sept Oct 2017 Nov Dec Jan 2018 Feb March April May June July August Sept Ref: level: Owner 2017 2017 2017 2018 2018 2018 2018 2018 2018 2018 2018 Risk: W227 Essex wide health DB 10 New 15↔ *15↔* *15↔* *15↔* *15↔* *15↔* *15↔* *15↔* *15↔* *15↔* *15↔* *15↔* systems ability to 15 manage any mass casualty event (including transport incidents, acts of terrorism, infectious diseases, CBRN) where number, type and severity of casualties could overwhelm the local health provision.

161

Risk ref + Risk Current controls Impact Likelihood Current Future or additional controls / Target Last date added risk actions planned to mitigate risk including risk review to register + rating costs + benefit rating date + responsible (I x L) (I x L) projected committee + closure correspondin date g Strategic Objective W125 Performance Failure: PAH: 4 5 20 PAH: 4 x 3 =12 Last review A&E 4 Hour Standard.  ED recruitment in progress and expected to be date: December  Trajectory agreed with regulators to recover the 4 complete by October, but until then there remains 2014 Standard: 95% hour A&E standard to 95% in March 19. high level of dependency on agency staff. September  Four consecutive months of improvement from  New front door model: Lead role recruitment complete 2018 Finance & March to June. - in post 13th August. Performance Aug 18  The drop in July performance was discussed at  Pathway development underway. Projected Committee SPQRG and the Trust are confident that this was a  Implementation of new Admission and Discharge SOP closure PAH: 81.5% blip in the recent trend of recovery. to improve patient flow: Ward improvement plans to date: SO. 1 be implemented Sept 18. {03/19} Addenbrookes: July 18 Addenbrookes:  Improvement Plan agreed  Managing non-elective demand through Increased GP Adden: 88.5%  HALO roles continue to embed the concept of ‘fit to streaming and increased ambulatory care referrals. sit’ with crews to support handover performance  ED staffing - Maximising shift rota fill rate and Barts: 85.0% improvement. supporting the new Junior doctor intake.  Re-launch of the emergency department internal  DTOC levels - System wide commitment to reduce to professional standards 3.5% continues.  Re-established a short-stay acute medical hub  Director of Operations led daily ED performance model in the EAU block which supported the meetings. significant increase in April ED performance  NHSE / CEO escalation meetings established Barts:  Extend and improve the A&E front-door model.  Reduce avoidable delays to ambulatory care and the Barts: Acute Assessment Units.  Continue to reduce the count of stranded (7 day length  New improvement approach introduced – of stay) patients. Optimum Conditions Model  Develop frailty pathways.  Working with the Emergency Care  Embed and standardise Rapid Assessment & Improvement Programme (ECIP) across its Treatment models of care. A&E provider sites  Trial of therapist functional streaming following  This work has been crystallised into a series ambulance handovers.

162

of Trust level strategic actions as well as tactical actions developed for each of the Trust sites

Risk ref + Risk Current controls Impact Likelihood Current Future or additional controls / Target Last date added risk actions planned to mitigate risk including risk review to register + rating costs + benefit rating date + responsible (I x L) (I x L) projected committee + closure correspondin date g Strategic Objective W103 Non-achievement of 08/18> LDB monitoring performance 4 5 20 08/18> A&E performance continues to be 4x4=16 Last 95% of patients seen, and progress of actions to recover challenged but is now showing consistent review May 2014 treated and admitted or performance. improvement: date: discharged within 4 Urgent Care hours of arriving at A&E Daily NHSE Winter Room reporting -  Recruitment campaign has been successful and August Board which correlates with an robust check and challenge across new staff will start induction in October 2018 increased risk of system partners – including weekends  ICP new model for integrated urgent care at SO. 1 mortality in ED Front Door has been agreed and is now in Projected mobilisation phase – this will ease pressure on closure Responsible ED date: committee:  PAH has implemented new operational Local procedures within ED to improve performance {Ongoing} Delivery Board

163

W215 Transformation savings from CAG in place to provide test & challenge to 4 4 16 Governance process being developed with ACP to 4 x 1 = 4 Last review service elements of the all business cases. secure joint system ownership and support to embed date: Finance and 2018-19 transformation QIPP in contracts. Performance programme including: All documentation from the Resilience team September Committee Adults, CHC, Medicines & in Midlands and East are reviewed and 04/18 - All business cases to be taken to the LDB for 2018 Older People may not be circulated to identify gaps in our review and embedding into contract. SO.1 delivered. programme / further opportunities. Projected PMO engine room being implemented in the CCG. closure Attain have carried out a review of PMO date: and project management across the organisation. Their recommendations have been discussed with exec and a new {03/19} gateway process has been introduced, together with new documentation for project management.

164

Risk ref + Risk Current controls Impact Likelihood Current Future or additional controls / Target Last date added risk actions planned to mitigate risk including costs risk review to register + rating + benefit rating date + responsible (I x L) (I x L) projected committee + closure correspondin date g Strategic 165 Objective

Risk ref + Risk Current controls Impact Likelihood Current Future or additional controls / Target Last date added risk actions planned to mitigate risk including costs risk review to register + rating + benefit rating date + responsible (I x L) (I x L) projected committee + closure correspondin date g Strategic Objective

W221 Lack of assurance of safe 07/17> Both areas now subject to internal 4 4 16 07/17> From 10/17 new CQC guidance on monitoring 4 x 1 = 4 Last review care at Princess Alexandra audit of all patient notes. mortality requires a portion of hospital deaths to be date: July 2017 Hospital with overall HSMR 07/17> #NOF investigated in-depth. 08/17> subject to review. PAH are making good progress rates higher than expected, No longer an outlier. 09/17> Sustained for 3 and expect to be able to comply with this September Quality standardised mortality rate months. requirement. 2018 Committee for latest reported period 07/17> Subject to Chief Executive scrutiny 07/17> A number of factors contributing to a rise in SO1 04/16 – 03/17. 2 main areas panel which WECCG’s Chief Medical the length of time to theatre are all now being Projected of concern are mortality Officer is present at. Key determinant of addressed. In particular fast track process out of closure from fractured neck of survival is time to theatre – with a target of Emergency Department and onto Henry Moore Ward date: femur (#NOF) and sepsis 48 hours. (dedicated orthopaedic geriatric ward). {ongoing} diagnosis. 10/17> Recent audits in key areas have 08/17> COPD a new flag with a detailed review National reporting for been submitted to SPQRG and show good underway. Pneumonia and gastro-intestinal mortality is SMHI which levels of patient safety. HSMR continues to infections review underway; these 2 areas highlight a reports 6 months later than be tracked monthly and for each of the last need to continue developing ceilings of care HSMR and is still within 4 months relative risk has been within principles. 09/17> Continue to monitor via Dr Foster. expected range. The next expected. The 12 month rolling risk however 10/17> COPD review is complete and suggests report is likely to have risen remains than expected and will do so for related to frailty and impacted by lack of palliative above expected range some time. care input. Pneumonia audit is still in progress. Audits and to remain above for for sepsis, AKI and massive blood loss are all positive. the next 2 quarters. 11/17> PAH above higher than expected. One new alert. 02/18> Latest data received for 10/17 shows mortality remains higher than expected. 07/18> Mortality remains higher than expected but peaked 3 months ago and shows a slight improvement in the latest figures. 08/18> Mortality Surveillance Group now meeting monthly at PAH to review wider number of deaths in line with national policy.

166

W230 Ambulance response 04/18> EEAST Risk Summit Jan 18 has 4 4 16 08/18> Ambulance conveyance audit 3x3=9 Last review times affected by ARP resulted in new Ambulance Handover repeated in July – appropriateness of date: October and PAH handover protocol and action plan to address conveyances sustained and therefore CCG 2017 performance poor performance implemented 25th not considering alternative transport offer for August 2018 February HCP heralded journeys Responsible Projected committee: Handover performance continues to be closure Local monitored daily date: Delivery {Ongoing} Board Fit2Sit handover now operational New paramedic roles support ED operational

SO.1

Risk ref + Risk Current controls Impact Likelihood Current Future or additional controls / Target Last review date added risk actions planned to mitigate risk including risk rating date + to register + rating costs + benefit (I x L) projected responsible (I x L) closure committee + date correspondin g Strategic

167

Objective

Risk ref + Risk Current controls Impact Likelihood Current Future or additional controls / Target Last date added risk actions planned to mitigate risk including risk review to register + rating costs + benefit rating date + responsible (I x L) (I x L) projected committee + closure correspondin date g Strategic Objective W126 Performance Failure: Reporting of new Ambulance 2 5 15 EEAST are now working towards delivery of the 3 x 2 = 6 Last Ambulance Response Response Programme (ARP) ISR and are carrying out a Workforce Review review December Times. response time standards rolled out in (including staff restructuring and changes to date: 2014 November 17. rotas etc), as well as reviewing their fleet. July 18 September Finance & Face to face fortnightly meetings Sector Heads have drafted 2018 Performance Cat 1 90th centile < 15 continue with EEAST and locality improvement/action plans for their STP areas Committee mins: commissioners. covering: Projected closure 15m 51s SO. 1 Operational Performance  Performance date:

Improvement action plan  Abstractions {03/19} Cat 1 mean time < 7 developed as a result of the final  Sickness mins: Independent Service Review (ISR) -  Alternative Working Duties 8m 26s live working document from  Handover to Clear Monday 4th June 2018.  Rapid Response Vehicles (RRVs) Cat 2 90th centile < 40  Appraisals

168

mins:  Finance 52m 30s To be reviewed at monthly locality meetings. Cat 2 mean time < 18 mins: 25m 12s

Cat 3 90th centile < 120 mins: 239m 14s

Cat 4 90th centile < 180 mins: 297m 18s

169

Risk ref + Risk Current controls Impact Likelihood Current Future or additional controls / Target Last date added risk actions planned to mitigate risk including risk review to register + rating costs + benefit rating date + responsible (I x L) (I x L) projected committee + closure correspondin date g Strategic Objective W212 Delay in procurement of 03/18> Additional clinical time has 4 4 16 08/18> Procurement process currently in ITT (4x1=4) Last IUC model (cancelled been commissioned from IC24 to phase with closing date for bids 31/8. review April 2017 12/17). increase clinical triage for NHS111 in date:  Reputational absence of IUC and CAS Small number of clarification questions SO.1  NHSE imposing the received to date demonstrating the value in August Responsible national model for IUC 04/18> Contract negotiations to extend time spent with providers for market 2018 committee:  QIPP delivery impact services beyond April 18 complete for engagement. Executive  Cost pressure NHS111 and GP OOH. Projected Team (due to Evaluation team allocated and training closure Health & 08/18> Extension for DOS service in underway. date: Care place until end of September {03/2019} Committee members being conflicted)

170

Risk ref + Risk Current controls Impact Likelihood Current Future or additional controls / Target Last date added Risk actions planned to mitigate risk including costs risk review to register + rating + benefit rating date + responsible (I x L) (I x L) projected committee + closure correspondin date g Strategic Objective

171

W166 Wider system’s abilities to 09/16> West Essex Cancer Board carries 3 5 15 Previous actions archived 3 x 1 = 3 Last meet cancer targets, out bi-monthly review of breaches. review November particularly the 62 day Monthly review of breaches by CSU 01/17> National focus and requirement for STP date: 2015 wait. and PAH. footprint. Addenbrookes and Mid September SO1 Essex at risk of not 07/16> Barts Health are meeting the 02/18> Trusts which were not hitting targets are 2018 meeting cancer targets standard consistently and making progress which is being monitored especially 62 day waits. Addenbrookes is delivering it’s RAP and through lead commissioners. showing progress. Projected 05/18> Trust written to and meeting to be held closure 12/16> Contract management through Tuesday 15th May with senior management to date: lead commissioner managing action discuss urology service. plans. For Barts additional control of {2018 – on 6 NELCSU overseeing their contract, Recovery for urology 62 day waits expected to consecutiv be 07/18, trust being urged to expedite more e months of allowing closer liaison. meeting quickly. targets} 06/17> Cancer performance is now tracked also at STP level. West Essex is (Refer to urology service actions.) an active member of the STP Cancer work stream. PAH continues to perform very well.

Addenbrookes not hitting their target, they are reporting all breaches to their Board.

11/17> Cancer improvement plan being progressed at Addenbrookes and Barts.

02/18> PAH continues to meet all cancer targets and is amongst the best in the country.

06/18> PAH failing 62/7 due to loss of urology workforce. Unlikely to deliver target until July 2018.

172

Risk ref + Risk Current controls Impact Likelihood Current Future or additional controls / Target Last date added risk actions planned to mitigate risk including costs risk review to register + rating + benefit rating date + responsible (I x L) (I x L) projected committee + closure correspondin date g Strategic Objective

173

W227 Essex wide health Emergency Planning Team in place to 5 3 15 Local Health Resilience Partnership plan to 5 x 2 =10 Subject to systems ability to support Essex CCGs. include Essex risks quarterly September manage any mass review 2017 casualty event NHS England monitors UK terrorism Mass Casualty Task and Finish Group formed to (including transport threat level as health services are part review recent incidents / exercises to inform Last SO.1 incidents, acts of of the response. CCGs assist with revision of the existing LHRP plan review terrorism, infectious maintaining continuity and resilience date: diseases, CBRN) where within our health and social care Early stages of development of plan with number, type and system and providing mutual aid to our private providers to include them in the event September severity of casualties system partners. of a mass casualty event. 2018 could overwhelm the local health provision. Core standards assurance process in 11/17> LHRP plan revised further by the task Projected Potential for associated place with NHS England and finish group on the 21st November , closure risks includes: validation exercise on the 12th December, Essex date: > distances of transfer Integrated Strategic Management for Health Exercise all systems to participate on 15th {Ongoing} times health training in place for acute, March 2018. Essex Vital signs multiagency > ability to create space community and ccg on call directors exercise 10th July 2018. LHRP plan to be for admissions in (180 trained and assessed to date). developed further in the next few months to specialist areas such as become LRF plan. paediatrics, burns, Trained loggists (approximately 50) trauma across Essex CCGs. 02/18> Following the exercise in March the > ability to discharge / CCG needs to support the Emergency Planning transfer patients to Incident response and business Team in the development of an operational create space in continuity plans in place across system plan that supports the LHRP plan and details specialisms how the non-acute pathway will be > transport - the need to operationalised in terms of PTS, P3 distribution, find alternative transport utilisation of the private sector and so on. to EAST / the need to increase PTS provisions / 06/18> This workshop took place in June and availability was a huge success and we will be working > capacity concern with the CCG in the future to deliver to West regarding the ability of Essex CCG and its providers the acute trusts to take the recommended 09/18> First draft of a plan from the June amount of P1 (priority workshop, another workshop on 27/9 for the one) casualties in the 1st Mid and South Essex STP. Once this is 60 minutes completed we will be looking at carrying one out in West but date is yet to be confirmed.

174

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 18

Date of Meeting: 27th September 2018

Report title: Board Assurance Framework 2018 - 19

Author: Grainne Stephenson Governance and Risk Manager Clinical lead (where Not applicable appropriate): Presented by: Dorothy Blundell, Director of Corporate Services Recommended actions / Following consideration by the CCG Board the Board Assurance next steps Framework will be reviewed and refreshed again by November 2018 to provide the necessary assurances relating to risks to the CCG’s strategic objectives. The Board is asked to: Approve the contents of this report and advise if there are any new risks to be included or any additional mitigating actions on the risks identified. Executive summary This report provides the Board Assurance Framework for 2018 – 19. It (maximum 500 word limit) currently shows the strategic objectives with the associated identified and purpose of the report: risk details, including controls and further actions required. The latest updates and additions are indicated in red text. The report is also comprised of a summary table and progress indicator. CCG Committees / Groups Executive Committee (September 2018) and Audit Committee previously consulted (September 2018). Equality Impact Analysis As this is a performance report an EIA is not required.

Key issues and risks: This report concerns the risks identified to achieving the CCG’s strategic objectives. Links to CCG This report supports all of the CCG’s strategic objectives. strategy/objectives Checklist for completion with all reports:

Indicate implications for: 1. Patient and public No adverse implications have been identified as the strategic engagement objectives take risks to patient and public engagement into consideration. 2. Resources No financial resources are directly required as this is a report. 3. Health outcomes This report has no direct impact on any health outcomes.

4. Quality and Performance Quality and performance implications are identified within the risks to the strategic objectives. 5. Information No information governance implications have been identified. Governance 6. Legal issues No legal implications have been identified.

175

7. Conflict of interests No potential conflict of interest issues have been identified.

8. Francis, Keogh and This report will support development and achievement of a whole Berwick Report systems approach to open and transparent patient centred recommendations leadership.

176

West Essex CCG Board Assurance Framework (BAF) Summary Table

Strategic risks profile

Total number of risks 7

Number of high (red) risks 0

Number of significant (amber) risks 5

Number of moderate (yellow) risks 2

Number of low (green) risks 0

Strategic risks maintenance

Number of risks where controls, 7 assurances and actions have been updated since July 2018 review

Strategic risks additions and closures since July 2018 review

Number of new risks 0

Number of closed risks 0

Strategic risks movement

Strategic risk movement since last BAF All risks have maintained their previous review (July 2018) risk level / rating.

Number of risks that have achieved 2 (SO5.1 – remains ‘live’ on the BAF their target risk rating rather than being moved to closed risks section) Strategic risks Board and committee review dates

Executive Committee 6th September 2018

Audit Committee 19th September 2018

CCG Board 27th September 2018

177

Progress Indicator SO1 2 09 18.docx SO1.1 09 18.docx SO2.1 09 18.docx SO3.1 09 18.docx Sept 2018.docx

SO3.2 09 18.docx SO3.3 09 18.docx SO4.1 09 18.docx SO5.1 09 18.docx

178

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 19i

Date of Meeting: 27th September 2018

Report title: Finance & Performance Committee Report

Author: Dean Westcott, Director of Finance, Contracting & Performance Clinical lead (where N/A appropriate): Presented by: Dr Rob Gerlis, Chair West Essex Finance & Performance Committee

Recommended actions / No further action required next steps The Committee is asked The Board is asked to note the report. to: Executive summary This is to update the Board on key points discussed at the (maximum 500 word Finance & Performance Committee meeting on 28th limit) and purpose of the August 2018 and the minutes from the meetings on 26th report: June 2018 and 31st July 2018 are attached for noting.

CCG Committees / Finance & Performance Committee Groups previously consulted Equality Impact Analysis N/A

Key issues and risks: None

Links to CCG N/A strategy/objectives Checklist for completion with all reports:

Indicate implications for:

57. Patient and public N/A engagement 58. Resources No financial resources are required

59. Health outcomes This report has no direct impact on any health outcomes

60. Quality and N/A Performance 61. Information N/A Governance 62. Legal and/or There are no legal implications

179

procurement issues 63. Conflict of interests No potential conflict of interest issues have been identified 64. Francis, Berwick and N/A Keogh Report recommendations

The Finance & Performance Committee met on 28th August 2018.

 Routine business was discussed and the Committee agreed that there were no items which needed to be raised at the Board or membership meetings.

Minutes of the meeting held on 26th June 2018:

WECCG F&P Minutes 26 06 18.doc

Minutes of the meeting held on 31st July 2018:

WECCG F&P Minutes - 31 07 18.doc

180

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 19ii

Date of Meeting: 27th September 2018

Report title: Report from the Quality Committee (QC)

Author: David Wallace Deputy Director of Nursing and Quality

Clinical lead (where Jane Kinniburgh, Director of Nursing and Quality appropriate): Presented by: Jane Kinniburgh, Director of Nursing and Quality

Recommended actions / None at present next steps The Board is asked to: The Board is asked to note the report.

Executive summary Points to Board from September meeting: (maximum 500 word limit) and purpose of the  Continuing Healthcare outstanding Retrospective report: reviews: CHC assurance processes have identified significant risk, both financial and reputational, in respect of 23 outstanding CHC Retrospective reviews. A task and finish group is being established to scope a business case and plan to address the backlog and manage ongoing cases and also to determine need for any additional resource for the CCG to undertake these reviews or whether they should be undertaken at STP level. These reviews may go back 2 years and Committee is concerned about the risks both financial and reputational. This matter is being escalated to the CCG Risk register for ongoing monitoring and assurance.  Update on the Princess Alexandra Hospital In-box Serious Incident: Positive outcome of SI at PAH. Harm reviews have been completed and no harm identified.

CCG Committees / Quality Committee Groups previously consulted Equality Impact Analysis Not applicable, report is for information only.

Key issues and risks:  To work to support and improve assurance processes and include as an Organisational risk.

181

Links to CCG Patients and quality at the centre of everything. strategy/objectives Checklist for completion with all reports:

Indicate implications for: Implications are noted within the minutes of the Committee.

65. Patient and public Implications are noted within the minutes of the engagement Committee.

66. Resources Implications are noted within the minutes of the Committee.

67. Health outcomes Implications are noted within the minutes of the Committee.

68. Quality and Implications are noted within the minutes of the Performance Committee.

69. Information Implications are noted within the minutes of the Governance Committee.

70. Legal and/or Implications are noted within the minutes of the Procurement issues Committee.

71. Conflict of interests No

72. Francis, Berwick and F-1,2, B -1,3,5 K-8 Implementing the Recommendations Keogh Putting the Patients first recommendations • F-109,117 K-3 Ensuring robust, transparent systems in place to support the process, complainants, staff and organisation to ensure that learning is embedded • F-124, 125, 133 Duty to require and monitor delivery of fundamental standards Responsibility for requiring and monitoring delivery of enhanced standards Roles of commissioners in complaints • F142 Unambiguous lines of referral and information flows

Minutes of the Meeting held on 3rd July 2018

182

FINAL QC Minutes - 3rd July 2018.pdf

183

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 19iii

Date of Meeting: 27th September 2018

Report title: Executive Health and Care Commissioning Committee Report

Author: Toni Coles, Director of Transformation

Clinical lead (where n/a appropriate): Presented by: Dr Rob Gerlis, Chair

Recommended actions / next steps The Board is asked to: The Board is asked to note the report

Executive summary Summary of Executive Health and Care Commissioning (maximum 500 word Committee dated 23rd August 2018 limit) and purpose of the report:

CCG Committees / Executive Health and Care Commissioning Committee Groups previously consulted Equality Impact Analysis Not applicable, report if for information only.

Key issues and risks: Not applicable

Links to CCG The agenda of the Executive Health and care strategy/objectives Committee supports the achievement of the CCG’s strategic objectives

Checklist for completion with all reports:

Indicate implications for: Implications are noted within the minutes of the Committee

73. Patient and public Implications are noted within the minutes of the engagement Committee

74. Resources Implications are noted within the minutes of the Committee

75. Health outcomes Implications are noted within the minutes of the Committee

184

76. Quality and Implications are noted within the minutes of the Performance Committee

77. Information Implications are noted within the minutes of the Governance Committee

78. Legal issues Implications are noted within the minutes of the Committee

79. Conflict of interests Implications are noted within the minutes of the Committee

80. Francis Report Implications are noted within the minutes of the recommendations Committee

The Executive Health and Care Commissioning Committee met on 23rd August 2018 and the following matters are brought to the Board’s attention:

 ACP and STP are now regular updates to the committee and are noted for information.

 Neighbourhood update:

o It was reported that in May 2017, the CCG invited practices within the neighbourhoods to produce plans to pilot new approaches to primary care in 3 areas: Moderate frailty, Primary care transformation and QOF and cancer screening variation. The PCCC signed off proposals for use of funds allocated to each neighbourhood with agreed KPIs under a memorandum of agreement. The projects started between September 2017 and January 2018 and 9 month evaluations will take place during July – November 2018. Decision on ongoing commissioning arrangements will take place August – December 2018.

o Neighbourhood data packs - Charlotte Mullins explained the report which will be produced for each neighbourhood within West Essex. The purpose of the report is to provide neighbourhoods with an understanding of emerging priorities.

o It was reported that Neighbourhood shutdowns are schedules as follows:  Harlow 18th September  Uttlesford 19th September  Epping 20th September The sessions will be facilitated by the Locality GP leads and neighbourhood GP leads. All GP practice staff in West Essex and wider neighbourhood team including EPUT, Social Care, and Voluntary sector are being invited to attend.

185

 Toni Coles reported on the ongoing commissioning concerns relating to the performance of the CCGs commissioned Healthy Mind PCPT/IAPT service. The CCG is to continue to work with HPFT (Health Minds) to deliver a Collaborative Action Plan to focus achievement of core 15% access target in line with an agreed trajectory.The recommendation is to develop a procurement process to commission additional short term capacity for the next 2 years to achieve as a minimum the Q4 18/19 Access target of 4.75% (Annual 19%) and future targets to 2020. This will be procured through the AQP route aligning with Hertfordshire to suppliment existing contract with HPFT accessible through CTS. It was agreed the CCG will continue to work with STP partners on longer term solutions for IAPT services.

 Anurita Rohilla reported that the CCG commissions high cost drug (biologic) treatment for Crohn’s disease and ulcerative colitis in line with NICE. West Essex patients are under the care of numerous hospitals for this treatment which includes The Rivers Hospital. The Rivers Hospital has been charging a higher price for biologic treatment for treating IBD patients than the equivalent treatments at NHS Trusts. Rivers hospital has been given notice that no new patients will start biologic treatment at Rivers from August 1st 2018. Current patients receiving biologic treatment at Rivers will be referred to an NHS Trust by April 1st 2019.

 It was reported that currently WECCG has a back injection policy for low back pain which covers NICE approved treatments (facet joint injections, medial branch blocks and epidural injections). However, the policy does not cover other types of back injections which the CCG is currently funding. In 2016-17 WECCG had the highest activity rate for interventional treatments for back pain, at 6.79 per 1000 population, both within our STP and when data measured against our similar CCGs in the Right Care. It was recommended that changes to the back injection policy commence when the community pain service is in place.

Minutes of the meetings held on 21st June and 19th July 2018:

Health & Care Health & Care Committee Minutes - 19Committee July 2018.docx Minutes - 21 June 2018.docx

186

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 19iv

Date of Meeting: 27th September 2018

Report title: Audit Committee Report

Author: Dean Westcott, Director of Finance, Contracting & Performance Clinical lead (where N/A appropriate): Presented by: Stephen King, Chair, West Essex CCG Audit Committee

Recommended actions / No further action required next steps The Committee is asked The Board is asked to note the report. to: Executive summary To update the Board on key points discussed at the (maximum 500 word Audit Committee meeting on 19th September 2018. limit) and purpose of the Minutes of the meeting on 18th July 2018 are attached report: for noting.

CCG Committees / Audit Committee Groups previously consulted Equality Impact Analysis N/A

Key issues and risks: None

Links to CCG N/A strategy/objectives Checklist for completion with all reports:

Indicate implications for:

81. Patient and public N/A engagement 82. Resources No financial resources are required

83. Health outcomes This report has no direct impact on any health outcomes

84. Quality and N/A Performance 85. Information N/A Governance 86. Legal issues There are no legal implications

187

87. Conflict of interests No potential conflict of interest issues have been identified 88. Francis Report N/A recommendations

The Audit Committee met on 19th September 2018 and the following matters are brought to the Board’s attention:

 The Audit Committee noted that there is still work to be undertaken on the Board Assurance Framework. The existing format will continue to be used noting that there is work being carried out with STP partners to review common processes and improve the use of the Board Assurance Framework.

 Business Critical Models – the Audit Committee received a review of the assurance process for Business Critical Models. It was noted that there are some assurance processes in place but there is still further work to be undertaken to provide the full assurance required. Approval was given to continue using the existing policy whilst further review work is undertaken.

 Court of Protection Orders – Internal Audit recommendations - the Audit Committee received an update from the Director of Nursing & Quality on progress made to improve the systems in relation to Court of Protection Orders. It was noted that capacity issues have now been resolved with posts being filled and it is expected to see significant progress over the next six months. The Audit Committee will monitor progress through regular Internal Audit update reports.

Minutes of the meeting held on 18th July 2018:

WECCG AC Minutes 18 07 18.docx

188

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 19v

Date of Meeting: 27th September 2018

Report title: Primary Care Commissioning Committee Report

Author: Peter Wightman Director of Primary Care and Localities

Clinical lead (where N/A appropriate): Presented by: David McConnell, Chair, Primary Care Commissioning Committee

Recommended actions / No further action required next steps The Committee is asked The Board is asked to note the attached minutes to: Executive summary This is to update the Board on the Primary Care (maximum 500 word Commissioning Meeting held on 18th July 2018. limit) and purpose of the report:

CCG Committees / Primary Care Commissioning Committee Groups previously consulted Equality Impact Analysis N/A

Key issues and risks: None

Links to CCG N/A strategy/objectives Checklist for completion with all reports:

Indicate implications for:

1. Patient and public N/A engagement 2. Resources No financial resources are required

3. Health outcomes This report has no direct impact on any health outcomes

4. Quality and N/A Performance 5. Information N/A Governance 6. Legal issues There are no legal implications

189

7. Conflict of interests No potential conflict of interest issues have been identified 8. Francis, Berwick and N/A Keogh Report recommendations

Minutes from the meeting of the Primary Care Commissioning Committee held on 18th July 2018.

Primary Care Commissioning Committee 18th July 2018 Part 1.docx

190

REPORT TO THE WEST ESSEX CCG BOARD MEETING IN PUBLIC

Agenda Item: 19vi

Date of Meeting: 27th September 2018

Report title: Remuneration and Terms of Service Committee

Author: Andrew Geldard, Chief Officer

Clinical lead (where N/A appropriate): Presented by: Bobbie Graham, Chair, Remuneration and Terms of Service Committee

Recommended actions / No further action required next steps The Board is asked to: The Board is asked to note the report. Executive summary To update the Board on key points discussed at the (maximum 500 word Remuneration and Terms of Services Committee meeting limit) and purpose of the on 30th August 2018. report: Due to the confidential nature of the business of this Committee, full minutes are not provided. CCG Committees / Summary points taken from the August meeting of the Groups previously Remuneration and Terms of Service Committee. consulted Equality Impact Analysis N/A

Key issues and risks: None

Links to CCG The remit and responsibilities of this Board Committee are strategy/objectives indirectly supporting all of the CCG’s objectives. Checklist for completion with all reports:

Indicate implications for:

89. Patient and public N/A engagement 90. Resources No financial resources are required

91. Health outcomes This report has no direct impact on any health outcomes

92. Quality and N/A Performance 93. Information N/A Governance 94. Legal issues There are no legal implications

191

95. Conflict of interests There are no conflict of interest issues in the presentation of this report. 96. Francis, Berwick and The document forms part of the CCGs overarching Keogh Report governance, and supports the recommendations recommendations provided in the Francis report.

The Remuneration and Terms of Service Committee met on 30th August 2018 and the Committee:

 Reviewed and agreed revised terms of reference for the Committee, to include the recently added responsibilities relating to STP staffing.

 Noted that guidance relating to the annual review of cost of living increases for VSM staff is awaited and will brought to the next available meeting. It was also agreed that the guidance on GP cost of living increases will be taken to the next meeting.

 Agreed to the contract extension for the Programme Director, ICP and agreed to the proposed use of a search and selection agency for the upcoming Director of Corporate Services vacancy.

 Agreed to a contract extension for the STP interim Finance Director.

 Agreed a salary for the Lay Member, Governance to bring the salaries for the lay members in line.

 Discussed a draft of the clinical leadership review.

 Noted that the national VSM framework is not yet available, but will be brought to the Committee when published.

192

Board Report – Corporate Services (communications, engagement, governance and general) – September 2018

Communications

Comms & A new communications and engagement strategy for the CCG has Engagement been drafted and will be brought to the November board meeting for Strategy approval. The strategy sets out our main communications objectives, target audiences, key messages and specific activities. It includes refreshed, and more communicable, vision and mission statements; a more succinct set of organisational values; a core narrative; and a series of key deliverables.

Support for national The communications and engagement team has worked to raise campaigns awareness of national health and care issues and promoted them across a variety of channels. These campaigns have included:

 National Suicide Prevention Day  Health awareness at festivals  Cervical Cancer screening  111

We will be focusing in the next couple of months on supporting the flu jab and ‘Help Us, Help You’ campaigns

Website A critique of the website took place in August internally and some quick, immediate changes were made to some outdated content. These were specifically focused on the general public areas, such as Get Involved and About Us. A more detailed evaluation of the CCG’s website will now begin. We want to see what people think about the new layout and functionality of the site and make any refinements as needed. We are speaking with the CSU who host the site to talk through these refinements and to talk about the future development over the next couple of years.

Social media A regular stream of communications has been put out via Twitter and Facebook on a variety of prevention messages, such as signposting to HealthHelpNow, 111 and Know Your Numbers blood pressure checking. We have also shared information and updates on health and social care partners’ campaigns, eg the launch of My Care Record in West Herts and the shortlisting of the STP System Led Support for Carers project.

Current numbers of followers on Twitter is 6910 and Facebook 265. 193

Plans are in place to boost these over the coming months through a new comms and engagement strategy (see above)

Videos A corporate video promoting the role, plans and activities of the CCG was completed and launched at the AGM on 26 July. Shorter vox pops will be available from next week on a number of key subjects identified in the video, which can be viewed on our YouTube channel.

The comms team plans to make more use of videos over the coming months and will be working with internal teams and partners to identify subject matter and campaigns they are suitable for.

Annual Report A summary version of the annual report, suitable for the general public was also launched at the AGM. The Key Achievements brochure includes the main achievements of the CCG over the past year as well as key messages and campaigns.

Internal We have commissioned a supplier to design and build a new staff communications intranet. An internal focus group has met and fed in ideas and an initial wireframe and design will be received in the next week. The aim, once launched at the end of October is to reduce the high number of all staff emails, provide a secure space for internal documents and engage staff, with measurement tools built in.

We are also meeting with all the internal teams to introduce the comms team, with individual members being assigned a couple of teams each to let them know what we do, how we can help and support their work and to link across teams to reduce duplication and overlap.

STP/ICP The team remains in regular contact with the main leads from the STP, East and Norths Herts and Herts Valley. Meetings are being arranged both at the CCG and at County Hall to re-engage ECC, Healthwatch Essex and the voluntary partners. Upcoming joint campaigns include an Open the Bag pharmacy campaign and working with Allied Health Professionals on a celebration day in October. Ian – did you want to add something from your ICP meetings and conversations with James?

Engagement The team have been out and about visiting key groups, such as the Events voluntary sector on 31 August at the Marketplace event in Epping Town Hall. A mapping exercise of all the key local events in the three areas and boundaries is underway to plan

194

The team continues to support the GP Shutdown events. At the September events the team are also conducting a short survey with GPs to get their opinion on how they want to receive information from the CCG.

Urgent Care The comms team has been regularly promoting alternatives to A&E including images for Jayex Screens and social media messaging. We are also attending national and local briefing sessions on the winter campaign (Help Us, Help You) ahead of a full campaign through October to January in liaison with the urgent care team.

Medicines Team members have attended the Medicines Champions meetings Optimisation and are supporting the pharmacy team in the development of the Over the Bag campaign and the launch of the new Community Pain Management service.

Patient engagement The team has continued to support the Harlow and Epping Forest patient forums over the last couple of months. The team also attended the Ongar forum where Hazel Angus and Rob Gerlis gave presentations on behalf of the CCG

A review of the CCG’s patient and public engagement is continuing and so far we have met with the chairs of the patient forum, the voluntary sector and local charities. The principal aim is to recruit a wider and more representative group of local residents. We also want to open up new methods of engagement and move away from solely relying on meetings.

Voluntary Sector Efforts are continuing with the voluntary sector leads for Epping Forest, Harlow and Uttlesford to improve general engagement and involvement between us – namely what we can do for each other and how we can use our various networks to reach the many different local audience groups. A number of ideas are being progressed including a discussion about the future of health and care with a group of young people, facilitated by the Livewire theatre company, and closer links with a newly-formed faith leaders and cultural forum.

Governance

Governance The Good Governance Institute is continuing with its review of decision-making systems at the CCG. The review has taken a little longer to complete than originally expected and has been broadened to take account of the emerging integrated care landscape. A report will be brought to the November board meeting.

In the meantime, the terms of reference for the board, audit, finance and performance committees are being reviewed and updated as

195

necessary.

Emergency planning As part of the CCG’s arrangements a business continuity exercise is resilience and taking place on 17 July. A drive to recruit ‘loggists’ to assist during response emergency incidents is also continuing.

Declarations of A review of the CCG register has been successfully completed.. Interest

Health & Safety A review of the risk assessments for offices and first aid, originally scheduled for July, is now being carried out in October to tie in with a reshuffle of desk arrangements in Building 4. This will be followed up with a campaign to remind staff to keep desk and floor space clean and tidy and clear of potential hazards.

Other

GP Board Member The appointment of a vice chair for the board has been successfully Elections concluded. See separate report.

HR Service Transfer The transfer of the CCG’s HR service from NEL CSU to The HR and ODL Shared Service started on 1 July is on track to be fully implemented on 1 August. Jeneva Allison has been appointed as the new HR Business Partner for the CCG. She starts on 1 August and will be based at the CCG four days a week, in Building 1.

Early priorities for the new service include a review of the CCG’s HR policies, to bring them in line with others, and an overhaul of the staff induction process. We also want to improve organisational development programmes and improve access to online training. The new HR service does not cover payroll.

This will continue to be provided by Serco.

196

Mrs F Mrs F has Glaucoma and attends regular six monthly check ups at St Margaret’s Hospital. Mrs F has had her last six appointments cancelled and has not been seen for 15 months. There were also two occasions when she attended for appointments and on arrival was told the person she needed to see was on annual leave. Mrs F was extremely frustrated about the situation and was concerned about the health of her eyes. The PAH Patient Experience Team investigated Mrs Fs concerns and an apology was provided about the lack of follow up and late cancellation of clinics. An explanation was provided about the medical vacancies in the Eye Unit and assurance was that temporary doctors are being recruited to avoid further cancellations and delays for patients. PAH have implemented a robust process to ensure that patients are now offered the option of attending an appointment at another hospital site if their appointments are repeatedly cancelled.

Mr R Mr R was seen at an ENT clinic at St Margaret’s Hospital in June 2018 and referred for a scan. Mr R had the scan but four weeks later had not received the results. He had left numerous messages with the ENT Department but had not heard back. Mr R was due to go on holiday for an extended period and wanted to have the results before he went away. The CCG Patient Experience Team arranged for the Assistant Service Manager at PAH to speak with the patient and his results were provided to him following this. Mr R was satisfied with the outcome.

197