LUTON CLINICAL COMMISSIONING GROUP BOARD MEETING Part 1 - HELD IN PUBLIC ON TUESDAY 21st January 2020, 13:00-15:30 Youthscape, Bute Mills, 74 Bute Street, Luton, LU1 2EY

A G E N D A

Standing Items Lead Suggested Timing Time

1. Welcome, Apologies and Chair’s introduction Dr Nina Pearson 3 mins 2. Declarations of Interests in relation to Agenda Items * Dr Nina Pearson 2 mins 3. Declarations of Hospitality relating to Agenda Items ** Dr Nina Pearson 2 mins 13:00-13:15 4. Minutes of the Meeting held in Public on 19th November 2019 Dr Nina Pearson 3 mins 5. Matters Arising from the Meeting held in Public on 19th November 2019 Dr Nina Pearson 5 mins

6. Patient Story Dr Safiya Virji 20 mins 13:15-13:35

7. Chairs’ Report – to follow Dr Nina Pearson 5 mins 13:35-13:40

8. BLMK Accountable Officer’s Report Patricia Davies 10 mins 13:40-13:50 *Board Members are reminded that it is their responsibility to update their declarations of interests, notifying any change in circumstances on a new form to LCCG within a maximum of 28 days. New declarations will be requested from all Board members at least annually. ** All Declarations of Hospitality should be confirmed by email.

Strategic Development

9. One Team Programme Geraint Davies 25 mins 13:50-14:15

10. Long Term Plan Update & 2020/21 Commissioning Delivery Planning Geraint Davies 25 mins 14:15-14:40

Break

Performance Items

11. Integrated Quality and Performance Report Nicky Poulain 10 mins 14:55-15:05

12. Month 08 Finance Report Liz Cox/Chris Ford 10 mins 15:05-15:15

Items for Assurance

13. Board Assurance Framework Michael Wuestefeld-Gray 10 mins 15:15-15:25

Items for Information

14. Minutes of Committee Meetings:

a) Clinical Commissioning Committee – 31st October 2019

b) Finance and Performance Committee – 1st November 2019 Dr Nina Pearson 5 mins 15:25-15:20 c) Patient Safety and Quality Committee – 31st October 2019

d) Primary Care Commissioning Committee – 24th September 2019

e) Transformation Board – 18th September 2019

15. Any Other Business Dr Nina Pearson 5 mins 15:25-15:30

Next Meetings Date Time Location Meeting Type Open to the Public? 18th February 2020 13:00-16:30 Conference Room, Arndale House Development No 17th March 2020 13:00-16:30 TBC Public Board Yes

Draft Minutes

Meeting: Luton CCG Board Meeting held in Public

Date: Tuesday 19th November 2019

Time: 14:15 – 16:30

Location: Art Studio, Youthscape, Bute Mills, 74 Bute Street, Luton, LU1 2EY

Present: Mahmood Aziz (MA) Lay Member, Finance & Procurement Geraint Davies (GD) Director of System Commissioning, Executive Team Patricia Davies (PD) Accountable Officer, Executive Team Chris Ford (CF) Chief Finance Officer, Executive Team Kathy French (KF) Independent Nurse Member David Kempson (DK) Lay Member, Audit & Governance, Deputy Lay Chair Jane Meggitt (JM) Director of Partnerships, Engagement and Communication, Executive Team Anne Murray (AM) Chief Nurse, Executive Team Dr Nina Pearson (NP) Chair Nicky Poulain (NPo) Chief Operating Officer Dr Uzma Sarwar (US) Clinical Director Dr Kirti Singh (KS) Clinical Director Gerry Taylor (GT) Corporate Director Public Health and Wellbeing, Luton Borough Council Dr Helen Turner (HT) Secondary Care Member Dr Safiya Virji (SV) Clinical Director Apologies: Dr Chirag Bakhai (CB) Clinical Director, Deputy Clinical Chair Rev. Lloyd Denny (LD) Lay Member, Patient & Public Involvement Angela Duce (ADu) Associate Director Strategy and Governance Dr Hetal Talati (HTa) Clinical Director Dr Sarah Whiteman (SW) Medical Director, Executive Team In Attendance: Chloe Allen (CA) Graduate Management Trainee Elaine Baugh (EB) Governance & Risk Support Officer (minutes) Amanda Murrell (AMu) Communications and Engagement Manager, Bedfordshire CCG Michael Wuestefeld-Gray (MW-G) Interim Assistant Director of Governance Risk and Corporate Affairs

Actions 76/19 1. Welcome, Apologies and Chair’s Introduction The meeting commenced at 14:35. The Chair apologised for the late start of the meeting.

The Chair welcomed all to the meeting and introductions were made. Apologies received as noted above.

The Chair reminded the meeting that as a General Election as been called for the 12th December 2019 the meeting is subject to Purdah conditions.

The Communications and Engagement Team were in attendance posting live ‘Tweets’ during the meeting.

77/19 2. Declarations of Interest in relation to Agenda Items There were no declarations of interest in relation to agenda items.

78/19 3. Declaration of Hospitality relating to Agenda Items There were no declarations of hospitality relating to agenda items.

79/19 4. Minutes of the Meeting held in Public on 17th September 2019 The minutes of the meeting held on the 17th September 2019 were reviewed with the following amendments noted:  69/19, page 6 – To be re-worded ‘…who they would not usually engage with’.  70/19, page 7 – Typographical and grammatical errors noted.  71/19, page 8 - Typographical and grammatical errors noted.

The Board approved the minutes of the meeting held on the 17th September 2019 subject to the amendments noted above. 80/19 5. Matters arising from the Meeting held in Public on 17th September 2019 The Board reviewed the Action Log with the following updates noted:  30/19a – Luton and Dunstable Hospital (L&D) and Bedford Hospital Trust (BHT) are proposing to merger with effect from April 2020 with a shadow Board in place from January 2020. Luton CCG and Bedfordshire CCG are endeavouring to hold a Board to Board meeting with the Shadow Board in the New Year. There is also a proposed Board to Board meeting with East London Foundation Trust (ELFT).  51/19a – A risk has been drafted, ongoing work still required.  51/19b – Work is ongoing, there is national support with clearing the backlog. As a system we are the best achieving on improvement for LeDeR in the country.  70/19 – The dates of the Parent and Carers Forum have been circulated. This is an ongoing programme of work.  73/19c – Agenda item 14.

NHS Luton CCG Constitution The updated draft Constitution will be presented at the Members Forum on Thursday 21st November 2019 for approval. The draft is using the NHS England best practice model. The Member Practices listed under section 3 has been updated. MW-G advised that typographical errors and amendments identified by DK have been corrected.

NP advised that specific areas will be brought to the attention of Member Practices at the Members Forum, which differ from the previous version on the constitution, including to quoracy detailed on page 62, which is less that the current position.

81/19 6. Patient Story NP presented a verbal Patient Story. NP explained the process for the huddles. The Patient Story focused on a couple, where the husband has had ten admissions this year

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and was discussed at a huddle.

The husband is in his 80s, multiple conditions i.e. diabetes, ischemic heart disease, COPD, dementia, severely frail. His admissions were usually related to his diabetes or as a result of a fall. His wife also has multiple conditions i.e. Parkinson’s, ischemic heart disease, osteoporosis and severely frail.

NP conducted a joint home visit and identified the following:  A supportive family network.  Both were receiving carers visiting 3-4 times per day.  The husband was in a single hospital bed in a single room at the front of the house. He was in gradual decline, feeling nauseous, spending most of his time in bed, sleeping, not eating or drinking, low mood and deaf.  The wife was in a single hospital bed in the lounge, with a recliner chair. She shared her anxieties and worries about her husband.

NP conducted an examination, resulting is some medication changes, others were de- prescribed and a referral made for a hearing-aid. For the wife, NP queried if she would like to go out more i.e. a Day Centre or the Hospice, she expressed an interest in going to the Hospice, which NP made the referral.

At the next Multi-disciplinary Team (MDT) meeting it was agreed to do some end of life planning and see if changes could be made with the arrangements at home. The husband was started on a mild antidepressant; however the couple did not what to make changes to the arrangements at home. The District Nurses continue to look after the husband and the wife was not eligible for Hospice Care.

Since the first contact with the family approx. 10 weeks ago the husband has had only one contact with the Out of Hours service, no admissions or Ambulance calls. NP felt that having a conversation with the wife about her concerns for her husband was good to have, although the interventions made have been very modest. NP suggests that it is better to see couples together in order to unlock unidentified issues.

Comments from the Board:  The Board felt this demonstrated the value of personalisation.  This was an example of changing people’s perceptions that there are non- medical approaches to feeling better.  The Board queried whether there was a model in place to develop this type of interaction with patients to identify issues which could be impacting on their health and wellbeing. The credence give from a visit from a GP or a senior nurse gives confidence to a situation, however this cannot be measured. Follow ups are conducted by a Care Co-ordinator.  The Board queried whether a system could be established where following a number of admissions the patient is flagged. This is the role of the huddle to review these patients; more complex cases are discussed at the weekly MDT meeting.  A second pair of eyes can see things from a different angle.  This incident has demonstrated the need to review patients as a couple rather than as individuals.  The weak link is hospital staff not looking at Care Plans on admission to find the professional that knows the patient very well.

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 The required model is to get health and social care to manage families together.  It sometime needs a professional to have an honest and open conversation with the patient and their family on the possible outcomes.  These types of stories are shared at the Luton Provider Alliance (LPA) and collated by Cambridge Community Services (CCS) for their newsletter.

82/19 7. Chairs’ Report The Chairs’ Report from the following Committees were presented:  Audit and Risk Management Committee – 15th October 2019  Clinical Commissioning Committee – 26th September 2019 and 31st October 2019  Patient Safety and Quality Committee – 26th September 2019 and 31st October 2019  Primary Care Commissioning Committee – 24th September 2019

The Chair advised that the autumn has been a particular busy period with members of the Board who attended several events:  CB has attended two conferences speaking on Diabetes.  US attended the Best Practice Conference where she spoke about Rapid Response service, which received positive feedback. Ideas were also gather from other areas which could be implemented locally.  NPo attended the HSJ Conference where Nottingham expressed an interest in our Integrated Health and Social Care model.  Jo Robertson from CCS and Dr Haydn Williams were regional finalist for the Peter Carr Award for Leadership, for their work on the Enhanced Care Model.  NP attended Expo, the NHS England and NHS Improvement (NHSE/I) Conference in September 2019. The Royal College of GPs in November 2019 to speak on Primary Care Networks and how it can make a difference to patients.  Caroline Capell, Associate Director has been attending Roadshows around the country profiling direct bookable appointment on 111.  NP also attended the Commissioning Finance Directors Workshop to talk about the new roles in General Practice.

It was noted that Lucy Nicholson, Chief Operating Officer, Healthwatch Luton has commented that Luton is far ahead of other areas and the need to promote this more.

The Board noted the Chairs’ Report. 83/19 8. Bedfordshire, Luton and Milton Keynes (BLMK) Accountable Officer’s Report PD had prepared a written BLMK Accountable Officer’s Report which was circulated to Board Members after the meeting.

The key national issues:  EU Exit guidance and the CCG role. The CCC continues to work on the resilience plans for the revised leave date of 31st January 2020.  Long Term Plan final submission will be on the 25th November 2019.  The updated Winter Resilience Plan was submitted last week on how the system will operate over the winter period.

The key local issues:

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 CCG Financial Resilience Plan (FRP), PD thanked the work of the Financial Resilience Group (FRG) for their grip and focus to ensure the CCG is responding contemporaneously to any variance against plan.  The Q1 over performance has added a £2.5m risk to the system.

Annual General Meeting (AGM) The CCG held the AGM on the 17th September 2019 outlining the achievements over the last financial year. The event was well attended and received positive feedback with attendees enjoying the event. PD thanked everyone who was involved in the event.

Performance Quality and Urgent and Emergency Care System wide assurance in terms of how we improve current performance and planning for has been provided on the Performance, Quality and Outcomes Report.

84/19 9. Winter Plan NPo presented the Winter Plan. The Board were asked to note the content and actions of the Luton System Winter Plan. The Winter Plan was co-produced and approved by the Luton and South Bedfordshire A & E Delivery Board, the Luton Transformation Board and the Luton Place Senior Leaders Group.

A & E attendance rates are level, however the emergency admission rates are higher. The Winter Plan fits with the FRP.

The Board queried the use of Step Up/Down Beds. The aim of Step Up beds is to give patients somewhere to go to receive the services and support they needs out of an acute hospital. This service is in partnership with the Local Authority and the Community Provider. There has been three occasions of using Step Up in the last month. Clarity is needs on what the evidence is telling us about the usage in Luton. The challenge is to get the message across to GPs that this service is available and to change the mind-set of Paramedics to utilise the service.

KS has a process in place where Ambulance staff is advised to call the practice before taking non-emergency patient to hospital. There have been occasions where the Ambulance has brought the patient to the practice. Patients have been advised to call the practice before calling for an Ambulance. The Practice is the best performing in Luton since putting this process in place.

Paramedics have been given by-pass numbers to all 26 practices in Luton; however there is not a systemic way for East of England Ambulance Trust (EEAST) to put this place. To test whether this process is working the Unplanned Care Team are making four random calls per week to see if the system is working and to give confidence to the Paramedics to use the service.

The plan will be monitored by the A & E Delivery Board. The Plans are also sent to NHSE/I for approval.

A key concern is the fragility of the Home Care market including Domiciliary Care; however this concern is not unique to Luton. There are issues with the Provider market in relation to the sustainability of workforce and financially which the Local Authority is looking to manage.

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The Board commended the Winter Plan and requested to be alerted to any problems which may arise over the winter period.

The Board noted the content and actions of the Luton System Winter Plan. 85/19 10. Bedfordshire, Luton and Milton Keynes (BLMK) Commissioning Collaborative (CC) Change Management Policy JM presented the Change Management Policy as part of the aligning the BLMK CCGs policies and procedures. Working with Arden and GEM Commissioning Support Unit (CSU), the HR (Human Resources) provider and implementing best practice the BLMK CC Change Management Policy is presented for approval.

The policy has the support of the Executive Team and was circulated for agreement by each individual CCG’s local policy approval routs including policy approval groups, staff members and Trade Union Representatives.

The review of the three individual CCG policies highlighted some areas of differences including TUPE, Personal and Professional Support, Pay Protection and Excess mileage payment periods. The issue around Pay Protection was one policy was based on length of service and the other based on the length of time in post. JM confirmed that this has been aligned to be based on length of service.

Comments from the Board:  The Board felt the title of the policy was misleading and needs to specify that this is in relation to workforce.  The policy has been developed based on HR best practice and advice.  The Board noted the Quality Impact Assessment was blank. The CCG needs to be completing the Integrated Impact Assessments for all new policies.

[The meeting adjourned for a break at 15:39] The Board approved the BLMK CC Change Management Policy. 86/19 11. Integrated Quality and Performance Report [The meeting resumed at 15:48]

NPo presented the Integrated Quality and Performance Report (IQPR) for July 2019 (Month 04). The IQPR was reviewed by the Patient Safety and Quality Committee (PSQC).

Comments from the Board:  The Board found the inclusion of the mitigations and action really useful.  The L&D were congratulated for achieving the RTT (refer to treat) target, however concerns were raised whether patients are being treated in date and clinical need order. Assurance is needed around management of the backlog and around the patients approaching 52 week breach. A deep dive is needed to assess the risks and to understand the RTT process.  There have been seven 52 week breaches. Only one was for the L&D which was due to the patient’s choice. A detailed review has been conducted on the other breaches. NELCSU are tracking all patients from 40 weeks. RTT will be discussed at the next Contract Review meeting and a deep dive will be conducted.  It was noted that the CCG needs to be mindful of the current cancer waiting times.  The Board queried the mixed sex accommodation breaches, as this seems very

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low. The policy has been changed recently which gives changes allowance for critical care. AM advised that she was no concerned and her team conduct patient experience visits.  The Board also queried Serious Incidents (SI) reporting, again seeming low. The consensus was as a system this was not an issue and GPs are not receiving complaints about this.  Ambulance handover delays were discussed; this has been discussed at the A&E Delivery Board. The Board felt that they need to understand if any ‘harm’ was caused by the delays. Deep dives have been conducted and presented to the PSQC. The Performance Report is reviewed at PSQC; the Board queried whether an assurance statement could be included in future reports.  NP commented that patients are reporting having hospital appointments /planned admissions being rescheduled for February 2020, which is impacting on GPs.  A discussion took place regarding ‘wrong site surgery’ however this is not a current issue in Luton.  There has been a small increase in C.diff cases across the system; this is being monitored by Infection Control Nurse.

The Board noted the IQPR. 87/19 12. Month 06 Finance Report CF presented the Finance Report for Month 06 (September 2019). The CCG has delivered a £183k surplus in the month, which is £67k adverse to plan. The year to date (ytd) overspend has increased to £2.4m. The surplus target of £3m is still forecast to deliver but the level of risk to achieving this remains high, the CCG remains in financial turnaround. Month 07 is showing continuing improvement.

The key headlines are:  The L&D Contact has underspent by £76k in month, however other Acute Providers increased. The CCG is working closely with the L&D to reduce non- elective activity.  Community Health has a ytd overspend of £259k due to high cost patients (Learning Disabilities and S117) and an uplift to the Keech contract.  Continuing Healthcare position is £258k favourable.

The financial positon is very challenging; the CCG is £2.4m off plan. There is a risk of approximately £2.3m.

Key comments from the Board:  The Board noted that the CCG is in an improving position.  QIPP plans are under delivering in areas where the CCG is dependent on others i.e. Elective, Planned and Primary Care. The focus is being clear on identifying the issues and the mitigations. Clinical behaviours need to change, however this is a challenge. The overall aim is for one voice looking after the population we are serving.

The Board noted the Month 06 Finance Report. 88/19 13. Emergency Preparedness, Resilience and Response (EPRR) Core Standard NPo presented the Emergency Preparedness, Resilience and Response (EPRR) Core Standard to the Board for assurance. This annual process is a joint submission for LCCG

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and BCCG.

The CCG assessed itself as being fully compliant against the standards and has since received confirmation from the panel, which consisted of NHS England, Public Health England and a representative from the Bedfordshire Public Health team.

The Board were assured by the EPRR Core Standards report. 89/19 14. Board Assurance Framework MWG presented updated the Board Assurance Framework. The area highlighted was the gap in assurance relating to the new Medical Director working across the three CCGs.

Key comments from the Board:  The Board were pleased with the number assurances which have been updated. However it was noted that some dates were still old and requested assurance that these were being actively monitored and reviewed e.g. BAF 4. Action – To review and update BAF 4. JM  Concerns were raised that updates to the risks are not being reflected in the printed report received by the Board. Action – To review the BAF to ensure that the report accurately reflects the risks have MWG been reviewed and updated.  The Board discussed the fact that the CCG’s objectives do not include a specific objective in relation to performance; there is no assurance on performance within the BAF. A risk is needed on the BAF which reflects that if the level of performance deteriorates to a point where the effort required to restore will impact on other areas of the organisations, SEND was used as the example. Action – To develop a BAF risk in relation to quality and performance, to accurately AM/MWG record the work being undertaken.  The Board suggested that some of the risk controls were more suited to the Corporate Risk Register than the BAF. Action – To review the BAF and to check with the Executive Team all actions have MWG been taken.

The Board noted the Board Assurance Framework. 90/19 15. Minutes of Committee Meetings The following Committee meeting minutes were presented for information only: a. Audit and Risk Management Committee – 16th July 2019 b. Clinical Commissioning Committee – 26th September 2019 c. Finance and Performance Committee – 29th August 2019, 26th September 2019 d. Patient Safety and Quality Committee – 25th July 2019, 26th September 2019 e. Primary Care Commissioning Committee – 9th July 2019 f. Transformation Board – 18th September 2019

The Board noted the minutes of Committee Meetings. 91/19 16. Any other Business With no further business the meeting ended at 16:22 17. Next meeting of Board Meeting held in Public  Tuesday 21st January 2020 , 13:00-16:30, Youthscape, Bute Mills, 74 Bute Street, Luton, LU1 2EY

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Subject: One Team Programme Briefing

Meeting: BLMK Governing Bodies

Date of Meeting: January 2020

Report of: Geraint Davies, Director of System Commissioning & SRO One Team Programme (BLMK)

1. Summary

Earlier this year, in response to the NHS Long Term Plan and following a Governing Body development session in September 2019, the BLMK executive team initiated work to take the three BLMK CCGs on a journey towards the disestablishment of the existing CCGs and the creation of one single new CCG for Bedfordshire, Luton and Milton Keynes by April 2021.

To that end, in November BLMK Governing Bodies approved the development of a Programme Plan, Programme Board and establish a dedicated team to deliver the programme. This Paper summarises the progress that has been made since November 2019.

2. Recommendations

The Governing Body is asked to note progress with the One Team Programme.

One Team Programme Briefing Page 1 of 1

Subject: One Team Programme Briefing

Meeting: BLMK Governing Bodies (Part 1)

Date of Meeting: January 2020

Report of: Geraint Davies, Director of System Commissioning & SRO One Team Programme (BLMK)

1. Background

In November 2019 the BLMK CCGs’ Governing Bodies gave approval for the BLMK executive team to develop the One Team Programme, which is the vehicle to deliver the three CCGs’ ambition to:

 Create a new single CCG for Bedfordshire, Luton and Milton Keynes (and disestablishing the existing three CCGs);

 Establish the new CCG as a strategic commissioner as part of the BLMK Integrated Care System; and

 Support the development of two Integrated Care Partnerships in Bedfordshire and Milton Keynes within the BLMK Integrated Care System. A dedicated team and Programme Board have been established, and the Programme Plan has been developed. This paper summarises the progress that has been made since November in setting up the Programme to realise our ambitions.

2. The One Team Programme Resources

Dedicated resources have been identified to lead the One Team Programme who will work closely alongside Governing Body members, the CCG membership, staff at all levels in the three CCGs and other senior stakeholders in BLMK ICS partner organisations. Russell Foster has been engaged on a three month interim basis (mid Nov- mid Feb) to provide the additional capacity and expertise needed to establish the programme, its governance arrangements and to develop the detailed programme plan. The dedicated team members are being supported by a number of senior level work stream leads who are all specialists in their own areas such as Governance, Communications & Engagement, Organisational Development, HR, Finance and IT. The full work stream list and resources is shown in Appendix 1. Working relationships have been established with our NHS E/I regional assurance colleagues, one of whom is a member of the One Team Programme Board, and the other provides day to day operational/technical support including arranging liaison with subject matter experts from other similar CCG Programme Teams.

One Team Programme Briefing Page 1 of 4

3. The One Team Programme Board

The One Team Programme Board will report to the three Governing Bodies and will comprise the following membership:

 One Lay Member from each CCG (one of which has been appointed as Chair of the Programme Board) (3 Lay members in total)

 One GP Member from each CCG (3 GP members in total)

 The SROs for the One Team Programme: Richard Alsop and Geraint Davies

 The Director of Partnerships, Communications and Engagement: Jane Meggitt

 The Chief Nurse: Anne Murray

 An NHS E/I Regional representative Governance, reporting templates and reporting cycles have been fully integrated with our established CCG governance processes – see Table 1.

4. The One Team Programme Plan Summary

A detailed Programme Plan has been drafted using the template from the Kent & Medway CCGs Programme which had been previously validated and assured by NHS England. The draft Programme Plan was reviewed with our Regional regulator before being submitted to our One Team Programme Board.

One Team Programme Briefing Page 2 of 4

The Plan sets out the key tasks deliverables and milestones within each work stream. A more detailed Gantt chart has been developed to manage the programme activity and delivery against the Gantt chart will be overseen by the Programme Board. The Plan will be continually updated and shared with Governing Bodies on a regular basis to support the GB’s tracking of progress.

There are three phases to the One Team Programme:

Phase 1: September 19 – March 20: Defining our story Phase 2: April 20 – September 20: Working Together as One Team – Winning Hearts and Minds Phase 3: October 20 – April 21: Fit for the Future – Creation of New Organisation

5. Next Steps

From January 2020 the Programme Team will focus on three key areas:

 Creating and socialising our Case for Change and Communications and Engagement Strategy (up to end of Phase 1).

 Ensuring our senior management structure and governance is fit for purpose for moving into shadow form by 1st April (beginning of Phase 2).

 Drafting and approving the documents required for our application to become One BLMK CCG (end of Phase 2).

One Team Programme Briefing Page 3 of 4

Appendix 1 - One Team Programme work streams, core membership and responsibilities

Role Title Responsibilities Resource

Programme Reporting to SRO with responsibility for Maria Wogan / Leadership management of entire programme, including Alison Joyner stakeholder management Programme Delivery Main focus on delivering TOM and Sandra Vanreyk Manager organisational structure and supporting AD to deliver other work streams Comms & To deliver all comms and engagement Ruth Adams Engagement requirements for single CCG Governance To delivery all governance requirements for Michael single CCG Wuestefeld- Gray Organisational To manage the OD work stream Karen Rhodes Development Human Resources To provide client-side management of AGEM Emma Richards team supporting delivery of HR work stream PMO Support Programme planning and reporting function Joyce Baskerville Target Operating To design the TOM & new organisational Maria Wogan Model Design Lead structure from the “Do Share Buy” outputs Finance workstream To develop the and deliver all finance Wendy requirements of single CCG Rowlands Digital Strategy To deliver the single ICT work stream Mark Peedle

Quality & Nursing To ensure CCG statutory standards for Quality Maria Laffan & Safeguarding are maintained Primary Care To manage the processes required to Alexia Stenning Commissioning implement new Primary Care operational delivery arrangements and ensure smooth transition to end state Primary Care commissioning

Estates & Property Develop and implement plans for new BLMK Stephen Makin CCG corporate estate BI, Contracting & Determine BI contract information and resource Stephen Makin Performance requirements, SOPs and corporate Management performance reporting to match future functions

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Agenda Item 10

PAPER FOR THE LUTON CLINICAL COMMMISSIONING GROUP BOARD MEETING IN PUBLIC TO BE HELD ON TUESDAY 21st January 2020 Youthscape, Bute Mills, 74 Bute Street, Luton, LU1 2EY

TITLE Long Term Plan Update & 2020/21 Commissioning Delivery Planning

PRESENTED BY (Plus contact details for Geraint Davies, Director of System Commissioning pre- Board enquiries)

LEAD CLINICIAN/MANAGER Liz Cox, Deputy CFO / Programme Director for System Commissioning

WHAT IS THE OBJECTIVE OF To update the Board on the response to the NHS Long Term Plan and the THE PAPER? development of a commissioning delivery plan for 2020/21 WHAT IS THE BOARD BEING To note the detailed context for the CCGs annual planning round as set out ASKED TO DO? within the paper. WHICH OTHER COMMITTEES None HAVE REVIEWED THIS PAPER? INTEGRATED IMPACT ASSESSMENT (IIA) HAS AN IIA BEEN CARRIED N/A OUT? WHAT IS THE IMPACT? POSITIVE/NEGATIVE/NEUTRAL* IF THE IMPACT IS NEGATIVE, HOW WILL IT BE MANAGED? EXECUTIVE SUMMARY Across the Integrated Care System (ICS) we have developed a longer term plan (LTP) for Wellbeing and Health for Central Bedfordshire, Bedford Borough, Milton Keynes and Luton (BLMK) spanning a 5 year period. This was submitted to NHS England at the end of November 2019. An Executive Summary of the final BLMK LTP response has also been developed. Both will be issued soon, following final sign off by NHS England.

This year has been a foundation year, laying the groundwork for the implementation of the Long Term Plan as a whole from April 2020 onwards. Work now needs to commence on detailed planning for commissioning and delivery that will specifically take place during 2020/21 in line with both national requirements and the BLMK LTP.

This update provides a summary for the Board on the likely national planning framework and requirements for progressing 2020/21 operational plans and a broad outline of the timeframes. Planning guidance is expected during the week commencing 13th January 2020. Our detailed commissioning delivery plan for 2020/21 will build upon our response to the LTP, and local place based plans, within the financial trajectories set for the CCG and Integrated Care System. Final plans are expected to be required by the end of March 2020, with several draft versions to be submitted ahead of this deadline.

LINK TO CORPORATE OBJECTIVES AND RISK WHICH CORPORATE OBJECTIVE DOES THE PAPER RELATE TO? Working with our partner organisations to drive and deliver the integrated priorities of the Bedfordshire, √ Luton and Milton Keynes Sustainability and Transformation Plan. Listening and working with patients and their families, carers, frontline staff, clinicians, social care professionals and system leaders in order to ensure a shared vision for health and wellbeing services that addresses health inequalities across Luton and the wider footprint. Actively commissioning innovative, locally accessible services that meet the health and wellbeing needs of √ the diverse population of Luton.

Prioritising the development of evidence-based approaches in order to support prevention, self-care and

early intervention.

√ Robustness in delivering our long term financial plan to maintain the financial sustainability of the CCG.

Commissioning evidence-based, responsive services that reduce variation manage the demand for √ healthcare and provide the best value for the local population.

Recruiting and retaining the best staff with the passion to deliver the CCG’s ambitions that make a

difference to our local population.

Ensuring a dynamic and effective approach to communication that engages the people of Luton in order to

successfully promote prevention and self-care and the delivery of effective health and wellbeing services.

Supporting a diverse and inclusive workforce that promotes individual and team development across the

system through innovation and partnership working.

LINK TO THE BOARD ASSURANCE FRAMEWORK WHAT ARE THE KEY RISKS ON THE BOARD ASSURANCE FRAMEWORK? Insufficient resources and workforce capacity across Luton to deliver the priorities of the Sustainability

and Transformation Plan. Insufficient engagement and ownership in the system vision leading to resistance to change which may

delay or prevent the progress of transformation. Individuals and organisations resist integration, continuing to work to internal strategies rather than the

system-wide vision. Communications and engagement strategy is not effective in engaging the public especially hard to reach

groups within Luton. The CCG fails to meet its statutory duty to deliver the agreed end of year financial position. The QIPP programme fails to deliver its key objectives and savings leading to an unplanned deficit and

failure to deliver the best outcomes for patients. The CCG is unable to recruit and retain staff and clinical leaders with the right skills and abilities to deliver

the CCG's strategy.

Board Meeting in Public Cover Sheet Revised 2019 2

1.0 Background

Across the Integrated Care System (ICS) we have developed a longer term plan (LTP) for Wellbeing and Health for Central Bedfordshire, Bedford Borough, Milton Keynes and Luton (BLMK) spanning a 5 year period. This was submitted to NHS England at the end of November 2019. An Executive Summary of the final BLMK LTP response has also been developed. Both will be issued soon, following final sign off by NHS England.

This year has been a foundation year, laying the groundwork for the implementation of the Long Term Plan as a whole from April 2020 onwards. Work now needs to commence on detailed planning for commissioning and delivery that will specifically take place during 2020/21 in line with both national requirements and the BLMK LTP.

This update provides a summary for the Board on the likely national planning framework and requirements for progressing 2020/21 operational plans and a broad outline of the timeframes.

2.0 Introduction

The NHS Long Term Plan (LTP) sets out the direction of travel for the NHS over the next five to ten years. All STPs/ICSs submitted a final response to NHS England at the end of November including:

• A Strategy Delivery Plan (narrative, plus trajectories for delivery in some areas)

• Supporting technical appendices including detailed template returns for workforce, finance and activity.

The plan is being collaboratively developed to provide a focus for partnership working for the next five years. In part it explains how we will implement the proposals in the LTP, but it goes beyond that to consider the wider action that is needed to improve wellbeing and health. It links closely with the four Health and Wellbeing Board strategies, and their constituent priorities. The plan is of a high level and has been designed to make it accessible for the public, patients and staff through production of an Executive Summary (Appendix A) incorporating feedback on the LTP from a number of engagement events held during April to August 2019.

In line with the NHS national annual operational planning timeframes, work has now commenced to develop and agree (in more detail) local commissioning delivery plans for the forthcoming year and ensure that they are reflected appropriately in service contracts.

3.0 National Planning Parameters for 2020/21

Detailed guidance, to assist systems and organisations in preparing for 2020/21 operational planning and contracting, is expected to be published the week commencing 13th January 2020. As with previous years, it is likely that plans will need to reflect the following elements:

 Delivery requirements for 2020/21 that reflect LTP commitments and local commissioning priorities  Organisational activity & financial plans for 2020/21 that reflect LTP system planning  Productivity, Efficiency & Performance assumptions that reflect LTP system planning  Workforce planning  Data & Technology planning

Board Meeting in Public Cover Sheet Revised 2019 3

4.0 Developing our Commissioning Delivery Plan

4.1 Context 2019/20 has been a foundation year for BLMK, seeing progress in the development of our Integrated Care System (ICS), the establishment of Primary Care Networks (PCNs) and the identification of two Integrated Care Partnership (ICP) footprints. 2020/21 will see further collaborative transformation as the local NHS architecture responds to the commitments laid out in the LTP. These changes lay the groundwork for the implementation of the LTP, the collective vehicle of which will be a range of local aligned strategies and plans as illustrated in the diagram below:

Going forward, it is important that the different elements of our wider system planning (as shown above) fit together cohesively, and that there is clarity of leadership for them.

4.2 Commissioning Delivery Plan for 2020/21

Whilst the overarching LTP has set out the strategic direction for the system across key priority areas, more detail is now required to outline service delivery, key outcome measures and system efficiencies at a commissioning level. This detail will form the basis of our Commissioning Delivery Plan for 2020/21, which will need to align to the commitments already set out in the LTP, place based plans, individual clinical service strategies and ultimately the clinical strategy and it’s delivery plans (when these are ready).

4.3 Planning Timeframes

A national planning timetable is likely to be included in the technical guidance, to be published shortly. However timeframes for the production of organisational level and STP/ICS system level operational plans are likely to reflect the following outline:-

National Guidance & Supporting Technical w/c 13th January Information published.

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Organisations & STP/ICS systems submit draft Mid-February Operational Plans.

Organisations & STP/ICS systems submit draft 28th February Operational Plans.

Contract agreed and signed with providers End of March

4.4 Financial Context

NHS England has set the financial trajectories (previously called control totals) for each ICS system for the next four years. Systems will be measured on their overall delivery as well as that of individual organisations. For BLMK this encompasses the 3 CCG’s of Bedfordshire, Milton Keynes and Luton, as well as the hospital providers (Bedford Hospital, Milton Keynes University Hospital and Luton & Dunstable) and 50% of Cambridge Community Services. Each organisation has been set a trajectory including a 0.5% stretch target to contribute to a Regional contingency reserve.

In addition to the allocations already notified to commissioners, the BLMK system will be in receipt of targeted transformation funds for mental health, primary care, cancer and long term conditions (£10m in 2019-20 rising to £30m by 2023-24) of which Luton will receive a share.

Draft Financial plans will be presented to Finance & Performance Committee at its meeting on 30th January 2020.

5.0 Recommendation

The Board is asked to note the detailed context for the CCGs annual planning round as set out within the paper.

Board Meeting in Public Cover Sheet Revised 2019 5 Integrated Care System

Living longer in good health Bedfordshire, Luton and Milton Keynes Longer Term Plan (2019 – 2024) for improving health and care

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Our priorities for the future are very much in line We want to work with communities Introduction with those set out in the NHS Long Term Plan. to help people stay healthy and well We’ve talked to colleagues to understand and learn from them about what is working well. Factors such as good jobs and housing affect But most importantly, we’ve talked to you, local our physical and mental health, so while we What’s this about? Making the best use of our skills people, to find out what matters most. need to look at how we can continue to improve and resources local health services, we can’t do this alone. This The organisations responsible for health and One of the biggest changes we’re making is to is why the NHS, your local councils and other care in Bedford Borough, Central Bedfordshire, Since 2016 hospitals, clinical commissioning create teams of health and care professionals organisations are working more closely together Luton and Milton Keynes are working together groups, GPs, community and mental health who will work with GP practices and with than ever, to really make a difference. to develop a plan for the next five years, trusts, ambulance trusts and local councils in community and mental health services, social 1 We know that local people want local services, responding to the NHS Long Term Plan that Bedfordshire, Luton and Milton Keynes have care workers and volunteers to provide more and so local health and care providers are was published in January 2019. At the heart of been working more closely together. This means tailored services in your area. planning to work together to break down the plan is making sure that you get the care we can contribute better to the overall health barriers and make it simpler for you when you you need, when you need it. and care needs of the people we serve and get are in need of help. the most out of the skills and resources we have available. These are ambitious plans and we’re excited about the positive improvements we’ll be Our ambition - why we’ve written We share a common purpose – we want people making for you and your family. Over the next this plan and what it means for you to live longer in good health. When people five years we will continue to work with you to and your family need care, we want them to get the very best shape our future together. available. To do this we need to look after our The purpose of our plan is to improve our staff, recruiting and retaining the highest quality services so that it’s easier for you to manage people. And we have a duty to spend public your own care as much as possible. When you money wisely on services that will make the do need us, we want to make sure that you biggest difference to local people. can get an appointment quickly, with the best person to help you in a place that is near to where you live. This will also help our hospitals work better, so that if you or your family needs specialist treatment, we can get you seen and treated without delay.

1 www.longtermplan.nhs.uk

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We have been out and about asking local people what their future NHS looks like and what would What you have told us is important to you and your family help them to stay as healthy and well as possible. Here are some of the things you told us:

“We want mental During the course of this year we have listened to 5. Our staff are excellent, but stretched. 2 health services to be local people, supported by local Healthwatch , to Therefore, we must recruit more people “More information get a better idea of what’s important to you and to work in health and care. To provide accessible to ALL” “I want access to what you think we could do better. high quality, compassionate and person- and support to centred care we need to recruit new people healthcare professionals at We know that people want to keep local services improve our diet and to work in the health and care sector, as well and to access healthcare when they need it. Here times convenient to me” as do more to retain our existing workforce. cooking skills” are some common themes we’ve heard: 6. You don’t want to have to repeatedly “More screening 1. You want to access local services, like GP tell your story to different health and services and hospital referrals, quicker. for older people” care staff. You want your care to be better People would like to get appointments coordinated across the different staff group, “Better use of sooner, with 80% of people we surveyed organisations and services and for us to use saying improved access to GP services was the social prescriptions” technology to help us do this. most important thing. “Good education to enable 7. When people are diagnosed with cancer, 2. Improving mental health services for me to understand how to they want to feel confident they can “Ability to access both children and young people and access better information and support. services online via look after myself” People of adults should be a priority. People recognise that treatment and care all ages should be able to get the help and after diagnosis works well but they would apps and Skype” support they need quickly and easily. like to see improved information to help them 3. You would like more support and make informed choices throughout their “More integration “More care in the information to help you lead a healthier diagnosis and treatment. between health services life. Our communities want to be healthier, community provided by and social worker teams, but need support to tackle things like obesity people who care” and diabetes. hospitals and charities” 4. New technology provides an opportunity to improve people’s care. You would like us to make the most of this opportunity. By investing in technology we can help people access services online and reduce the pressure on our services.

2 https://www.healthwatch.co.uk/report/2019-09-04/ what-people-have-told-us-about-health-and-social-care- april-june-2019

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The big issues we currently face as a local health and care system 20 Almost 1 million people live in Bedfordshire, Luton and Milton Keynes YEARS

The NHS has for some time been challenged We have considerable health inequalities. by a number of big issues. These are slightly A baby girl born in Central Bedfordshire today can People are living on different depending on where you are in the expect to live for 84.4 years, over 6 years longer average as much as 20 country. Across our region we are working hard than a baby boy born in Luton (78.3 years). years in poor health (the gap between healthy with partners to face these big issues head on. Bedford Borough The number of people seeking treatment life expectancy and life Almost one million people live in Bedford at our A&E departments continues to rise expectancy). Borough, Central Bedfordshire, Luton and and this places pressure on ambulance Milton Keynes, one of the fastest growing areas and hospital providers. Our plans are aimed in the country. The characteristics of these at supporting people to seek appropriate Bedford osital different places affect what local people need treatment and only attending A&E departments 45% from their health and social care services. when really necessary. OF PEOPLE Milton Keynes We could be doing better on circulatory With a 20 year gap in life expectancy and respiratory diseases. Coronary heart Only 45% of people and healthy life expectancy, more disease admission rates are higher than using social care in people will mean more care will need nationally in our area. Hospital admissions for BLMK feel they have as asthma in under 19s are high in Milton Keynes. to be provided. Without action now, much social contact as Admissions for cardio-pulmonary disease are Milton keeping people healthy and happy in they would like. high everywhere except Luton. Keynes entral Bedfordshire the future will be much, much harder. osital We are also facing workforce shortages and significant financial pressures. We can’t Some specific challenges we have are: continue to provide both the high quality and 2/3 OF CHILDREN We have a growing population. Our wide range of services we do today without population could increase by nearly 90% making changes; to work smarter and more Luton unstale osital by 2050. This would include an 80% increase efficiently to get better value for every pound of Luton In the most deprived in the number of children and young people, taxpayers’ money. areas of Luton and a 70% increase in the working age population Bedford Borough, two and nearly 150% increase in the population We need to make sure we can meet thirds of children are aged over 65. We need to make sure we have these challenges head on and that is living in poverty. the right health and care services in place to support this. why we have put together this plan, which shows what we will change 4 local councils 3 community health 102 GP Practices More people are living with long term providers over the next five years and what 3 acute hospital trusts‡ 22 Primary Care health conditions, such as diabetes and 2/3 difference it will make to you and OF ADULTS 2 mental health Networks (PCNs) arthritis that cannot be cured but can be clinical your family. 3 providers effectively managed. The quality of healthcare commissioning that people receive and their general health groups* 2 ambulance trusts and wellbeing varies. Two thirds of adults in BLMK are overweight ‡ Bedford Hospital and Luton & Dunstable Hospital will become Bedfordshire Hospitals Foundation Trust in April 2020 or obese. * The 3 CCGs will create a single, new CCG in April 2021

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Our goals – what we want to achieve Our top six changes for helping you live longer in good health

We recognise that getting the fundamentals right 2. Making sure we’re there for you when As you’d expect, our plan is extensive. There are of these are set out here. They are our top six will help us successfully deliver the rest of our five you need us most: Sometimes people can’t lots of things we need to do differently to make changes and they’re aligned to the promises set year plan. There’s lots of things we can do, but get the right appointments quickly, or they a positive change to the health and care services out in the NHS Long Term Plan. we think these are four of the most important: have to wait too long to see a specialist. And you and your family can access. The biggest then they have to tell their story over and over 1. Making sure that every person in again. We have to make our services work Bedfordshire, Luton and Milton Keynes better together. Creating opportunities for you to see a range of staff in your lives as healthy a life as possible, for as 1 community, offering you more coordinated and personal care long as possible: People living in some parts 3. Making sure that Bedfordshire, Luton and of our area currently suffer significantly poorer Milton Keynes is the best health and care health than others and on average, tend to die system to work in: In order to look after you, Improving the way our hospitals work so you get faster treatment in an younger. We have to do something about this. we need to look after our people. If we can emergency and don’t wait too long for an operation or other hospital care help them to work better together and feel 2 more supported, they’ll be better able to give you consistently high standards Giving you better information and support to help you stay well and of compassionate care. 3 manage illness sooner 4. Making the most of our funding: The NHS Long Term Plan provides future investment into local services which, for our Giving you choice and control over the way your care is area, means we have an extra £234 million 4 planned and delivered over the period of the plan, including an allowance for inflation. By achieving our six changes (see next section), we Making sure the right people are there to support you will be making the best 5 use of public money and ensuring as much money as possible goes into Getting the most out of technology patient care. 6

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There are 22 Primary Creating opportunities for you to see a range of staff in your Care Networks (PCNs) in Bedford supporting 1 community, offering you more coordinated and personal care Bedfordshire, Luton and Borough has a population Milton Keynes. These are 4 PCNs of 184,097 teams of health and care staff working together, Our GPs, nurses, social workers, mental health Here are some examples of the changes you can Bedford Borough workers and other staff need to work together, expect to see in your local PCN: led by GP practices. in teams, in the community to better meet your needs. This means you will be able to see the From 2020 you’ll be able to see a clinical right person, when and where you need to and pharmacist, who will use their specialist Central knowledge of medicines to assess and treat you Bedfordshire your care will be better organised to meet your has 7 PCNs individual needs. as needed. There will be staff who can provide you or your family with mental health and Milton Keynes Many of you have told us that you’d prefer to be wellbeing support when needed. There will also supporting a cared for at home as much as possible, near to be social prescribers, whose job it is to connect population of your family and friends, rather than having to be people, especially the more frail and vulnerable, 258,461 in hospital or residential care. In order to make with non medical support, day centres, charities entral Bedfordshire this happen we need to spend more money on or community groups to improve wellbeing and Milton Keynes your local GP and community health services. In help tackle loneliness or social isolation. has the last year or so, many of our GP practices have 6 PCNs Further support in PCNs will continue and provided evening and weekend appointments Luton supporting from 2021 this will include physiotherapists so that working families can see a GP at a time has a population supporting a to suit them. Over the next four years we’ll be who have completed extra orthopaedic 5 PCNs of 237,690 training to enable them to support you and population of continuing this investment and introducing some over 300,000 Luton new approaches. your family with injuries or illnesses involving muscles, bones or joints. In some instances, Since July, we’ve created 22 teams of you’ll be able to self-refer to see these staff different health and care staff across BLMK and in others, you might be directed by key who are now working more effectively staff. You’ll see new staff, such as Physician together to meet your health and care Associates, who are trained to do some of the You will also see the introduction of some We are planning to introduce an urgent needs. These teams are called Primary Care work of your GP and some of the work of the new ways of working to get you the service for people who need crisis support Networks (or PCNs). They are led by local GPs Practice Nurse, like examining you, interpreting support and help you need quicker. at home, so we can prevent them from being admitted to hospital, unless it’s and include Nurses, Physiotherapists, Mental your test results and diagnosing what’s wrong. About half of our GP practices already offer online necessary. This will mean that by 2022 if you Health Workers, Pharmacists, Social Workers consultations and this will become more widely By March 2022 we’ll introduce the Advanced or your family are clinically judged to need and others. There are lots of advantages to available during 2020. The opportunity to talk to a Paramedic Practitioner, who will be there to urgent care from our community services, we’ll working in this way, one of which is that you GP via a telephone appointment will also continue support ‘same day clinics’ for minor illness and see you at home within two hours. If you then don’t have to repeat your story time and time and expand. We are testing video consultations injury, assessing and treating you as required, as need further services to help you return to daily again and our teams of staff are quicker at in some of our practices, so you can talk to a GP gathering the information they need from you well as carrying out health check reviews and life, we’ll provide this within two days. home visits on behalf of your GP. ‘live’ from home, without having to come to the and others to organise your care. As these surgery. This will become more widely available And for people who live in Care homes, teams have only been in place for a short period during 2020. And for some patients with particular there’ll be extra support to help them manage of time, you might not be aware of these Long Term Conditions we’ll be testing group what is often a wider range of health needs, changes in your own GP practice. Over the sessions in the practice to help manage diabetes, meaning faster and more effective help from a coming years we plan to further develop high blood pressure and similar conditions, as well range of staff according to need. This support these PCNs and the staff who work in them. as ensuring these patients always see a GP and are will be available to all BLMK care homes by 2021. offered longer appointments.

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you up to date with information about how long diagnosed with cancer and to this end we want Improving the way our hospitals work so you get faster treatment in an you’ll have to wait, so that when your GP refers to ensure that everyone in our region receives 2 emergency and don’t wait too long for an operation or other hospital care you, you’ll know straight away how long it’s going the best possible care in the unfortunate event to be before your operation. of a cancer diagnosis. This includes ensuring consistency across primary care so that everyone We understand that waiting for treatment is with an urgent two week cancer referral is seen difficult for everyone. None more so that those At the moment when people can’t see their GP Day Emergency Care services or whether you’ll by a cancer specialist within this timeframe. when they want to, they sometimes go to A&E. need to be seen in A&E. This will ensure you This means that our hospitals slow down and get the treatment you need, in the quickest and planned operations can sometimes get cancelled most appropriate way. We also plan to improve Giving you better information and support to help you stay well and while we deal with more emergencies. We need the availability of emergency ambulance services to reduce the pressure our hospitals are under and across our area, ensuring delays are minimised. 3 manage illness sooner that’s why we’re investing in more opportunities We’ll make sure that when you don’t need to for you to see the right health staff in the go to hospital, you can be treated at home or community. This will help our hospitals work faster where the emergency has occurred. and better and ensure you get the treatment you In future we need to do more to reach out to Modern technology provides us with new ways need more quickly and conveniently. Here are We’ll also ensure you get the latest up to people who we know are likely to be at greater to provide this kind of proactive care such as some of the things we have started and will be date information about where and when risk of becoming ill, or those whose health helping you to monitor your own health and rolling out: you can access Urgent and Emergency Care might deteriorate to the point where they need share information with those supporting you. services. This will help everyone to use urgent hospital care. Making sure that everyone across BLMK and emergency services more effectively, so As a result, we expect you will have gets the same access to the NHS 111 that our hospitals can continue to treat you and We want to help you reduce your risk of greater confidence in managing your own service. We want to make sure that, where your family quickly in an emergency and routine developing avoidable health conditions by health and there will be less variation in appropriate, you can access our Clinical Advisory operations and procedures aren’t cancelled enabling you to make healthy choices where treatment and outcomes for people with Service or CAS for short. This is a telephone unnecessarily. Soon we will extend our Same possible e.g. by stopping smoking, being conditions such as cardiovascular disease, service run by GPs, Clinical Advisors, Nurses, Day Emergency Care service, enabling you or active or staying a healthy weight. However respiratory disease and cancer. Paramedics, and Pharmacists which allows you your family to be treated on the same day, we recognise that your health is influenced by many things such as where you live and work, to talk directly to a healthcare professional from without the need for admission to hospital. We also anticipate that fewer people the comfort of your own home. If necessary, so support will be tailored to your needs and will need to attend or be admitted you will be booked directly into an appointment We want to make sure you don’t wait any help you make the best possible choices. Public to hospital as they will be skilled with your own GP surgery. longer than necessary for an operation. We services don’t have all of the answers so we recognise that waiting for an operation for too will work with communities to help you and at looking after themselves when We’re currently working to extend this service long can have a negative impact on your health your family stay well and healthy e.g. to reduce appropriate. This reduces pressure more widely in care homes, so that staff there and wellbeing. When this happens it impacts social isolation and loneliness. on our system, so that care can be can speak with a clinician at any time, day the rest of our service as more people end up provided for those who need it most. or night. We want to ensure that this service needing extra support while they’re waiting, As well as this, we want to ensure that is available to all care homes across BLMK. like prescriptions for pain relief, time off work anyone at risk of developing health conditions, We believe this will help support care home and sometimes even having to go to A&E for is identified and supported as early as possible. residents better, so they’re don’t have to go to emergency treatment. We have a lot of information available to us. hospital unless necessary. By using this data better, we’ll be able to We’re increasing the amount of planned spot people who might not realise they have We will improve the way you are managed operations we do, year on year, so that we conditions like High Blood Pressure, Diabetes or when you arrive in A&E. You will be greeted can reduce the long waiting lists and speed up Stroke, so that together we can support you to by a healthcare professional who can quickly the time it takes for you to get your operation manage your health. You can help us by taking decide which one of our urgent services is (currently a maximum of 18 weeks from when up any offer of screening or immunisations. best for you, whether this is one of our Urgent your GP first sent you for a specialist opinion). Treatment Centres, Urgent GP Clinics or Same As well as this, we’re improving the way we keep

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Giving you choice and control over the way your care is 4 planned and delivered 5 Making sure the right people are there to support you

You’ve told us that you think you’d benefit Other support includes questionnaires Demand for health and care services is growing, range of levels, so anyone who wants to join from care that is built around your individual that help us understand your level of largely as a result of there being more people in us has the chance to do so. We are offering job needs and that you’d like support to build the knowledge and confidence about your our area and that generally we are living longer. guarantees following successful completion of knowledge, skills and confidence to manage long term condition. This helps us support To properly meet this growing demand we local training programmes. your health conditions and improve the way you in developing your own capability to recognise we need to do things differently in the you live. We want to help support this, so we’ve manage your health and care, giving you way that we recruit, train and retain our people. Addressing our workforce shortages; we developed a range of measures that will give tailored information and support you can act This includes improving the working lives of staff, have challenges across many of our health and you more choice and control over your health on. This is known as a Patient Activation so that people feel more supported at work and social care roles and our initiatives to recruit, train and care needs. Measure or PAM for short. Linked to this we better able to balance the challenges of their and retain staff are targeted at all health and care are using more and more social prescribing, working lives with those they may face at home. staff. We are taking a specific focus on key areas, The first of these is a process to give which is when we refer you to a range of local including addressing nursing shortages, with you support from your clinician to take non-clinical services to help improve your health In order for our staff to continue to offer current vacancy rates averaging at 14%. We will decisions, choose tests and treatment and wellbeing. compassionate, responsive and understanding attract more nurses through nurse cadet schemes options based on evidence and your care and to develop a more joined-up, and creating ambassadors for nursing within personal preferences. We will build on this Personal Health Budgets are an amount personalised approach, we need to value and local schools. We are also increasing the number ‘shared decision making’, initially focusing of money to support your health and invest in our staff through the delivery of a of clinical placements available for students. With on people with Chronic Obstructive Pulmonary wellbeing and are available to adults workforce plan that enables health and care staff GP vacancies at 10-12% we are also supporting Disease but extending this to include people who are receiving NHS funded long term to work as teams around local communities. new GPs with coaching, mentoring and training with mental health and learning disabilities health and personal care outside hospital. opportunities and more varied job roles. and those with long term conditions such as We’ve now made these available for wheelchair We will require not just continued growth in cancer, diabetes and stroke. We will also use this users and will be expanding this to more our workforce, but also a shift in our thinking Supporting and developing our staff; we approach for people with frailty and those at people across our area. These approaches are and the way in which we train and compose our are focusing on making our organisations the teams in health and care settings. We do need the end of their life. collectively called a Comprehensive Model best place to work through offering flexible ‘more’, but we also need ‘different’. of Personalised Care. ways of working, more opportunities for training and development and staff health and Different will mean there will be much stronger wellbeing services. We are also attracting those links between integrated health and care teams who have left health and care jobs to return and within Primary Care Networks. There will be new recruiting, where we can, from overseas. We are roles and existing staff will increasingly develop developing rewarding roles that enable staff to skills that support joined up approaches. We develop more integrated care skills and rotate will release staff time to care as technology and across services. This includes rotational health scientific innovation transforms care pathways. and social care apprenticeships, paramedic Here are some of the key things we’ve already rotations across ambulance and GP services, started to do: specialist children’s nurses working across hospital and community services and cancer Growing our own people; by engaging care teams offering mobile lung checks and better with local schools and colleges to attract working alongside GP and community teams. young people as they consider careers and at We will also support our staff with the skills to recruitment fairs and local initiatives for those work with evolving technologies, which enable seeking a change of career. We want to make teams to share information and work more sure there are opportunities across a broad effectively to support care needs.

14 15 Living longer in good health Living longer in good health Bedfordshire, Luton and Milton Keynes Longer Term Plan Bedfordshire, Luton and Milton Keynes Longer Term Plan

We are developing a range of new roles including: All these new roles, together with a greater focus on training and development, will mean • Physician Associates, who are trained to Getting the most out of technology our people are even better equipped to support 6 support our doctors. As well as carrying out patients, in some instances freeing up other some patient examinations, they are able to professionals like GPs, to concentrate on those interpret test results and diagnose illnesses. with more complex health needs. • Nurse apprenticeships and nurse associate Our lives are all now heavily influenced by We’re already setting up systems so you Improving our culture and leadership by roles are two new ways of getting into advances in technology and innovation and in can get advice from your GP practice via creating a more supportive environment for our nursing, working with registered nurses and health and care we know that there are constantly an online consultation and we’ve recently people. This will include the introduction of a healthcare support workers to care for a wide new ways in which we can support you, your introduced a new app for outpatients at Milton new ‘Leading Beyond Boundaries’ programme range of patients in different settings. Our families and our own people to improve the Keynes University Hospital. This allows you to to strengthen and support healthy, inclusive and numbers of nurse associates in training will services we provide. In the next five years there view and amend your appointments and access compassionate leadership at all levels. As part increase to 91 within 2020 and we are also will be new and exciting changes in IT, but in the other information. We will be looking to expand of our shared learning, we have already started growing support roles within maternity and meantime we want to harness the best of today’s this offer across our other hospitals. In Luton a to create opportunities for our clinicians to within mental health services, such as Peer technology to improve the way we communicate pilot with care homes is testing the adoption meet and discuss key issues. We will evolve this Support Workers. between our hospitals and GP practices, the of a remote monitoring app for the most over time to create clinical networks bringing information we share and the speed with which vulnerable patients to identify and treat health • Advanced care practitioners are existing together local clinicians to shape future working, we can respond to your needs. issues earlier, thereby reducing unnecessary professionals from a range of traditional based on their own experience and industry admissions to the Emergency department. Early Importantly, we want to ensure you are involved backgrounds such as pharmacists, nurses best practice. indications suggest this has reduced attendances in your personalised health care plan, adding paramedics or occupational therapists, who at A&E in this area by 17%. undertake further education so that they have in details of how you prefer to be treated and Looking after our people better, using more skills to support local communities. monitoring your own conditions and alerting your our staff in the right way to make the doctor or community nurse if there’s a problem. All these innovations will help us to most of their skills and expertise will We also want to make sure that the treatment support you and your family, creating we’re providing is consistent, has worked to make ultimately help us give you the best a single digital care record for all you better, and is good value for money. possible treatment in whatever setting health and care organisations, so that you may need our care and support. Some of our other priorities include: you don’t need to tell your story time • Hospital based health care staff being and time again and we can provide able to write in your notes, so your GP or you with more joined up care. other community health professional can see relevant details about your care and treatment.

• In an emergency, all healthcare staff being able to see an extract from your GP record, so they can make faster and more accurate clinical decisions.

• We’re currently testing remote monitoring of high-risk residents in care homes, so we can act quicker when there’s a problem.

16 17 Living longer in good health Living longer in good health Bedfordshire, Luton and Milton Keynes Longer Term Plan Bedfordshire, Luton and Milton Keynes Longer Term Plan

Improving Care for Major Health Conditions How will we pay for this? What happens next?

As well as the big changes we’ve set out • Introducing multi-disciplinary respiratory Under the NHS Long Term Plan published in Some changes will take longer to implement, above, we’re also taking action to improve care hubs to identify and manage complex January 2019, the NHS will receive increased particularly those that address long-standing for major health conditions, such as cancer, respiratory disease closer to home, and funding of £20.5 billion per year by the end of health inequalities across our area. diabetes, stroke and mental health, and for improve outcomes. This will include improved five years. Under this deal, funding for our local This plan is designed to be live and agile, helping people at key stages of their life. These include: quality of diagnostic tests, increased uptake of area is increasing by between 3.2% and 4.4% us to drive continual improvement. We recognise vaccinations (influenza and pneumonia) and per year over the period of the Long Term Plan • Improving uptake for bowel, breast and we won’t get everything right first time – but we increased uptake of Pulmonary Rehabilitation. which is greatly welcomed. cervical screening programmes to reduce will ensure that we test and learn from different the number of people diagnosed with cancer • Developing stroke services so there is This will enable us to invest in the priority areas approaches elsewhere and challenge our at a late stage. This will improve survival rates consistent access to high performing stroke identified in the NHS Long Term plan (local GP and understanding of what we can do here. and provide faster cancer diagnosis, with units and rehabilitation, so people have the community services, mental health and cancer) We have a responsibility to work together to most people receiving a definitive diagnosis best chance of long-term recovery with the as well as target funding towards local needs. respond to the challenges we face so that by that will confirm or rule out cancer, within 28 possibility of living independently. days of referral. The increased funding will enable us to deliver 2024 people’s health and wellbeing in our area • Providing universal access to structured services better and smarter by investing in is better, our health and care services are better, • Establishing three new mental health education, both face-to-face and digital, to technology, prevention, earlier intervention and we get better value for money. support teams to work in schools and help people with Type 2 Diabetes manage and treatment. As we have used your feedback to help guide colleges. They’ll support children and young their condition, according to their individual and develop our plans, we want to continue to people who may be experiencing mental needs and preferences, which means they are involve you as we develop more detailed plans health issues to get the right support, so that likely to have fewer complications, and need to help us achieve what we have set out in this they can stay in education. fewer visits to their GP or hospital. Longer Term Plan. • Expanding mental health services to • Ensuring health, care and therapeutic You can find out more about our plans for the provide earlier intervention and support for services work better together and have future by watching this short animation: Together mothers from pre-conception to 24 months the capacity to meet the needs of children and we can grow a healthier future for everyone. after birth, and further support for their young people with special educational needs. partners, to prevent problems escalating into If you have any feedback please share with the a crisis situation. Healthwatch in the council area you live.

• Taking a proactive approach to identify people with high blood pressure and provide supported self-management to control this. This will mean a better experience, reduced risk of heart failure and stroke, and fewer unnecessary visits to hospital.

18 19 999

111

Integrated Care System Item 5.3 DRAFT

Integrated Quality & Performance Report NHS Luton CCG

M05 August 2019/20 Report Created: 06/11/2019 Version 1.1 Contents Page

Link to Corporate Objectives & Risk 3 Link to Board Assurance Framework 4 Luton CCG - NHS Constitution 5 LDH - NHS Constitution 6 Ambulance 7 LCCG and LDH Summary 8 Quality and Safety - Luton CCG 10 Quality and Safety Summary 11 East London Foundation Trust (ELFT) 14 ELFT Summary 15 Cambridgeshire Community Services (CCS) 16 Outcomes Framework 17 CCS and Outcomes Framework Summary 18 Better Care Fund (BCF) 19 BCF Performance Summary 21 Appendix A – Indicator’s Lead Reference 23 Appendix B - NHS England CCG Improvement and Assessment Indicators 24 Contact 25

2 LINK TO CORPORATE OBJECTIVES AND RISK

WHICH CORPORATE OBJECTIVE DOES THE PAPER RELATE TO?

Working with our partner organisations to drive and deliver the integrated priorities of the Bedfordshire, Luton and Milton Keynes  Sustainability and Transformation Plan. Listening and working with patients and their families, carers, frontline staff, clinicians, social care professionals and system leaders in order to ensure a shared vision for health and wellbeing services that addresses health inequalities across Luton and the wider footprint. Actively commissioning innovative, locally accessible services that meet the health and wellbeing needs of the diverse population of  Luton.

 Prioritising the development of evidence-based approaches in order to support prevention, self-care and early intervention.

Robustness in delivering our long term financial plan to maintain the financial sustainability of the CCG. Commissioning evidence-based, responsive services that reduce variation manage the demand for healthcare and provide the best  value for the local population. Recruiting and retaining the best staff with the passion to deliver the CCG’s ambitions that make a difference to our local population. Ensuring a dynamic and effective approach to communication that engages the people of Luton in order to successfully promote prevention and self-care and the delivery of effective health and wellbeing services. Supporting a diverse and inclusive workforce that promotes individual and team development across the system through innovation and partnership working.

3 LINK TO THE BOARD ASSURANCE FRAMEWORK

WHAT ARE THE KEY RISKS ON THE BOARD ASSURANCE FRAMEWORK?  Insufficient resources and workforce capacity across Luton to deliver the priorities of the Sustainability and Transformation Plan. Insufficient engagement and ownership in the system vision leading to resistance to change which may delay or prevent the progress of  transformation.  Individuals and organisations resist integration, continuing to work to internal strategies rather than the system-wide vision. Communications and engagement strategy is not effective in engaging the public especially hard to reach groups within Luton. The CCG fails to meet its statutory duty to deliver the agreed end of year financial position. The QIPP programme fails to deliver its key objectives and savings leading to an unplanned deficit and failure to deliver the best outcomes for patients.  The CCG is unable to recruit and retain staff and clinical leaders with the right skills and abilities to deliver the CCG's strategy.

4 Luton CCG – NHS Constitution

5 LDH – NHS Constitution

6 Ambulance

7 LCCG and LDH Summary

RTT Performance

• Both LCCG and LDH are non-compliant against the 18 week threshold in August 2019. Monthly monitoring of RTT and the waiting list is in place with the LDH; key mitigating actions identified including waiting list validation; out sourcing elective work to other providers; and retaining agency consultant cover, recruitment remains challenging due to consultant pension issue.

• At the end of August 2019 there was 1 patient waiting in excess of 52 weeks at Royal Brompton & Harefield NHS Foundation Trust, as per the agreed process contact will be made with the Trust to seek assurances of an appointment date and to ensure there is no clinical harm to the patient.

Diagnostics

• LDH remain compliant against the national standard. LCCG is adverse to the standard largely owing to 99 patients waiting more than 6 weeks for an Audiology assessment with Cambridge Community Services.

Cancer

There were 3 cancer pathway breaches for August; 2 for urology and one head/ neck: • Renal cancer First definitive treatment received on day 84 (nephrectomy). A Complex diagnostic pathway was noted. The patient was seen on day 14, followed by CT scan on day 30. Following this report, the patient encountered a further wait of 11 days for chest CT to exclude metastatic disease. • Prostate First definitive treatment took place on day 152 (radiotherapy at MVH). RCA showed delayed diagnostics, pathway slightly complicated by multiple urological red flags requiring diagnostics. Learning from this case has been shared by the consultant to the team. RCA conclusion: No evidence of harm. • Head and neck (larynx squamous cell carcinoma) First definitive treatment occurred on day 99 (radiotherapy at MVH). This delayed pathway was due to complex diagnostics. Initial investigations showed no evidence of malignancy. Subsequent investigations showed a very early stage carcinoma that were not visible on previous CT.

8 LCCG and LDH Summary

NHS Constitution

Mental Health

• ELFT achieved 85.7% access target for Early Intervention in Psychosis in August, against a target of 50%. ELFT achieved a year average of 83.1%. • The August figure for seven day follow up for discharged patients is down to 92.5% against a target of 95%. Note that this covers all discharges, not just patients on CPA (a change to reporting requirements in-year). The annual performance last year was at 89.7%. • The IAPT service has exceeded the 6 week (75%) and 18 week (95%) targets, achieving 99.4% and 100% respectively.

Ambulance

• LDH, EEAST and LCCG are working together to ensure handover delays are minimised. There has been a change to the process, with the new approach commencing at the start of July with the aim to save time on each handover. This will be reviewed imminently.

• A local group attended by EEAST, LCCG & BCCG has been set up and is focussing on ‘See & Treat’, ‘Hear & Treat’ and alternative ambulance conveyance pathways to support admission avoidance work. In addition promotional work with EEAST is also taking place to ensure ambulance staff are aware of the pathways and criteria to access them.

• ‘Hear & Treat’ and ‘See & Treat’ figures for Luton are positive against national indicators with See & Treat achieving between 34% - 38% against a national target of 35.5% and Hear & Treat achieving over 9% against a 7% national target.

• The Tripartite Handover policy between LCCG, LDH and EEAST has been agreed by LCCG and EEAST and is currently with LDH for sign off.

Cancelled Operations

• There were no reported cancelled operations at LDH in June.

9 Quality and Safety – Luton CCG

10 Quality and Safety Summary

Quality and Safety

IPC:

There was a significant spike in C.Diff cases being identified in August. However the increase this year continues to be proportionate to other CCG’s and providers. LCCG continues to perform well regarding this metric regionally and nationally. No recurring themes have been identified from these cases.

Pressure Ulcers:

There has been an increase in the number of Pressure ulcers being identified by the acute Provider but a sharp decline in those identified by the community provider after admission to their services. In the acute provider there have been a number of pressure ulcers relating to medical devices such as Plaster of Paris and Prosthetics. The trust have initiated their own investigations into this with the development of their action plan.

Health Checks:

The number of Health checks offered and declined has continued to fall this month.

Friends and Family Test:

There has been a significant improvement in the percentage of patients who would recommend the care in the delivery suite in Maternity. All other areas continue to perform well against this measurement.

11 Quality and Safety Summary

Quality and Safety

MMR Coverage: Actions to improve Luton’s childhood immunisation uptake include:

• Luton CCG and Luton Borough Council Childhood Immunisation leads are working with Cambridge Community Services 0-19 teams, and flying start, to raise awareness of the importance of providing 2nd dose MMR to under 5s.

• A new working group has been established and at the recent meeting a plan was agreed to achieved improved update.

• Luton CCG continues to work with NHS England and the Child Health Immunisation Service Provider (CHIS) introducing a new approach to scheduling childhood immunisations in Luton. The practice manager forum are integral to success.

• CHIS are contacting parents in writing advising them to make an appointment with the surgery for the immunisation to be given. Some practices have offered up clinical appointments for children to be booked into directly by the CHIS, and a letter is then sent to the parent advising them of the appointment at the surgery to have their immunisations.

• Plan to formulate a robust communication and engagement plan to encourage uptake. The two main target groups for communication are: • Parents and guardians of these children and the need to present for vaccination. (Messages will be designed to debunk some of the myths regarding the MMR vaccine) • Health professionals who will be offering the MMR vaccine to the target group and those responsible for ensuring children are protected from measles.

• The CCG and Public Health, are working towards identifying local barriers and solutions to increase uptake through engagement with GPs, to ensure there is a consistency in approach across Luton. This will be followed up by a thematic analysis of these barriers in order to develop evidence-based solutions that can be tailored to improve uptake in Luton.

12 Quality and Safety Summary

Quality and Safety Stroke:

• In the most recently published Sentinel Stroke National Audit Programme (SSNAP) results for the Luton and Dunstable Hospital NHS Foundation Trust (LDH) covering the period April to June 2019 the provider has retained its overall ‘B’ rating. The 3 individual domains where the provider fell below its overall B score are: (D)Stroke Unit (to unit in 4 hours and 90% stay on the unit) (C)Thrombolysis (D)MDT working

• The provider has an internal stroke action plan group focused on the areas highlighted above.

• The BLMK Stroke Action Group continues to meet bi-monthly and the Stroke Strategy Group monthly. The priority to 31st March 2020 is to agree the BLMK model of care for Stroke, including acute stroke pathways and rehabilitation.

Note: SSNAP covers the following Domains: Patients scanned in 1 hour of clock start; Patients admitted directly to a stroke unit within 4 hours and spend 90% of their hospital stay on a stroke unit; % of patients given Thrombolysis; % of patients receiving specialist assessment (swallow assessments by SaLT); Access to Occupational Therapy Access to Physiotherapy Access to Speech and Language Therapy (SaLT); Access to Multidisciplinary Team Working; Standards by Discharge Processes

13 East London Foundation Trust (ELFT)

14 ELFT Summary

East London Foundation Trust (ELFT)

Mental Health Standards:

The percentage of patients referred to CMHTs starting treatment within 28 days was 97.1% against a target of 95%, with a YTD average of 95.8%. The adult community caseload seen within the last 6 months, not on CPA has been below target for eight months, achieving 82.9% in August. The yearly average last year was 88.9%. The CCG has asked ELFT for a plan to bring this up to target.

15 Cambridgeshire Community Services (CCS)

16 Outcomes Framework

17 CCS and Outcomes Framework Summary

Cambridge Community Services:

• The subjective recording of Adult Admission Avoidance shows limited variation over recent months as does GP liaison activity. Reported Paediatric Admission Avoidance also remains at consistent levels.

• Neonatal BCG vaccinations are compliant with the target and work is still in progress to transfer this activity to the maternity pathway to sustain performance.

Outcomes Framework

Dementia Care: • The national dementia diagnosis rate for people aged 65+ is estimated to be 66.7% and Luton achieved 69.41% in Q1 2019-20. The target has been achieved for three consecutive quarters, but an action plan will remain in place until performance is maintained for a calendar year.

IAPT Access and recovery: • The national data for Q1 2019-20 for LCCG reported 3.20% against a target of 5.50% (19% annual) for IAPT Access, showing an increase over Q4. The service is closely monitored, with a trajectory to achieve the 19% annual access target by end of Q4 2019/20. • The IAPT recovery rate for Q4 was 46.43%, against a target of 50%.

Treating and caring for people in a safe environment and protecting them from avoidable harm

• C difficile infections are within ceiling for Q1 2019-20

• There were no cases of MRSA bacteraemia in Q1.

18 19 BCF Performance Summary Section 75

The first Deed of Variation is awaiting authorisation. Work is on-going on the remaining schedules in preparation for the 2nd Deed of Variation, JSCG approval planned December 19. BCF Audit. Action update: • Action 1 complete - FSG and JSCG ToR’s refreshed and agreed at JSCG 5th July. • Action 2 underway - A narrative has been provided by LBC Finance for the Luton BCF Plan. The narrative will also meet the audit action to evidence the impact on the system against the BCF BAU funding allocated to adult social care. CCG will provide quarterly data to evidence the impact of BCF BAU funding to CCG schemes. Clarity is required as to who is the key CCG contact for this action. BCF Assurance and Performance Reporting Cycle. The BCF 2019-2020 plan template and associated guidance has now been received and is underway. Work continues towards the final draft plan, with Project Managers and Directors input where required . An initial draft has been circulated for comments or track changes and to demonstrate the current position. This is not a final draft, further work is still required. The NHSE submission deadline is 27th September, however due to circumstances affecting the timeline for Luton, an extension approved by the BCF Board. The programme remains RAG rated Green. The DToC data provided by the Luton and Dunstable hospital for the end of July, shows a total of 82 bed delays, against a target of 171. Late and inaccurate reporting issues continue with the mental health provider, ELFT. Discussions remain ongoing between the Multi-Disciplinary Discharge Team and ELFT with the objective to ensure the process is embedded appropriately. Mental Health DToc reporting issues are not isolated to Luton. The issue has been raised for discussion on the national & regional DToC forums; mental health provider reporting is widely considered difficult. However, as expected, areas receiving consistently good quality mental health DToC reports have cited a jointly agreed process and commitment to the whole pathway. No social care delays reported.

Luton & Dunstable Hospital have advised the bed delays for July are: • 6 days - Await CCG funding, Code B • 1 day - Health funded nursing placement, Code C • 3 days - Health funding package of care (CCS) • 43 days - ABI CCG • 9 days - Delirium Bed • 7 days - Residential placement (MHT SS), Code D(1) • 13 days - Self Funders, Code G Delays for people with Acquired Brain Injury remains a local problem for the Luton and South Beds system. There are concerns that addressing ABI delays is complex as it requires scale working across BLMK. The Multi-Agency Discharge team will review the patient data and report directly to the CCG.

20 BCF Performance Summary

L&DH ELFT Acute None acute

NHS Social Care Both Delayed MH Delayed Monthly Delayed days Delayed Days per Delayed Days Delayed Days Days Days Total per day 100,000 population

BCF Target Total BCF Target by Delayed Days per number of days RAG (provisional) 100,000 population (will also include Set Aug 2018 other providers)

Jan-19 98.0 4.0 0.0 0.0 102.0 3.4 2.1 3.9 171.0 GREEN

Feb-19 62.0 0.0 0.0 0.0 62.0 2.1 1.3 3.9 171.0 GREEN

Mar-19 118.0 0.0 0.0 5.0 123.0 4.1 2.5 3.9 171.0 GREEN

Apr-19 149.0 0.0 9.0 0.0 158.0 5.3 3.2 3.9 171.0 GREEN

May-19 170.0 0.0 1.0 0.0 171.0 5.7 3.5 3.9 171.0 RED

Jun-19 109.0 0.0 5.0 0.0 114.0 3.8 2.3 3.9 171.0 GREEN

Jul-19 75.0 0.0 0.0 7.0 82.0 2.7 1.7 3.9 171.0 GREEN

Aug-19 0.0 0.0 0.0 0.0 0.0 0.0 0.0 3.9 171.0 GREEN

21 BCF Performance Summary

Achievement against BCF DToC ambitions

Full Year DToC

Period NHS Social Both MH Delayed Average Average BCF Target BCF Target by RAG (provisional) Delayed Care Delayed Delayed days Delayed Delayed Total number of Days Delayed Days Days Total Days per Days per Delayed days Days Day 100,000 Days per (will also population, 100,000 include other population providers) Set Aug 2018

Q1 262 0 0 0 262 2.9 1.8 3.9 513 GREEN Q2 498 0 1 0 500 5.5 3.4 3.9 513 GREEN Q3 319 0 0 0 319 3.5 2.2 3.9 513 GREEN Q4 278 4 0 5 287 3.0 2.0 3.9 513 GREEN Full Year 3.9 2052 1357 4 1 5 1381 3.7 2.3 GREEN

Luton Year End 2018-2019 Delayed Bed Days Under Target 671

22 Appendix A – Indicator’s Lead Reference

D o m a i n Indicator C a t e g or y Da s hboa r d - Data Source L e a d A&E W a i t s LDH SQPR Car o lin e C a p e l l A m b u l a n c e H a n d o v e r (Arrival to Han d o ver ) LDH SQPR Car o lin e C a p e l l

C a n c e l l e d Op er atio n s N H S E n g l a n d statistics Jen n ie R u s s e l l

C a n c e r W a i t - 2 w e e k NHS D igital C a r o l e Gillesp ie C a n c e r W a i t - 31 d a y NHS D igital C a r o l e Gillesp ie NHS Constitution C a n c e r W a i t - 62 d a y NHS D igital C a r o l e Gillesp ie C a t e g o r y A A m b u l a n c e C a l l s EEAST Car o lin e C a p e l l D i a g n o s t i c test N H S E n g l a n d statistics Ad r ian Shentall M e n t a l H e a l t h NHS E n g l a n d statistics / N E L C S U Performance Portal Lo r ain e R o s s a t i M i x e d Sex NHS E n g l a n d statistics / N E L C S U Performance Portal Jen n ie R u s s e l l R T T 18 w e e k s N H S E n g l a n d statistics Ad r ian Shentall A&E A s s e s s m e n t LDH SQPR Jen n ie R u s s e l l Breastfeeding LHD SQPR a n d CCS SQPR Jen n ie R u s s e l l C o m m u n i t y Services Q u a l i t y Stan d ar d s Cambridgeshire C o m m u n i t y Services A m a n d a Flo wer D e l a y e d transfers of c a r e N H S E n g l a n d statistics Lo r ain e R o s s a t i

Friends a n d F a m i l y T e s t NHS E n g l a n d statistics / N E L C S U Performance Portal Jen n ie R u s s e l l

H e a l t h C h e c k s Lu to n B o r o u g h Co u n cil Pau l Lindars Healthcare A s s o c i a t e d infections NHS E n g l a n d statistics / N E L C S U Performance Portal Jen n ie R u s s e l l Quality & Safety M e n t a l H e a l t h Stan d ar d s ELFT SQPR Lo r ain e R o s s a t i MMR C o v e r a g e N H S E n g l a n d statistics Pau l Lindars N u m b e r of Pr essu r e Ulcer s L D H , CCS a n d E L F T S Q P R s Jen n ie R u s s e l l Safer Surgery C h e c k l i s t LDH SQPR Jen n ie R u s s e l l Serious Incidents a n d N e v e r E ven ts L C C G Q u a l i t y t e a m Jen n ie R u s s e l l Stroke L D H S Q P R / LDH Stroke reporting A m a n d a Flo wer VTE LDH SQPR Jen n ie R u s s e l l D e m e n t i a C a r e N E L C S U Performance Portal Lo r ain e R o s s a t i Improving A c c e s s to Psychological N E L C S U Performance Portal Lo r ain e R o s s a t i O u t c o m e s F r a m e w o r k T r eatin g a n d car in g for p e o p l e in a s a f e environment a n d protecting t h e m f r o m Public H e a l t h E n g l a n d Jen n ie R u s s e l l Admissions to residential a n d n u r sin g c a r e Lu to n B o r o u g h Co u n cil K a t e Su th er lan d D e l a y e d tr an sfer of c a r e N H S E n g l a n d statistics Lo r ain e R o s s a t i N o n E lective a d m i s s i o n s NHS E n g l a n d statistics / N E L C S U Performance Portal Car o lin e C a p e l l Better Care F u n d Patien t / Service U s e r f e e d b a c k H S C I C Indicator Portal Pau l Lindars Reablement / rehabilitation ser vices H S C I C Indicator Portal A m a n d a Flo wer End of Life Public H e a l t h E n g l a n d w e b site C a r o l e Gillesp ie 23 Appendix B – NHS England CCG Improvement and Assessment Indicators

24 Board

Finance Report November 2019

Chris Ford - Chief Financial Officer

January 2020 Executive Summary The position in the month is a £73k deficit, which is £321k adverse to plan. As a result the ytd overspend has increased to £2.7m. The surplus target of £3m is still forecast to deliver but the level of risk to achieving this remains high so the CCG remains in financial turnaround. The financial recovery plan continues to be monitored weekly through FRG. The key headlines for the month are as follows: 1. Acute L&D - The L&D contract has overspent by £220k in the month which has increased the ytd overspend to £3.1m. Despite the overspend in month the run rate remains consistent with the CCG’s forecast. The contract position is overspent by £2.6m at month 7 which has been extrapolated to month 8 based on the CCG’s budget profile. 2. Acute QIPP outside of contract – this QIPP scheme was phased to start last month but the delivery of Gastroenterology is not expected until Q4. This has resulted in an overspend of £328k this month. 3. Mental Health – is £341k overspent in month due to overseas visitors costs which have exceed the allocation received and an increase in collaborative commissioning costs with Luton Borough Council (LBC). 4. Community - The in month underspend of £118k is due to lower contracted costs with Virgin Intermediate Care and non contracted activity. This has been offset by a continued overspend on MSK and an increase on Out of Borough placements. 5. Primary Care – the in month position is £350k favourable due to an underspend on extended access and the Gynaecology pathway re-design QIPP investment not required to the anticipated level. 6. Medicines Optimisation – is £310k overspent in month due to September activity being £200k higher than plan, this includes £45k of Cat M impact which is now reflected in the forecast for future months. 7. Other– is underspent by £695k in the month due to the release of non recurrent one-off benefits following a review by the Finance team. This is reflected in the forecast position which has also improved by a further £1.3m to reflect the level of savings required to deliver the financial recovery plan. 8. Risk – the level of risk to delivery of the control total remains high

Performance Financial Targets Description Current Month Previous Month Movement To deliver financial plan Forecast outturn surplus in line with agreed plan £3m £3m n Risk to Delivery of Surplus Unmitigated risk to financial position £2.5m £2.5m n Performance against running cost limit To keep forecast outturn expenditure within allocation of £21.92 per head £21.82 £21.49 $ Capital To keep expenditure within allocation n/a n/a n Cash To maintain cash balances within 1.25% of drawdown per month 0.13% 0.24% # Better Payment Practice Code To pay 95% creditors within 30 days of receipt of invoices or goods per month 99.00% 99.00% n QIPP Delivery Year to date delivery against net savings target of £12.5m in year 91.69% 87.06% #

Note: Better Payment Practice Code statistics based on year to date achievement. 2 Income & Expenditure

In Month YTD Forecast Commissioning Segment Budget Actual Variance Variance Budget Actual Variance Variance Budget Actual Variance Variance £000 £000 £000 % £000 £000 £000 % £000 £000 £000 % Allocation Programme (25,578) (25,578) 0 0.0% (198,629) (198,629) 0 0.0% (300,324) (300,324) 0 0.0% Allocations Delegated Co-Comm (2,583) (2,583) 0 0.0% (20,667) (20,667) 0 0.0% (31,157) (31,157) 0 0.0% Allocation Running Costs (402) (402) 0 0.0% (3,217) (3,217) 0 0.0% (4,826) (4,826) 0 0.0% Allocation Deficit B/F 979 979 0 0.0% 7,829 7,829 0 0.0% 11,744 11,744 0 0.0% Total Confirmed Allocation (27,584) (27,584) 0 0.0% (214,684) (214,684) 0 0.0% (324,563) (324,563) 0 0.0%

Acute 14,624 15,475 (851) -5.8% 114,515 119,557 (5,042) -4.4% 172,354 180,286 (7,932) -4.6% Mental Health 3,656 3,997 (341) -9.3% 27,807 28,132 (325) -1.2% 41,856 42,157 (301) -0.7% Community Health 2,714 2,596 118 4.3% 19,196 19,237 (41) -0.2% 28,662 28,872 (210) -0.7% Continuing Care 657 639 18 2.7% 5,321 4,535 786 14.8% 7,981 6,690 1,291 16.2% Primary Care 405 55 350 86.4% 3,301 2,926 375 11.4% 4,919 4,575 344 7.0% Primary Care Co-Commissioning 2,604 2,578 26 1.0% 20,585 20,356 229 1.1% 31,157 30,695 462 1.5% Medicines Optimisation 2,342 2,652 (310) -13.2% 18,595 18,737 (142) -0.8% 27,792 28,176 (384) -1.4% Other 520 (175) 695 133.7% 3,430 2,007 1,423 41.5% 5,425 397 5,028 92.7% Better Care Fund 401 379 22 5.5% 4,629 4,437 192 4.1% 6,944 6,656 288 4.1% Total Programme Budgets 27,923 28,196 (273) -1.0% 217,379 219,924 (2,545) -1.2% 327,090 328,503 (1,413) -0.4%

Running Costs 392 440 (48) -12.2% 3,135 3,249 (114) -3.6% 4,708 4,804 (96) -2.0% Total Admin Budgets 392 440 (48) -12.2% 3,135 3,249 (114) -3.6% 4,708 4,804 (96) -2.0%

Total Programme & Admin Budgets 28,315 28,636 (321) -1.1% 220,514 223,173 (2,659) -1.2% 331,798 333,307 (1,509) -0.5%

Contingency Fund 0 0 0 0.0% 0 0 0 0.0% 1,509 0 1,509 100.0% Total Application of Reserves 0 0 0 0.0% 0 0 0 0.0% 1,509 0 1,509 100.0%

Total Expenditure 28,315 28,636 (321) -1.1% 220,514 223,173 (2,659) -1.2% 333,307 333,307 0 0.0%

Total - In-year 248 (73) (321) -129.4% 1,999 (660) (2,659) -133.0% 3,000 3,000 0 0.0%

Total - Cumulative (731) (1,052) (321) -43.9% (5,830) (8,489) (2,659) -45.6% (8,744) (8,744) 0 0.0%

3 Income & Expenditure Headlines – by Exception

Acute • The L&D has over performed in month by £220k, which has increased the ytd position to £3.1m above plan. The in month position is based on the month 7 SLAM received from the trust (which is £2.6m above plan) and has been extrapolated to month 8 using the CCG’s point of delivery monthly forecast profiling. The remaining overspend of £574k is due to prior year. • Non-L&D providers including the Ambulance trust have a ytd overspend of £421k with an in month adverse movement of £174k. The ytd overspend is despite a £167k benefit from prior year. There have been adverse movements in Royal Free, East & North Herts and Royal Brompton and in month underspends at Spire, GOSH and Bedford. The forecast shows an overspend of £461k. • There has been a further adverse movement of £463k in month for QIPP outside of contract which is now over plan by £1.4m ytd. The forecast has been revised down to take account of the Right Care QIPP scheme of £1.6m which was agreed at FRG on 14th November would not be delivered.

Mental Health • In month adverse variance of £341k is mainly due to overspend on overseas visitors costs as the allocation received is not sufficient to cover the expected costs. There has also been increase in Learning Disabilities (LD) and collaborative commissioning ytd costs as per the latest information from LBC. The forecast is £301k above plan because of an increase in the number of complex patients offset by release of investment accrual against the ELFT contract due to business cases not being received. The CCG will still meet the investment standard.

Community Health • In month favourable variance of £118k is because of a release of intermediate care beds accrual of £160k as the activity has been under plan to date, partially offset by increase in Out of Borough cost and continued overspend on Keech and MSK. The ytd is £41k adverse because the contract uplift with Keech was agreed after the budgets were set, an increase in Out of Borough Placements as per the Section 75 information from LBC and over performance on the MSK contract due to increases in the number of GP referrals. The forecast is £210k above plan for the same reasons, offset by an underspend on intermediate care of £410k.

4 Income & Expenditure Headlines – by Exception

Continuing Care • The in month position is £18k favourable due to lower activity on Adults and over performance on the Adults Case Management QIPP. The ytd is £786k favourable because of the transfer of one patient’s cost to MH complex patients, in addition to a receipt of prior year personal health budget (PHB) credit, over performance on Adults Case Management QIPP and staff vacancies earlier in the year. The forecast is £1.3m below plan and has assumed that the ytd underspends will continue.

Primary Care • The in month £349k underspend is mainly due to the £290k underspend on Extended Access and the release of the Gynaecology Enhanced Services QIPP investment. The forecast of £344k underspend is due to the same reasons in addition to Out of Hours offset by the GP IT full year costs of £91k not budgeted for, as a separate allocation was received in 2018/19 that was built into CCG baseline for 2019/20.

Primary Care Co-Commissioning • The in month £28k underspend is mainly due to the closure of Sundon Park and underspends on Prescribing, Enhanced Services and Locums. The ytd is £231k favourable due to the same reasons, in addition to no spend against the budget for indemnity costs, which are now funded centrally. The forecast of £463k underspend assumes no spend against this budget for the remainder of the year.

Medicines Optimisation • The in month overspend of £311k is mainly due to September activity being £200k above plan, of which £45k relates to the CAT M cost pressure. The ytd overspend of £142k includes £181k prescribing cost pressure due to CAT M offset by underspends on the Methotrexate Homecare project, QIPP delivery and staff vacancies within the team. The forecast of £383k overspend includes the full year £362k CAT M cost pressure offset by the expected underspend on the Methotrexate Homecare project and over delivery on QIPP. The shortage of drugs (NCSO) is to plan ytd and forecast to budget for the remainder of the year, which was set at 2018/19 outturn. Although there is an expectation that the NCSO costs will be higher this year, this has not yet materialised.

5 Income & Expenditure Headlines – by Exception

Other • The in month position is underspent by £695k due to the release of non recurrent one-off benefits. The forecast variance of £5m underspend reflects the level of savings required to deliver the recovery plan. This has increased from £2.2m in month 7, to £3.5m in month 8, due to the release of the Right Care QIPP scheme of £1.6m.

Running Costs • In month adverse variance is due to an increased share of Executive Team overhead charges. This has also impacted on the adverse ytd performance along with property costs for The Lodge and Arndale House relating to 2018/19 plus the use of interims to cover key roles

6 QIPP Programme • The current forecast outturn position is £11.4m, which is £1.1m (9%) less than plan.

• Actual realised ytd is £6.9m, which is £627k (8%) less than plan.

• There was a £388k negative in-month movement from last month, largely due to the Right Care scheme of £1.6m being removed as agreed at FRG on 14th November. This has been offset by £1.2m of new opportunities identified.

• The amount of risk in the programme is £726k, which is £1m less than previous month. This is largely due to a proportion of the risk in the scheme Enhanced Models of Care / At Home First and Right Care Initiatives being acknowledged in the forecast.

• FRG is managing those schemes at greatest risk, which is now Enhanced Models of Care / At Home First. The focus is on supporting and recovering the Elective, Planned and Primary Care programme.

• Details are provided in Appendix M.

7 QIPP Programme Unplanned & Emergency care

• Urgent and Emergency Care is reporting 98% delivery ytd and forecast at 99% full year. Although the programme is 98% financially on- track, there is movement within the schemes that make up the programme. The schemes Integrated Urgent Care ED & 999 Validation, Ambulance Conveyances and NHS 111 - Children's Rapid Response Service (0-4yr) are under-delivering, while Direct Bookings, UTC, Self Care and GP Heralded are over-delivering.

• Full utilisation of the Children’s Rapid Response clinic remains a challenge. However, actions are being taken to improve uptake – e.g. Practice visits completed for practices with high numbers of children attending ED. Changes to Direct bookings and DOS set up has seen a slight increase in appointments being filled and discussions with Paediatrics Assessment Unit and ED to look at 0-6 month pathway.

• Ambulance Conveyances is also currently under-delivering against plan. There is under utilisation of Hear & Treat / See & Treat, however the Directory of Service Lead has worked with the community provider to ensure all entries on the DOS are accurate for community pathways. Initial analysis of the most conveyed patients to ED is complete and now ensuring any alternative pathways are replicated on the DOS and promoted with EEAST staff. Further analysis is required to look at potential gaps in our community provision.

Elective, Planned & Primary Care

• Elective, Planned & Primary Care is 51% from plan ytd and 52% from plan full year. This programme is the furthest from plan and contains the greatest amount of risk. Recovery and support is being prioritised into this programme, as it is integral to achieving the QIPP target.

• The Advice & Guidance (A&G) scheme is yet to show savings due to slow mobilisation of specialties going live, however progress is still being made with certain specialties and some savings are expected from Q4.

• The Enhanced Models of Care/At Home First scheme reported in month savings of £97k ytd. A further proportion of the risk has been realised this month and acknowledged in the forecast at £873k full year.

• PoLCE and Rehabilitation Pathways both continue to over perform – combined £444k ytd added in month.

• Right Care Gastroenterology are all reporting delivery to plan as savings were expected from Q3. In addition, three schemes are due to deliver savings from January 2020, which are Neurology, High Intensity Users and BLMK Respiratory Transformation. Any early warnings to slippage will be brought to the attention of FRG. 8 QIPP Programme

• Right Care QIPP scheme savings of £1.6m have been removed from the programme in month, this leaves just the Gastroenterology scheme of £73k which has slipped in month from Q3 to Q4.

• Cardiology Services, ENT Community Service and Gynaecology Pathway Re-design schemes have released investments back into the programme. In addition, new schemes are being recognised into this POD – these are Admissions Avoidance at £150k ytd, Intermediate Care Beds at £388k (added in last month but savings have been stretched again in month) ytd and MSK at £20k ytd.

CHC

• CHC is £764k above plan ytd and £1.1m above plan full year. Whilst DST beds and Children’s CHC remain small financial risks, this is being offset by over achievement in CHC Case Management.

• CHC Personal Health Budget and CHC Budget Management are added as new lines to report the significant underspend of £276k ytd and £315k respectively.

Mental Health & LD

• Mental Health & LD is 80% below plan ytd and forecasting 4% above plan full year. Learning Disability scheme is reporting a zero delivery, however, this is offset by Mental Health Complex Case Management scheme which is added this month at £28k ytd and forecasting £253k by the end of the year, this will have a significant full year effect in 2020/21.

Medicines Optimisation

• Medicines Optimisation is 49% above plan ytd and forecasting 45% above plan full year. A majority of the 12 schemes are forecast savings greater than plan, most notably Biosimilars (FYE), Self Care (OTC) and COPD Inhaler Optimisation. Methotrexate Homecare is an addition to plan which is delivering an extra £260k full year. Also added this month is PCN Pharm/Tech forecasting savings at £117k this year.

Children, Young People & Maternity

• Neonatal QIPP is reporting zero delivery to plan full year. This is largely due to no confidence in delivery and no progress in recovering the shortfall.

9 QIPP Programme Risk Profile • Of the £12.5m QIPP target, £8m (63%) has already been delivered through schemes that have over or partially delivered against ytd targets in addition to schemes that have already fully realised the annual plan. • There is currently £1.1m non-delivery gap which means the forecast is 9% under target. • £85k of schemes have not yet started. These schemes are at the implementation stage, with savings expected to be realised from January. • £3.5m (28%) is forecast to deliver for schemes that are already under way for which the savings are due to crystallise from December onwards. • The pie chart and table below shows this risk profile breakdown:

10 QIPP Programme Risk Profile • The below chart shows the risk profile by delivery area. The RAG ratings are discussed as part of the monthly PMO meetings where KPI information is reviewed alongside progress reports with key risks and milestones highlighted. The position is then agreed with Project Leads and signed off by Senior Responsible Officers, Finance and PMO.

11 QIPP Programme

Next Steps and forward planning:

The PMO is working with Finance to continue strengthening the QIPP programme by:

• Reducing Risk: Ensure the QIPP programme does not slip further. PMO has drafted a milestone tracker that will help spot early signs where savings may not be realised and to take necessary actions in order to push the run-rate.

• Stretch: Continue working with Commissioning teams to see where existing QIPP schemes can be stretched. Progress has been made in stretching existing CHC schemes as these are areas of spend that are arguably easier to influence given the limited time remaining in 2019/20. Acute spend will be more challenging to influence given the timeframes.

• Identify more Opportunities: A significant amount of work has been completed with Commissioning and Finance teams in the month to identify a number of new opportunities within Elective, Planned and Primary Care, Continuing Healthcare, Mental Health & Learning Disabilities and Medicines Optimisation PODs. These collectively have contributed £1.2m to the programme.

12 Statement of Financial Position

31st The key movements are explained March 31st March November - November - November- 2020 below: 2019 Plan Actual Variance Forecast £000 £000 £000 £000 £000 • Receivables continue to be NON CURRENT ASSETS lower than plan in November Property, Plant and Equipment 322 292 290 2 274 with 93% of debt under 120 322 292 290 2 274 CURRENT ASSETS days old. Trade receivables 2,032 2,000 1,394 606 2,000 • Prepayments and accrued Prepayments & Accrued income 1,455 1,500 2,371 (871) 1,500 income is higher than plan due Cash and Cash equivalents 52 20 31 (11) 20 to an increase in prepayments TOTAL CURRENT ASSETS 3,539 3,520 3,796 (276) 3,520 for Prescribing Rebates £390k, CURRENT LIABILITIES GP IT £220k and Keech Hospice Trade and other payables (21,253) (21,500) (26,605) 5,105 (21,500) £287k. Staff costs payable- PAYE/NIC and pensions (531) (210) (191) (19) (210) • Trade payables are higher than TOTAL CURRENT LIABILITIES (21,784) (21,710) (26,796) 5,086 (21,710) plan mainly due to an increase

NET CURRENT ASSETS/(LIABILITIES) (18,245) (18,190) (23,000) 4,810 (18,190) in accruals and payables with Luton Borough Council - £5.3m. TOTAL ASSETS LESS CURRENT LIABILITIES (17,922) (17,898) (22,710) 4,812 (17,916) This relates to - BCF £2.8m, Mental Health £1m, Learning TOTAL ASSETS EMPLOYED (17,922) (17,898) (22,710) 4,812 (17,916) Difficulties of £0.9m, Children’s TAXPAYERS EQUITY Services £0.3m and other General Fund - Brought forward (17,922) (17,898) (22,710) 4,812 (17,916) £0.3m. TOTAL TAXPAYERS' EQUITY (17,922) (17,898) (22,710) 4,812 (17,916)

13 Better Payment Practice Code

Compliance with Department of Health target of paying 95% of valid invoices within 30 days of receipt

100%

98%

96% NHS Number

94% NHS Value Non NHS Number 92% Non NHS Value

90% Target

88%

86% April May June July Aug Sept Oct Nov Dec Jan Feb Mar

The target for the number of NHS invoices paid in November dropped by 1% to 97%, the other targets remained the same as September. All BPPC targets have been met to date in 2019/20.

14 Better Payment Practice Code

Table showing the YTD performance across all 6 BPPC categories

Previous year YTD 2019/20 2018/19 Month 8

Total Percentage of monthly bills paid within target based on no. 96% 98% Percentage of monthly bills paid within target based on value 99% 99%

NHS supplies Percentage of monthly bills paid within target based on no. 96% 97% Percentage of monthly bills paid within target based on value 99% 100%

Non-NHS supplies Percentage of monthly bills paid within target based on no. 96% 98% Percentage of monthly bills paid within target based on value 98% 99%

15 Rolling 12 Month Cash Flow Forecast

Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 2019 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 Receipts Balance b/fwd 58 31 239 211 276 36 48 183 23 73 218 218 BACS/NHS 467 700 800 600 500 500 650 400 450 600 400 430 CHAPS CCG-Drawdown 23,800 25,600 26,300 27,100 25,800 24,500 29,350 26,500 27,250 30,400 26,600 26,700 CCG-Drawdown additional 500 Other- PPA funding from NHSE Cash Report 11 11 11 11 11 11 11 11 11 11 11 VAT 38 40 42 40 30 60 35 55 50 40 55 45 Retro CHC payments from NHSE

Total Receipts 24,363 26,882 27,392 27,962 26,617 25,107 30,094 27,149 27,784 31,124 27,284 27,404 Payments Creditors NHS (19,336) (19,037) (20,800) (19,500) (20,000) (20,000) (21,500) (22,000) (22,500) (22,000) (22,000) (22,000) Creditors CHAPS/BACS (4,422) (7,031) (5,806) (7,606) (6,006) (4,456) (7,806) (4,526) (4,606) (8,306) (4,606) (4,606) Salary CHAPS (248) (240) (240) (245) (240) (253) (255) (250) (255) (250) (255) (255) Pensions (74) (70) (70) (70) (70) (75) (75) (75) (75) (75) (75) (75) Tax & NI (117) (120) (120) (120) (120) (125) (125) (125) (125) (125) (125) (125) Standing Orders /Direct Debits (135) (145) (145) (145) (145) (150) (150) (150) (150) (150) (150) (150) Other-PPA expenditure by NHSE not cash-backed Capital Payments

Total -Expenditure (24,332) (26,643) (27,181) (27,686) (26,581) (25,059) (29,911) (27,126) (27,711) (30,906) (27,211) (27,211) Balance c/fwd-per Ledger 31 239 211 276 36 48 183 23 73 218 218 193

Treasury Performance (1.25% of the monthly drawdown) Percentage 0.13% 0.93% 0.80% 1.02% 0.14% 0.20% 0.62% 0.09% 0.27% 0.72% 0.82% 0.72%

November figures are actuals and December to October figures are forecast. The month end cash balance of £31k is lower than the treasury performance target of £298k, 1.25% of the monthly drawdown.

16

Agenda Item 13

PAPER FOR THE LUTON CLINICAL COMMMISSIONING GROUP BOARD MEETING IN PUBLIC TO BE HELD ON TUESDAY 21st January 2020 Art Studio, Youthscape, Bute Mills, 74 Bute Street, Luton, LU1 2EY

TITLE Board Assurance Framework

Michael Wuestefeld-Gray PRESENTED BY Programme Lead for Governance, Bedfordshire, Luton and Milton Keynes (Plus contact details for CCGs pre- Board enquiries) [email protected] 07 887 296 151

LEAD CLINICIAN/MANAGER

WHAT IS THE OBJECTIVE OF To provide the Board with the updated Board Assurance Framework THE PAPER? identifying the key risks and mitigations for the CCG. To be assured that the Controls offer assurance that the risks are being WHAT IS THE BOARD BEING appropriately managed and that the actions to further reduce the risk are ASKED TO DO? appropriate. The Board to confirm that the BAF incorporates the key risks to the delivery of the Corporate objectives. WHICH OTHER COMMITTEES None HAVE REVIEWED THIS PAPER? INTEGRATED IMPACT ASSESSMENT (IIA) HAS AN IIA BEEN CARRIED N/A OUT? WHAT IS THE IMPACT? POSITIVE/NEGATIVE/NEUTRAL* IF THE IMPACT IS NEGATIVE, N/A HOW WILL IT BE MANAGED? EXECUTIVE SUMMARY

The Board Assurance Framework has been reviewed by the Senior Leadership team and assurances provided where available. The Framework continues to be a dynamic document and is regularly updated between Board Meetings and associated actions are implemented.

The sub-committees of the Board review elements of the Corporate Risk Register at their meetings reviewing any medium to high risks. This provides additional assurance that the CCG’s risks are managed effectively.

LINK TO CORPORATE OBJECTIVES AND RISK WHICH CORPORATE OBJECTIVE DOES THE PAPER RELATE TO? Working with our partner organisations to drive and deliver the integrated priorities of the Bedfordshire, X Luton and Milton Keynes Sustainability and Transformation Plan. Listening and working with patients and their families, carers, frontline staff, clinicians, social care X professionals and system leaders in order to ensure a shared vision for health and wellbeing services that addresses health inequalities across Luton and the wider footprint. Actively commissioning innovative, locally accessible services that meet the health and wellbeing needs of X the diverse population of Luton.

Prioritising the development of evidence-based approaches in order to support prevention, self-care and X early intervention.

X Robustness in delivering our long term financial plan to maintain the financial sustainability of the CCG.

Commissioning evidence-based, responsive services that reduce variation manage the demand for X healthcare and provide the best value for the local population.

Recruiting and retaining the best staff with the passion to deliver the CCG’s ambitions that make a X difference to our local population.

Ensuring a dynamic and effective approach to communication that engages the people of Luton in order to X successfully promote prevention and self-care and the delivery of effective health and wellbeing services.

Supporting a diverse and inclusive workforce that promotes individual and team development across the X system through innovation and partnership working.

LINK TO THE BOARD ASSURANCE FRAMEWORK WHAT ARE THE KEY RISKS ON THE BOARD ASSURANCE FRAMEWORK? Insufficient workforce capacity across Luton to deliver the priorities of the both the Integrated Care X System and the Integration with Luton Borough Council Insufficient engagement and ownership in the system vision leading to resistance to change which may X delay or prevent the progress of transformation. Individuals and organisations resist integration, continuing to work to internal strategies rather than the X system-wide vision. The CCG may not be effective in engaging and involving the public, clinicians and organisations in the X transformation of the NHS in Luton. The CCG may fail to meet its statutory duty to deliver the agreed end of year financial position and the X system control total. The QIPP programme may fail to deliver its key objectives and savings leading to an unplanned deficit and X failure to deliver the best outcomes for patients. The CCG may be unable to recruit and retain staff and clinical leaders with the right skills and abilities to X deliver the system-wide strategy.

2 Standard Risk Register

Report Date 15 Jan 2020

Risk Status Open

Risk Area Board Assurance Framework

Page 1 of 11 Standard Risk Register

Risk Ref Risk Title Weaknesses and Consequences Inherent Risk Control Residual Action Required Risk Risk Priority Priority

Page 2 of 11 Standard Risk Register

Risk Ref Risk Title Weaknesses and Consequences Inherent Risk Control Residual Action Required Risk Risk Priority Priority BAF 1 There is a risk that Weaknesses I = 5 L = 4 Bedfordshire, Luton and Milton Keynes I = 5 L = 2 Increase joint working across the three CCGs there will be Recruitment of GPs into Luton 20 Commissioning Collaborative established with 10 within the STP Footprint in order to maximise insufficient workforce Recruitment of Practice Nurses Executive Team working across the three CCGs. capability and capacity. capacity across the Small team within the CCG Collaborative working though the STP Priority 2 Person Responsible: Patricia Davies Luton System to Retention of staff Transformation Boards to improve capacity across deliver the priorities of To be implemented by: 31 Dec 2019 Consequence the system. the both the Shortage of GPs to deliver the changes Recruitment Process underway for the Luton CCG and Luton Borough Council co- Integrated Care Retention of staff who feel under appointment of Accountable Officer. located and integrated working to avoid System and the pressure duplication. Person Responsible: Nicky Poulain Integration with Luton Unable to deliver at pace Borough Council NEL CSU appointed for the functions of Contract To be implemented by: 01 Mar 2018 Management, Performance and Business BLMK and NHSE looking at options for the Intelligence appointment of Accountable Officers across the New Medical Director working across three CCGs STP. Paper for discussion at the Committees in and Executive Lead for Primary Care Workforce, Common on 21/2/18 strengthening links with Health Education England Person Responsible: Nicky Poulain (Local Action Workforce Board (LWAB for BLMK). To be implemented by: 28 Feb 2018 OD plan, staff meetings, PDP's for all staff in place. Training, development, appraisal process in Recruitment to Board Clinical Director Vacancies. place along with talent mapping matched to the Person Responsible: Angela Duce objectives of the organisation. To be implemented by: 30 Sep 2018 Permanent appointments to the Board, Executive Extend current terms of office for Governing Body and within teams in the CCG to ensure the members to 1st October following ballot from required longer term capacity and capability to Member Practices to ensure stability during the deliver the CCG business professionally and integration programme. consistently. Person Responsible: Angela Duce To be implemented by: 01 Oct 2018 Appointment of Joint Executive Team across BLMK STP Person Responsible: Patricia Davies To be implemented by: 31 Dec 2018

Page 3 of 11 Standard Risk Register

Risk Ref Risk Title Weaknesses and Consequences Inherent Risk Control Residual Action Required Risk Risk Priority Priority Development of Strategy across the Integrated Care System to meet the requirements of the Long Term Plan. (Agreed Executive Lead Geraint Davies) Person Responsible: Liz Cox To be implemented by: 25 Nov 2019

Page 4 of 11 Standard Risk Register

Risk Ref Risk Title Weaknesses and Consequences Inherent Risk Control Residual Action Required Risk Risk Priority Priority BAF 2 There is a risk of Weaknesses I = 4 L = 3 Bespoke clinical leadership for priority areas and I = 4 L = 2 User-friendly Annual Report to be developed and insufficient Primary Care and Patients may not 12 programmes throughout the CCG 8 utilized to spread the message at the Annual engagement and believe in the vision General Meeting. Executive and Clinical Board Directors alignment ownership in the GPs feel overburdened to PCNs Person Responsible: Sarah Frisby system vision leading Acute sector do not own the issue to resistence to Focused agenda at PLT and Member's Forum To be implemented by: 12 Sep 2017 change which may Consequence Communications and Engagement Team to delay or prevent the Poor outcomes for the population Luton engagement in the STP to provide the develop system wide messages to enable progress of Pace and scale not achieved shared vision engagement in the transformation across BLMK transformation. Acute sector overperformance - eating PCN chairs meetings with Clinical Directors to Person Responsible: Sarah Frisby into scarce resources ensure engagement Commissioning plans not achieved To be implemented by: 01 Nov 2017 Primary Care Investment Scheme to support Development of the Luton 'place-based' Practice Clusters to drive change and strategy transformation plan delivery. Person Responsible: Nicky Poulain Work with LMC liaison committee to ensure that the CCG is working within the GP legal framework To be implemented by: 01 Jul 2018 Work with RCGP ambassador to drive the Place-based transformation plan to be reviewed at Primary, Community and Social Care each A&E Delivery Board and Luton Sustainability Plan Transformation Board. Person Responsible: Caroline Capell To be implemented by: 31 Oct 2018 Facilitated programme of organisational development across senior leadership teams of both the CCG and Luton Borough Council to be implemented. Person Responsible: Nicky Poulain To be implemented by: 31 Dec 2018 Action Plan developed and implemented in response to the 360 Stakeholder Survey and Staff Survey using SIG Person Responsible: Sarah Frisby To be implemented by: 30 Jun 2019

Page 5 of 11 Standard Risk Register

Risk Ref Risk Title Weaknesses and Consequences Inherent Risk Control Residual Action Required Risk Risk Priority Priority BAF 3 Individuals and Weaknesses I = 4 L = 3 Board to Board meetings held with major I = 4 L = 2 Development of BLMK Commissioning organisations resist Primary, Community and Social Care 12 providers to ensure shared vision 8 Collaborative Five Year Strategy and key integration, continuing do not have effective relationships workstreams to be delivered at Scale in response Commissioned Cambridge Community Services to work to internal Poor commitment to integration to the Long Term Plan to be coordinating provider for 'At Home First' strategies rather than Acute sector continues to work to own Person Responsible: Geraint Davies the system-wide strategy Luton Primary, Community and Social Care vision. Transformation Board to ensure system working To be implemented by: 30 Nov 2019 Consequence Partners held to account through Better Together Development of Joint Strategic Commissioning Unnecessary admissions to acute for (At Home First) Integrated Partnership Board with Luton Borough Council some patients Utilise the agreed outcomes of the ICS CEO's Person Responsible: Nicky Poulain High number of short stay admissions group and Individual Workstreams CCG finances strained due to acute To be implemented by: 31 Dec 2018 sector over performance Voluntary sector resources not fully utilised

Page 6 of 11 Standard Risk Register

Risk Ref Risk Title Weaknesses and Consequences Inherent Risk Control Residual Action Required Risk Risk Priority Priority BAF 4 The CCG may not be Weaknesses I = 4 L = 3 Communications and Engagement Strategy in I = 4 L = 2 Implementation of Comms & Engagement effective in engaging Lack of public engagement, insufficient 12 place and monitored through the Communications 8 Strategy for the BLMK area with place specific and involving the co-production and Engagement Steering Group actions. public, clinicians and Difficulties reaching diverse population Health and Social Care Reference Group to Person Responsible: Sarah Frisby organisations in the Provider engagement support engagement with public. transformation of the Primary Care engagement To be implemented by: 01 Jun 2020 NHS in Luton. Voluntary Sector engagement Monitoring of the SLA between Luton CCG and The CCG will develop & deliver an Action Plan in Bedfordshire Communications and Engagement Consequence response to the Stakeholder survey. Each action Team to ensure services meet the needs of CCG Communication of CCG's intentions not will be referenced to a particular element of the effective survey and be assigned a responsible owner, Patients not engaged in commissioning prioritisation and target completion date. Following of services this the CCG will identify an appropriate group or Behaviours slow to change committee to monitor the progress of these actions Providers working in silos in order to ensure that they are delivered in line with assigned targets. Person Responsible: Sarah Frisby To be implemented by: 31 Jul 2019 The CCG Commissioning Collaborative will seek the views and engage with patients, public, providers and staff in the development of the response to the NHS Long Term Plan Person Responsible: Jane Meggitt To be implemented by: 15 Nov 2019

Page 7 of 11 Standard Risk Register

Risk Ref Risk Title Weaknesses and Consequences Inherent Risk Control Residual Action Required Risk Risk Priority Priority BAF 5 The CCG may fail to Weaknesses I = 5 L = 4 A number of business functions such as payroll, I = 5 L = 4 Assess the success of the Cambridge Community meet its statutory duty Possible Acute Sector Over delivery 20 financial services, prescriptions payments and 20 Services and the Luton and Dunstable Hospital to deliver the agreed Insufficient head room in the budget Electronic Staff Records, are outsourced plan to mitigate emergency demand and agree risk end of year financial Challenging control total share for 2019/20 Accounts audited externally position and the Possibility of QIPP schemes not Person Responsible: Chris Ford system control total. delivering Capacity of the CCG to deliver the Areas of CCG business subject to internal audit in To be implemented by: 31 Oct 2018 QIPP and manage.. line with annual programme. Implementation of the Financial Recovery Plan Consequence Contract Management with major providers to Person Responsible: Chris Ford The CCG will not meet its financial control activity target and will be subject to special To be implemented by: 31 Mar 2020 Financial Assurance Meetings held with NHS measures England's Regional Chief Finance Officer Development and implementation of the Financial Recovery Plan for 2017/18 Financial Sustainability Plan in place, reviewed by the Executive Team on a weekly basis Person Responsible: Chris Ford Joint Activity Management Plan in place To be implemented by: 30 Sep 2017 Additional training will be provided to ensure that Luton financial position being reviewed at Chief budget holders and budget managers use BI to Officers' meeting each fortnight review their budgets on a regular basis. Opportunities and Risk log reviewed on weekly Person Responsible: Liz Cox basis To be implemented by: 30 Dec 2017 Review of financial risks and mitigation take place Deep dive review of shared Learning Disability at weekly Financial Resilience Group Meetings Services across CCG and LBC with issues escalated to F&P. Person Responsible: Angela Duce To be implemented by: 29 Jan 2018 Expenditure savings programme for the Better Care Fund in liaison with Luton Borough Council. Person Responsible: Chris Ford To be implemented by: 30 Mar 2018 Evaluation of risk inherited on Primary Care Commissioning Budget. Person Responsible: Chris Ford To be implemented by: 31 May 2018

Page 8 of 11 Standard Risk Register

Risk Ref Risk Title Weaknesses and Consequences Inherent Risk Control Residual Action Required Risk Risk Priority Priority Evaluate the financial overhang from 2017 and into 2018/19. Person Responsible: Liz Cox To be implemented by: 31 May 2018 Risk sharing agreement to be developed with Cambridge Community Services and the Luton and Dunstable Hospital to mitigate emergency demand Person Responsible: Chris Ford To be implemented by: 30 Jun 2018 Actions to mitigate cost pressures sitting outside the budget as per risk and mitigation log. Person Responsible: Chris Ford To be implemented by: 30 Jun 2018

Page 9 of 11 Standard Risk Register

Risk Ref Risk Title Weaknesses and Consequences Inherent Risk Control Residual Action Required Risk Risk Priority Priority BAF 6 The QIPP programme Weaknesses I = 4 L = 3 Exec review performance on weekly basis I = 4 L = 2 Barriers and issues to implementation and may fail to deliver its Programmes not achieving desired 12 including the effectiveness of the Financial 8 progress of the QIPP/CIP programme to be taken key objectives and outcomes Recovery Plan to the A&E delivery board and P2 Transformation savings leading to an Poor engagement from L&D Board. Financial Resilience Group meets weekly with a unplanned deficit and Pace and scale not achieved monthly in-depth focus on QIPP performance. Person Responsible: Chris Ford failure to deliver the Acute sector continues to over best outcomes for performance Implementation of the Joint QIPP/CIP programme To be implemented by: 31 Jul 2019 patients. monitored through the Joint QIPP/CIPP Group Rightcare programme to identify additional in year Consequence PMO Structure and Governance in place through opportunities to provide additional headroom. Poor outcomes for patients Financial Resilience Group ensuring robust Person Responsible: Nicky Poulain Not achieving financial position accountability and governance. Won't meet priorities of the STP To be implemented by: 31 May 2018 Joint work with Bedfordshire CCG to review opportunities for QIPP savings with L&D contract. Person Responsible: Nicky Poulain To be implemented by: 30 Jun 2018 A process of reviewing the reasons for success and failure of QIPP schemes will be undertaken to ensure that best practice and lessons learnt are identified and recorded. To be reported through F&P Committee. Person Responsible: Russell Foster To be implemented by: 30 Jun 2018 Implementation of joint QIPP and Cost Improvement Programme (CIP) with Luton and Dunstable Hospital, East London Foundation Trust and Cambridge Community Services. Person Responsible: Russell Foster To be implemented by: 31 Oct 2018

Page 10 of 11 Standard Risk Register

Risk Ref Risk Title Weaknesses and Consequences Inherent Risk Control Residual Action Required Risk Risk Priority Priority BAF 7 The CCG may be Weaknesses I = 4 L = 3 BLMK Commissioning Collaborative provides I = 4 L = 2 Implementation of improved staff/clinician unable to recruit and Succession planning across the system 12 resilience at individual CCG level, with a shared 8 engagement programme of work retain staff and clinical Competing with larger CCG's with recruitment review process in place. Person Responsible: Sarah Frisby leaders with the right better benefits Engagement with staff through staff meetings and skills and abilities to Integration programme demanding To be implemented by: 15 May 2019 annual staff survey deliver the system- capacity Implementation of HR/ODL Strategy wide strategy. Small pool of clinicians Robust system of performance management and development in place to identify talent and map Person Responsible: Nicky Poulain Consequence gaps in knowledge across the organisation High turnover of staff slows down To be implemented by: 30 Sep 2019 progress Staff Involvement Group (SIG) is in place to Monitor the progress of Appraisal completion Small teams so cannot achieve the ensure engagement will staff across the CCG, reporting to Exec on a weekly pace and scale Workforce strategy developed with shared service basis until end of the appraisal period. Knowledge management provider Person Responsible: David Foord Working with Strategic Workforce group across To be implemented by: 28 Sep 2018 four CCGs to ensure optimise opportunities

Page 11 of 11 Agenda Item 14

PAPER FOR THE LUTON CLINICAL COMMMISSIONING GROUP BOARD MEETING IN PUBLIC TO BE HELD ON TUESDAY 21st January 2020 YOUTHSCAPE, BUTE MILLS, 74 BUTE STREET, LUTON, LU1 2EY

TITLE Minutes of Meetings

PRESENTED BY Dr Nina Pearson (Plus contact details for Clinical Chair pre- Board enquiries) [email protected] Angela Duce LEAD CLINICIAN/MANAGER Associate Director for Strategy and Governance [email protected] To provide an update on the most recent activities of each of the sub- WHAT IS THE OBJECTIVE OF committees of the Board. The paper serves to provide assurance that the THE PAPER? committees are carrying out their functions effectively. WHAT IS THE BOARD BEING To receive the updates and to be assured. ASKED TO DO? WHICH OTHER COMMITTEES Each committee has reviewed and confirmed the appropriate minutes HAVE REVIEWED THIS PAPER? INTEGRATED IMPACT ASSESSMENT (IIA) HAS AN IIA BEEN CARRIED Not applicable OUT? WHAT IS THE IMPACT? POSITIVE/NEGATIVE/NEUTRAL* IF THE IMPACT IS NEGATIVE, HOW WILL IT BE MANAGED? EXECUTIVE SUMMARY

The most recent approved committee minutes are provided for information for the Board. Summaries of the activities of committees where the minutes are yet to be approved can be found in the Chairs’ report.

LINK TO CORPORATE OBJECTIVES AND RISK WHICH CORPORATE OBJECTIVE DOES THE PAPER RELATE TO? Working with our partner organisations to drive and deliver the integrated priorities of the Bedfordshire,  Luton and Milton Keynes Sustainability and Transformation Plan. Listening and working with patients and their families, carers, frontline staff, clinicians, social care  professionals and system leaders in order to ensure a shared vision for health and wellbeing services that addresses health inequalities across Luton and the wider footprint. Actively commissioning innovative, locally accessible services that meet the health and wellbeing needs of  the diverse population of Luton.

Prioritising the development of evidence-based approaches in order to support prevention, self-care and  early intervention.

 Robustness in delivering our long term financial plan to maintain the financial sustainability of the CCG.

Commissioning evidence-based, responsive services that reduce variation manage the demand for  healthcare and provide the best value for the local population.

Recruiting and retaining the best staff with the passion to deliver the CCG’s ambitions that make a  difference to our local population.

Ensuring a dynamic and effective approach to communication that engages the people of Luton in order to  successfully promote prevention and self-care and the delivery of effective health and wellbeing services.

Supporting a diverse and inclusive workforce that promotes individual and team development across the  system through innovation and partnership working.

LINK TO THE BOARD ASSURANCE FRAMEWORK WHAT ARE THE KEY RISKS ON THE BOARD ASSURANCE FRAMEWORK? Insufficient resources and workforce capacity across Luton to deliver the priorities of the Sustainability  and Transformation Plan. Insufficient engagement and ownership in the system vision leading to resistance to change which may  delay or prevent the progress of transformation. Individuals and organisations resist integration, continuing to work to internal strategies rather than the  system-wide vision. Communications and engagement strategy is not effective in engaging the public especially hard to reach  groups within Luton.  The CCG fails to meet its statutory duty to deliver the agreed end of year financial position. The QIPP programme fails to deliver its key objectives and savings leading to an unplanned deficit and  failure to deliver the best outcomes for patients. The CCG is unable to recruit and retain staff and clinical leaders with the right skills and abilities to deliver  the CCG's strategy.

Board Meeting in Public Cover Sheet Revised May 2019 2 Item 3

Meeting : Clinical Commissioning Committee

Date : Thursday 31st October 2019

Time : 13:00 – 15:00

Location : Conference Room, 3rd floor, Arndale House, Luton CCG

Present: Kathy French (KF) Chair Board Independent Nurse Luton Clinical Commissioning Group Nicky Poulain (NPo) Chief Operating Officer Luton Clinical Commissioning Group Dr Safiya Virji (SV) Clinical Director, Urgent Care& Primary Luton Clinical Commissioning Group Care Development Dr Sureena Goutam (SG) GP Fellow, Primary Care Development Luton Clinical Commissioning Group Team Dr Chirag Bakhai (CB) Deputy Clinical Chair &Clinical Director, Luton Clinical Commissioning Group Planned Care Dr Uzma Sarwar (US) Clinical Director, Children Luton Clinical Commissioning Group Dr Helen Turner (HT) Board Secondary Care Clinician Oxford Dr Anitha Bolanther (AB) GP / Cluster Chair Luton Clinical Commissioning Group Richard Jones (RJ) Head of Medicines Optimisation Luton Clinical Commissioning Group Gerry Taylor (GT) Corporate Director, Luton Borough Council Jennis Cain (JC) Commissioning PA Luton Clinical Commissioning Group

Apologies: Amanda Flower (AF) Associate Director Luton Clinical Commissioning Group Dr Nina Pearson (NP) GP Clinical Chair Luton Clinical Commissioning Group Dr Manraj Barhey (MB) PCN Chair, Medics Cluster Luton Clinical Commissioning Group Maud O’Leary (MO’L) Service Director, Adult Social Care, Luton Borough Council Dr Kirti Singh (KS) Clinical Director, MH, Personalisation & Luton Clinical Commissioning Group Primary Care Development Dr Hetal Talati (HTa) Clinical Director, Children & Primary Care Luton Clinical Commissioning Group Development Angela Duce (ADu) Associate Director, Strategy and Luton Clinical Commissioning Group Governance Anne Murray (AM) Chief Nurse BLMK CCG Lewis Andrews (LA) Allied Health Professional Governing Luton Clinical Commissioning Group Body (Board) Member Amanda Lewis (AL) Corporate Director, People Directorate Luton Borough Council Presenters Emily Martin (EM) Specialist Speech and Language Therapist Cambridge Community Services Anne Graffe (AG) Medicines Optimisation Pharmacist Luton Clinical Commissioning Group Aneet Judge (AJ) Medicines Optimisation Pharmacist Luton Clinical Commissioning Group Naisha Henry NH) Medicines Optimisation Projects Lead Luton Clinical Commissioning Group

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1. Welcome, Apologies and Chair’s Introduction KF welcomed all members to the meeting, introductions were made and apologies were noted. Apologies were received from Amanda Flower, Angela Duce, Dr Nina Pearson, Dr Kirty Singh, Dr Hetal Talati and Liz Cox 2. Declarations of Interest & Hospitality in Relation to Agenda Items There was no declaration of interest. 3. Minutes of the last meeting 26th September 2019 and matters arising The minutes of the meeting held on the 26th September 2019 were presented and the following points of accuracy were noted for correction:  P.2 Paragraph 3 under matters arising it should read ‘PLT’ instead of PTL  At the bottom of page 2 the contact name is ‘Tracy Fitzsimmons’ not Tracy Fitzgerald.  On P3 the fourth paragraph should read ‘upfront cost to the CCG’ because there is a tariff  P4 second paragraph should read ‘CB clarified that the provider will take on both clinical and administrative responsibility for the project therefore should be minimum workload for primary care’. The remainder of the minutes were reviewed and agreed as an accurate record. 4a. Committee Action Log There were no actions due for October.

4b. Committee Forward Work Plan The Planner was noted and updated by the Committee, please forward any suggestions for future agenda items to Amanda Flower.

4. Implementation of pathways to support the management of patients in the community Appendix 1: Gastro –oesophageal reflux disease and dyspepsia in adults (GORD) pathway Appendix 2: Irritable Bowel Disease / Irritable Bowel Syndrome (IBD/IBS) Appendix 3: Non Alcoholic Fatty Liver Disease (NAFLD) Appendix 4: Faecal Immunochemical Test (FIT) These draft pathways were presented to the committee for consideration.

Comments were as follows:-

All pathways:  Need red flag symptoms listed  Need the drugs and doses detailed whenever a therapy is suggested

GORD pathways:  It was noted the sentence ‘to eat more than 3 hours before bed’ to change to ‘Advise’ not to eat within 3 hours of going to bed’  Don’t abbreviate RAS  Remove ‘Consider onward referral to Nutrition & Dietetics’  There is an arrow missing under ‘Partial response’ after potent PPI box

Irritable Bowel Disease / Irritable Bowel Syndrome (IBD/IBS)  There was a general steer from the Committee that FCP use should be targeted rather than universal – if there is diagnostic uncertainty  Change name of pathway to Suspected Irritable Bowel Syndrome

Non Alcoholic Fatty Liver Disease (NAFLD)  AB suggested that FIB4 score should be done earlier in the pathway –ICE already includes all the tests.  Another suggestion was to have FIB4 done at the time of repeat LFTs and have a route into the pathway from US (requested routinely) showing fatty liver.

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Faecal Immunochemical Test (FIT) There was a general query from the committee regarding whether FIT should be completed at same time as FBC and ferritin or should only follow abnormal FBC and ferritin. The Committee was divided on this point however it was concluded that the pathway was appropriate as presented.

Decision: FIT pathway agreed by the committee

Action: Dr Hetal Talati and Donna Holding to review pathways based on the CCC feedback and bring back to the November meeting.

6. Implementation of Grey List Policy

This Grey List Policy will support clinicians in de-prescribing items considered to be deemed a low priority. The recommendations within the policy should help to reduce the variation and quality of prescribing, improve patient safety where the medication poses considerable safety risks, make better use of available funding and support clinicians to make better prescribing decisions.

AJ gave a brief overview of the policy and explained that NHS England produce a list of medicines that should not routinely be funded by Primary Care based on 3 reasons: lack of evidence, the availability of more cost effective options, and a low priority for NHS funding.

The policy covers 59 items. Most of the items included on the Grey List are based on the NHS England guideline; some items are based on what we deem a low priority locally and are evidence based. In secondary care if a medication is not deemed appropriate to be prescribed, there is a formal process within the hospital e.g. the pharmacy team will challenge inappropriate prescribing which does not adhere to hospital formulary – if a clinician feels the medication is appropriate, a form will be completed and need sign off by senior member of pharmacy team. Within Primary Care there is currently no such process. The process which should be followed if a clinician deems it appropriate to prescribe an item included in the Grey list is described in the Grey List policy.

The policy is a helpful resource for clinicians to use and can support where patients are prescribed certain drugs that it is difficult to deprescibe. If a patient is prescribed a medication that is on the grey list, the patient will have a clinical review. Appendix G, The Grey List includes all the items included in the Grey List, as well as background resources, and recommendations of an alternative if appropriate.

If a clinician deems it appropriate to prescribe an item on the Grey List after clinical review, The Grey List Request Form should be completed. The process is similar to the IFR process; the clinician will have to complete this request form, which is embedded within the clinical system. This is the case for all practices who use Emis and SystmOne (there are 3 clinical systems in Luton, Emis, Vision and SystmOne). The process has been streamlined as much as possible. Practices are happy with the form. Some of the information (such as patient demographic information) will be pre-populated already onto the form. Once completed the form will be emailed to the ITP email address and then this request will get reviewed at the weekly meetings. Based on the information that is provided, the ITP panel will decide whether the patient can be prescribed the drug; this will then get feedback to the GP. AJ stated she has also included a patient information leaflet and contact number which can be given to the patient at the point of when the GP completes the Grey List request form

How it will work  To implement a phased approach  Pop-ups will come up on the GP clinical systems for EMIS and SystmOne practices to highlight Grey list item  Message will be linked to the policy  Practices can run searches to identify patients who are already on grey list item. This process will be incentivised as this is additional work for practices.

It will be is broken down into 3 phases. The items in Phase 1 are those items which have the highest costs and 3 | P a g e pose safety risks.

The searches for each phase have been generated for practices to run. The search will show which patients are prescribed a grey list item. These patients will then need a clinician review to see if the item is appropriate. The Grey list item will be stopped, switched to a suitable alternative or the patient will be advised to purchase it over the counter if appropriate.

NPo commented that this is a comprehensive piece of work for both patient education and engaging with clinicians. This is limited clinical effectiveness, and pragmatic to support clinical decision making.

CB disagreed with the proposal for incentivising the Grey List and criticised it as fundamentally unfair and gave an example that i.e. Pastures Way Surgery, which works hard to achieve top figures for prescribing, will probably only, receives £45 while other practices will receive more money for doing less work. CB felt that the proposed model of incentivising does not reward the right behaviour.

GT commented that on the IRA with regard to patients buying items over the counter that they don’t need; she asked if there was another way people could be supported.

HT also disagreed with the incentivising the policy; she felt that if an item should not be prescribed for the reasons noted this should be followed and clinicians should use the IFR process where they feel there is exceptionality.

CB stated incentivising should be on population size not on the amount of items prescribed.

CB commented that he would agree the whole concept subject to changing how it is incentivised.

Decision: The committee approved the Grey List Policy.

Action: Amend how the policy is incentivised to base this on population size at PCN level. For review in 5 months’ time (March 2020). 7. Introduction of a new online referral form for Speech and Language Therapy (SaLT) Service for children 0-5 years

This paper was presented to the CCC to seek approval for the implementation of a new online brief screening tool and referral form for GPs to use to determine if a referral to SaLT is required for children aged 0-5.

Luton has secured funding from the Department of Education to make a systems change as to how we work to support early communication and language needs. As part of this programme we are working to develop a graduated response to children’s communication and language development needs.

New screening tools are being developed to allow professionals working with the family to explore the child’s communication needs and consider which intervention and / or advice route may be appropriate. This means that the family receives the right support for child’s needs from the outset leading to improved outcomes.

EM stated that SaLT have created a screening tool which will be on Systm0ne with drop down boxes for completion. If a parent has concerns the tool will allow the clinician to look at the different areas of communication and the Red, Amber, Green approach will guide the priority areas.

There is a ‘10 top tips’ advice sheet which can be printed out and handed to the parent to go away with, this contains supporting information such as links to useful reading and further websites.

Where ‘Green’ is indicated the family and child will be offered universal support. Where ‘Amber’ is indicated children will be linked to a notification that will go to Flying Start they will review the referrals to establish the

4 | P a g e support the child needs. Where ‘Red’ is indicated a referral will go directly to the specialist SaLT service.

HT asked about the next stage to implementation. US stated that there is non-recurrent funding to support this transformation and embed the changes in the system.

Decision: The CCC supported the proposal 8. Proposal - Blood Glucose Testing Strips To minimise variation in access, a national minimum set of criteria and an associated reimbursement package was announced for CCGs in April 2019 for up to 20% of their population with Type 1 Diabetes in respect of Flash Glucose Monitoring. These funding arrangements are in place for 19/20 & 20/21. Both Luton and Bedfordshire CCGs have adopted the NHS England guidance with patient initiation occurring via secondary care specialist teams.

AG stated there is a need to capture and audit various measures to assess the clinical and cost effectiveness of the technology. This data will be required to justify on-going funding beyond the NHS England arrangements.

AG stated she did talk to the teams in the set up period regarding the Blueteq system which is used to monitor uptake and assess reasons for access in line with the clinical criteria. However the Blueteq system does not currently capture all the desired parameters, and is viewed as an administrative burden by the specialist teams. Blueteqs proposal is to have additional fields to be built in to record the appropriate data. This will ensure data is recorded in one place. Bedfordshire CCG has already approved the proposal.

Decision: The committee agreed the proposal. 9. 2019 Flu Planning Campaign This paper was presented to the CCC to inform the committee about the national flu immunisation programme in 2019-20 and to note how it is being implemented locally.

NH reported there is only one change to the eligibility criteria of the national programme; for the first time school year 6 children are included in the national programme. Otherwise, eligibility criteria remain the same as last year. Locally the project undertaken last year at Maidenhall School to give children the porcine free formulation was successful, this year the project has expanded to include 6 states schools and 4 faith schools in Luton. The project is managed by the school immunisation programme team.

There are plans for CCS nurses to run flu clinics in conjunction with NOAH. They will run 3 clinics in Nov, Dec and Jan 2020.

It was noted that NHS England in Luton is offering 75p per patient to increase uptake in the ‘super at risk’ group. The groups in question are:  Under 65 with chronic liver disease  Under 65 with chronic neurological disease (including learning disability patients)  Under 65 with immunosuppression  Pregnant women

NPo asked what our proactive plan is for the various ages and what our aspirations are.

NH stated that the plan includes NH and RJ making an appearance as guests on an Inspire FM Radio Programme to promote public awareness; also letters have been sent to patients, in addition to text messages from GP Practices. There was an opportunity to use digital advertising to promote the flu vaccine on the 25 foot screens in the Mall for 8 weeks. The plan is for a 10 second slot that loops (about 30 an hour) starting 3rd November 2019, this cost will be shared with Luton Borough Council. The Committee agreed that this was a good opportunity for flu vaccine promotion.

HT queried if we know what is preventing people from taking the vaccine – it is worth having a myth busting list. HT suggested when you check-in at your GP Practice the ‘check-in’ screen could promote the flu vaccine. 5 | P a g e

NPo suggested that L&D clinicians wear flu badges to remind patients to have the flu vaccine.

Decision: The Committee noted the points mentioned in the update and agreed with further flu vaccine promotion 11. Any Other Business NP gave a brief update regarding the regional meeting that she attended and stated she intends to engage with clinicians working in the L&D to look at practice variation on the non-elective work to understand about the use of 111. There is a proposal to utilise ambulance staff in the future; where patients claim they cannot get an appointment in primary care Ambulance staff will be aligned with the Primary Care Networks in a supportive and formative way.

US suggested it would be useful to have in the Members Pack for each practice, patient appointments per 1,000 for whoever works in the surgery GPs, nurses etc. This would provide a clear picture of what is being delivered locally.

Date of next meeting will be on: - Thursday 28th November 2019

Venue: LCCG, Conference Room, Arndale House, 3rd floor, The Mall, Luton, LU1 2LJ

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Meeting: Finance and Performance Committee

Date: 1st November 2019

Time: 3.30 – 11.30

Location: Conference Room – Arndale House

Present: Mahmood Aziz (MA) Chair & Lay Member for Finance & Procurement Kathy French (KF) Independent Nurse – Board Member Kath Cragg (KC) Assistant Director – Contracts, NELCSU Jennie Russell (JR) Deputy Director of Nursing & Quality Nicky Poulain (NP) Chief Operating Officer Liz Cox (LC) Deputy Chief Finance Officer Apologies: Michelle Powell (MP) Director of Service, NELCSU Chris Ford (CF) Chief Financial Officer Dr Chirag Bakhai (CB) Clinical Director Planned Care Uzma Sarwar (US) Clinical Director Children & Primary Care Development Anne Murray (AM) Chief Nurse In Attendance: Andrew Bland (AB) Head of Financial Management Stephen Makin (SM) Head of Finance, NHSE/I

119/19 Welcome, Apologies and Chair’s Introduction

There were apologies from Chris Ford, Uzma Sarwar, Chirag Bakhai, Anne Murray (Jennie Russell attended on her behalf) and Michelle Powell (Kath Cragg attended on her behalf)

120/19 Declarations of Interest in relation to Agenda Items

There was no declarations of interest

121/19 Minutes of the Meeting held on 26th September 2019 and matters arising

114/19 – change from “main” to “may”

122/19 Action Log

The action log was reviewed and updated.

123/19 Non-Emergency Patient Transport Contract Update

Nicky Poulain provided a verbal update.

Herts Valleys CCG, as consortium lead, has agreed with East of England Ambulance Service Trust (EEAST) that the existing contract will continue. The paper brought to the last meeting requested:

a) Contract extension for 15 months – procurement advice has now been received from Attain to support this b) Contract disproportionate increase for Luton CCG

NP noted that there had been communication issues and a compromise had been reached whereby High Dependency patients would be taken out of the contract as this was not sustainable. NP added that there were further opportunities if there is a single provider for 999 and non-emergency patient transport if this is fully linked with 111. It may be more appropriate to make a direct contract award in future, rather than tender for this service, given the limited number of potential providers and the issues we have managed when providers have failed.

MA asked that an updated paper be presented to the committee for consideration of the request to extend the contract and potential rebasing of the contract.

Action: NP / LC to draft NEPTS paper for November meeting NP/LC

124/19 Virgin LICRS Contract Extension

Nicky Poulain presented the paper which asked the committee to approve extending the contract with Virgin for the Luton Intermediate Care and Rehabilitation Service (LICRS).

NP noted that the contract had developed well and is delivering. MA noted that the paper was limited in scope and did not provided the context and rationale for extension, in particular assurances from Attain, whether there are other providers available who could provide this service, and whether this will deliver value for money.

KF added that there are no quality issues with this service that have come through PSQC.

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NP agreed to revise the paper and circulate to the committee virtually for approval

Action: NP to revise the paper and circulate to the committee for virtual NP approval

It was observed that the paper should have come to the committee in April in case the committee did not approve the contract extension, and therefore allowed sufficient time to do something different from March 2020.

The paper was not approved.

125/19 CHC Re-procurement

JR apologised that a paper was not circulated to the committee as it was only finalised late yesterday afternoon.

The CHC department use a database and electronic payment mechanism. The current supplier gave notice in the summer and a full procurement has taken place, with the support of NHSE. The paper sets out the process followed and asks for approval of the preferred supplier. The intention is for double-running for a three month period with both the new and existing suppliers. This presents a cost pressure to the CCG which is not fully managed.

MA understood that there is an operational issue if this procurement is not approved, but there is a governance process to follow to provide assurance.

JR agreed to update the paper. MA asked that it reflect the agreement from the existing supplier that they will extend the contract for the whole handover period with the new supplier.

MA asked for this to be added to the risks log due to the potential additional staffing costs of managing CHC if a new system is not in place imminently.

Action: JR to update paper for approval at November meeting JR

126/19 External Audit Contract Extension

Liz Cox presented a paper requesting approval to extend the current external audit contract for a further two years.

The paper had previously been to Audit Committee and approved.

The Committee approved the paper.

127/19 MDT Integrated Contract Monitoring Report (Month 5)

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Kath Cragg presented the month 5 Integrated Contract Monitoring Report.

The main issues remain non elective activity at L&D; community paediatric services at CCS and RTT slippage at L&D.

MA queried Luton CCGs share of the £310k additional funding made available to CCS for community paediatrics. LC stated our share to be c£200k and the remainder is from Bedfordshire CCG as the service sees patients from Luton and south Bedfordshire. A business case was approved by the committee earlier in the year.

KC highlighted there were issues at the L&D with cancer breaches; discharge summaries and ambulance handovers.

It was noted that the issue with pensions is not exclusive to L&D. MA asked for the paper to reflect that this is a national issue.

Action: KC to reflect that pensions is a national issue in the next MDT report KC

KF asked if there is any benchmarking of this and RTT. NP noted that whilst the RTT position was deteriorating at L&D, in other areas it was worsening at a faster rate. MA asked if we could compare our RTT position with others.

Action: KC to benchmark RTT performance in next MDT report KC

KC noted that ELFT CPA performance had deteriorated after one good month. MA asked if there was a root cause analysis and NP confirmed that this was done ahead of the contract performance notice being issued.

KC asked if there are any MH patients out of area due to pressure on beds. NP stated that PICU is out of area for females as it was not viable to deliver the service locally due to small numbers of patients. This was a significant change to four years ago when there were significant patients going out of area.

SM asked why the length of stay had reduced, but the occupied bed days were fairly static. This implied a higher through-put of patients. KC agreed to investigate.

Action: KC to investigate ELFT data on length of stay and occupied bed days KC

KF noted that annual leave was given as an explanation for a reduction in CPA performance but felt this was not a sufficient reason for peaks and troughs as this should be business as usual.

KC noted that the patient who had a 52 week wait at royal Brompton had now been identified as a NHSE-commissioned patient, not Luton CCG.

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The outpatient deep dive is underway and will be reported shortly.

KC highlighted that of £1.6m claims and challenges raised to date, £368k had been accepted, but the current cycle has not completed and this figure is expected to rise.

The committee noted the report.

128/19 Month 6 Finance Report (September 2019)

Liz Cox presented the month 6 finance report, highlighting that the CCG delivered a surplus in month, and whilst slightly below plan, this was having a positive impact on the year to date overspend.

The committee noted the report.

129/19 Financial Recovery Plan

Liz Cox presented the financial recovery plan and noted it had been presented to NHSE the day before, and was well received.

The committee had previously seen many of the slides and in particular the activity analysis from the Non Elective deep dive.

LC highlighted particular risks to the position, in particular QIPP delivery. NP noted that there were no detailed plans to deliver the RightCare QIPP at the start of the year and whilst some new schemes have been identified in-year, this has always been a significant risk to the financial position. LC also raised the risk on the counting and coding challenge which is still under informal discussion with L&D.

The committee noted the report and the ongoing risks to delivery of the control total in 2019/20.

130/19 BLMK Finance Update 2019/20

Liz Cox presented the financial position across BLMK at month 6.

LC noted that the position at Bedfordshire CCG was increasingly challenging and would have an impact on everyone across the system.

The committee noted the report.

131/19 BLMK Recovery Trajectories 2020/21-2023/24

Liz Cox presented the BLMK Recovery Trajectories for the next four years.

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LC noted that the paper had been presented to the ICS Chief Executives group on 24th October but had been superseded by changes to the CCG response. Updated finance, activity and workforce figures were due to be submitted by 12pm on 1st November. There had been a significant amount of work between organisations to reach agreed positions, but these did not reflect commitments from either party regarding next year’s contract negotiations.

It was noted that the three CCGs financial returns now demonstrated compliance with the regional requirement to contribute 0.5% surplus to a contingency fund. BLMK were one of only two areas that did not accept this positon in initial submissions and it is now felt that this should be built into plans. Bedfordshire CCG would not be submitting a plan to continue repayment of its historic deficit.

The committee noted the change to Luton CCGs planned financial submission and acceptance of its control trajectory for 2020/21 to 2023/24.

132/19 AOB

There was no other business.

133/19 Date and Time of next meeting

Thursday 28th November 2019 10.30-12.30 – Conference Room

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Luton CCG Board Patient Safety and Quality Committee Minutes 31st October 2019 15:15-17:15 Conference Room, Level 3 Arndale House, The Mall, Luton, LU1 2LJ

PSQC Members Name Role (LCCG unless otherwise stated) Initials Present Apols Kathy French Independent Nurse Board Member (Chair) KF  Nicky Poulain LCCG Chief Operating Officer NPo  Gerry Taylor Corporate Director Public Health, Commissioning & GT  Procurement Dr Anitha Prabhu GP & Clinical Lead for Cancer APB  Bolanthur Lloyd Denny Lay Board Member – Patient, Public & Stakeholder LD  Engagement (Deputy Chair) Jennie Russell Deputy Director of Nursing and Quality JR 15:50-16:00 only Chris Harvey Head of Quality CH  Anne Murray Chief Nurse (BLMK Commissioning Collaborative) AM 

Advisors on circulation list attending as required Name Role (LCCG unless otherwise stated) Initials Present Alison Franklin Infection Prevention and Control Nurse AF Caroline Capell Assistant Director of Unplanned Care (for Nicky Poulain) CC Richard Jones Head of Medicines Optimisation RJ Tess Dawoud Assistant Head of Medicines Optimisation TD Angela Duce Assistant Director – Governance AD Carol Blomfield CDOP Manager CBlo Dr Chirag Bakhai Clinical Director CB Gill Humberstone Complaints and FOI Manager GH Apologies Michelle Powell NELCSU Head of Delivery MP Lynda Harris Head of Information Governance LH Paul Lindars Head of Primary Care PL Clare Flower Quality Manager – Patient Safety CF Apologies Sheelagh Coe Quality Manager- Patient Experience SC Apologies Julie Hall Head of Safeguarding Adults and Designated Nurse JH Apologies Melinda Gibson Deputy Designated Looked After Children’s Nurse MG Apologies Others in attendance Name Role (LCCG unless otherwise stated) Initials Present Kath Gerrard Quality Support Manager – Patient Safety (Minutes) KG  Kamini Patel Commissioning Project Manager KP 

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Item Comment Action APB clarified that as the only GP she may need to leave future meetings early- KF agreed that this would mean that the meeting was not quorate. 1 Apologies and introductions Apologies were received as shown above.

2 Declarations of Conflict of Interest No further conflicts of interest were declared.

3 Minutes and Matters Arising not within Action Log The previous minutes from 26th September were reviewed and agreed as an accurate record. 4 Action Log Review The action log was reviewed and updated.

5 Governance and Strategy 5.1 ICS and Integration Update including workforce JR had sent apologies for the meeting. The Committee members agreed that this is a key meeting for the Deputy Director to attend, even if for just a part of the meeting to provide assurance on quality governance and workforce issues, which are becoming a key issue for most NHS organisations. LDH Maternity is reporting challenges in recruiting midwives, the Committee needs to have assurance from the wider system. LD also said that mid-range and junior staff especially being made nervous by uncertainty regarding employment, with the recruitment challenges in providers has an impact on quality. In her absence the Committee requested a paper for the next meeting to capture what would have been said, especially in regard to the impact on staff.

JR joined the meeting at 15:50 to provide an update:

The BLMK Executive recently attended an away day to look at future plans. They will shortly be reviewing the portfolios of some of the staff. As part of that review the Finance team have already moved to one BLMK-wide team, with changed line management. The Urgent Care team is now managed by Mike Thompson, COO for Beds CCG, and Caroline Capell is directly line managed by him, although she is still based in the Luton office. Nicky Poulain now holds the BLMK portfolio for Mental Health. Other roles, including the portfolios for ADs and Deputy Directors of Nursing are yet to be finalised. A monthly senior staff meeting provides updates for cascading to staff, who are also updated through blogs from the BLMK Accountable Officer, Patricia Davies, and through staff meetings.

The BLMK Medical Director and the Finance Director are currently off sick, AM is covering the Medical Director role temporarily.

It has not been possible to recruit to the Adult Safeguarding GP role, so two nurses, accountable to the Medical Director have been

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recruited, to provide safeguarding support for primary care.

Some old CDOP cases are being reviewed to progress them.

Medina Road now under caretaker cover. Some safety concerns have been raised by the caretaker, who has given assurance that patients potentially affected have been reviewed and risks mitigated.

LD expressed concern that this Committee and the Board is unaware of the detail of these radical and substantive changes, which are Action happening very quickly, and suggests that a detailed update be TBC presented to the Board. The report should describe the proposed changes in order to provide assurance that they are for the betterment of our people, and that change management HR processes are being followed for staff. What will be the impact on the Committee which is used to having Luton specific representation? All agreed that it is not the remit of this Committee to question staff structure, but require assurance in terms of the impact on quality and governance.

The Committee suggested these changes be reflected on the Risk Register. If personnel are being moved from Luton, and/or given additional responsibility, then there could be a dilution of resources- with a consequent impact on the people of Luton.

5.2 Risk Register The committee received and noted this report.

The report still contains old dates and the names of staff who are no longer involved – has the register been updated? Is the 4Risk system

providing the correct report?

The Committee is audited to confirm that current CCG risks have

been reviewed, so it is essential that the correct, up-to-date

information is regularly being presented to the Committee.

CH will review, check and provide an up to date report for the next CH meeting. If it is not possible to print the correct report then highlights of key risks from the Register will be projected on screen and reviewed at the meeting.

5.3 Integrated Quality and Performance Report

The committee received and noted this report for July (M4)

Only received today so the Committee have had little time to review the report. Some of the difficulties in getting this report on time are related to delays in the sign-off process through Amanda Flower, Jennie Russell and Nicky Poulain. KF will add this to the Chair’s Report.

RTT performance noted.

Cancer- a detailed update report is included on the agenda today.

Health Checks (page 10) – Work is ongoing, the numbers have decreased, but are not doing badly in the national context.

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MMR – No update to the data since December 2018. Business Intelligence had been asked to add recent data but it was not completed prior to the report submission. See action log item 525 – Lucy Hubber to provide an update, and to include the information in the report she made to HSCEG. 5.4 QIPP/FRG CH reported that there are ongoing plans to rectify the financial position.

KF noted concerns regarding the Unplanned Care expenditure for

which a deep dive is planned.

Due to annual leave JR has not attended the FRG meeting for two weeks so cannot provide any further update.

5.5 Health and Social Care Engagement Chair’s Report The committee received and noted this report.

LD reported that the new group is wider in format, more representative of the population, is settling in well and having deeper conversations. The group appreciates the opportunity to set their own agenda, and the regular Q&A sessions with clinical and Executive members of the CCG and BLMK.

GT suggested that the group needs greater engagement from Social Care, which LD will take back to the group. LD

KF asked that the minutes of the H&SCEG meetings be attached to the Chair’s Report for additional information. This means that the names of the H&SCEG members will be published with the minutes LD – LD will go back to the group to get their views.

6 Provider Quality 6.1a Provider Quality Exception Report The committee received and noted this report. CH presented highlights:

CQC outstanding at Stockwood domiciliary care agency.

LDH have submitted the Final Report for the wrong side nerve block Never Event previously reported. A further Never Event – a misplaced naso-gastric tube with no harm - was recently reported.

CCS have workforce issues especially district nursing and health visitors. A new rostering system is being slowly embedded, expected to take up to 18m to realise the full impact.

HUC have workforce issues affecting shift fill, including GP shifts, which were not been escalated appropriately. A resilience plan is now in place, and the provider is currently under increased surveillance. APB commented that there seems to be increased workload for GPs

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being asked to follow up on diagnostics and prescriptions. CH advised that the team need more specific details in order to be able to address such concerns. HUC have a complaints process. There is a dedicated CCG e-mail inbox for reporting concerns, CH to clarify CH and confirm the contact details with primary care. Non-Emergency Patient Transport Service (provided by EEAST) – a contract extension is currently under discussion. 6.1b Update on Cancer Services The committee received and noted this report.

Kamini Patel presented highlights in CFs absence. She clarified that the LDH and LCCG figures are different as they measure different data.

Performance has been good. HVCCG have asked to look at how LDH achieve their good performance.

Breast symptom performance is down, due to an increased number of referrals, which it has been determined are coming from areas outside Luton, likely to be attracted by the good reputation.

The annual media campaigns for breast awareness usually lead to an increase in referrals, which was not seen from Luton GPs this year. Further awareness-raising for GPs is planned.

LD asked about the targets on page 2- what is the trajectory? KP confirmed that it is expected to get worse, as Referral to Treatment Times (RTT) across many specialities will be adversely affected by the consultants’ pensions issue, and a lack of theatre space due to essential repairs.

Robust discussion followed addressing concerns that each percentage figure represents an individual patient facing a serious, potentially life-threatening condition.

KP assured the Committee that the commissioners and the Cancer Action Group are focussing on each cancer pathway, identifying specific issues and exactly where any problems lie, aiming for a complete picture by February 2020.

KP advised that a target for 28 day faster diagnosis of cancer is being introduced from April 2020, the work on cancer pathways will allow commissioners to categorically state where the issues lie and where commissioning decisions need to be focussed. Cancer Alliance funding is available which will be used to target those specific areas to achieve the required standards.

As part of this focused work, the pilot for early screening of lung cancer launches this week.

6.2 LDUH Q1 Quarterly Quality Report The committee received and noted this report.

CH presented highlights in CF’s absence: Performance in delivering

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harm-free care is above the national average.

Falls are down by 9%. A lot of work has been done with a range of measures including improvements to bathrooms, measuring lying and standing blood pressures, and the enhanced supervision from “Baywatch”.

Mortality metrics are all positive.

A spike in pressure ulcers has been reported, reflective of the national picture, due to new guidance for reporting. There is a surprising increase in reports for medical devices such as walking boots, plasters and thromboembolic deterrent stockings (TEDS). This will be reviewed further at the LDH Quarterly Quality meeting in December.

KF raised concerns regarding the workforce especially the vacancies and sickness absence in Maternity. CH confirmed that Maternity is unable to meet the midwife staffing levels required, and are currently reporting a ratio of 1:33 against the national target of 1:28. This reflects 8 midwives per shift rather than the expected 13. The Committee requested that be challenged with the Trust on how they meet safe staffing levels. Continuity of Carer is at 4.4% against a target of 20%. Increased SIs are being reported. Everything is reading risk. KF asked that these Maternity risks be escalated with some urgency to AM; and a deep dive for assurance be sought at the Contract Review Meeting and Maternity meetings. To be reported back to the CF/CH next PSQC meeting in November.

APB raised some concerns on individual cases which will be addressed with CF outside the meeting.

6.3 Nursing Home Quarterly Report The committee received and noted the report.

RMR presented highlights. The main concern at the moment is Capwell Grange, where the required improvement is not being seen. A detailed robust plan is being established, with provider performance meetings to support improvement. Concerns include safeguarding issues and staff development. CQC is due to re-visit. The Hospital at Home is providing support.

The MDT approach at Mulberry Court is working well, using SystmOne to allow sharing of information. The Serious Adult Review (SAR) starts in early November. The CQC rating has improved to “Requires Improvement”.

418 champions have been trained across 4 homes. A further phase of the programme aims to add further modules (such as Verification of death training), keep learning embedded and encourage learning from best practice.

Close working with Luton Council colleagues and the Falls Team is

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allowing sharing of best practice.

6.4 Items for Escalation to QSG No new items identified.

7 Patient Safety 7.1 Safeguarding Children Quarterly Report The committee received and noted the report.

LDH Level 3 training poor compliance will be raised with the LDH as part of the Quality Meeting. The need for a CQN was queried – CH confirmed this route is an option and has been used in the past.

MG, JH and JR are covering the workload in the interim until the new appointee, Teresa, starts.

LAC performance is poor. MG is now back from maternity leave and will drive the work forward. Staff changes in LAC over the last 2 years have had an impact. The Committee asked for assurance with CH/MG a plan and trajectory for improvement by the next meeting.

7.2 Safeguarding Adults Quarterly Report The committee received and noted this report.

The LeDeR Conference on 31st October shared learning and lessons.

Luton CCG is still an outlier in terms of outstanding LeDeR reviews. A shortage of reviewers is an issue - there are none from the local authority yet,. GT asked for details of the requirements for the role to JH allow her to identify potential reviewers from her team.

The BCCG lead is leaving the post in December which will put further pressure on the system.

Patricia Bowles has been appointed as MASH Nurse which will relieve some of the pressure on Safeguarding, provide robust review and joined up working.

7.3 Annual CDOP Report The committee received and noted this report.

GT presented highlights:

The report covers the whole of Bedfordshire, with Luton specific details at the end of the report (page 24). There are no significant differences from previous years, and, in response to queries, no particular themes have been identified.

In 2018-19 there was a small increase of 2 deaths in Luton over the previous year, slightly above the average of the last 5 years. Infant mortality rates are higher than the national average, although similar to statistical neighbours. Consanguinity and maternal obesity

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remains issues. Tracking of information and the offer and acceptance of support for obesity is difficult. An audit of service issues is in progress.

A small number of suicides were reported; a pathway has been introduced for suspected suicide. Implementation of the new national arrangements for CDOP is now in place locally, increasing the involvement of service providers in supporting the process.

The Panel has recently looked specifically at perinatal deaths.

8 Patient Experience 8.1 Learning from Complaints Quarterly Report and FoI Quarterly a&b Report The committee received and noted these reports.

GH sent her apologies for the meeting. The Committee note that all the targets seem to be met, and performance is quite good.

8.2 Provider Complaints Q3 Quarterly Report The committee received and noted this report.

CH presented is SC’s absence. This is the second report which the Committee find useful to see all the information together. The themes from providers are consistent with previous themes.

9 Documents received 9.1 Documents Received / of Interest The committee received and noted this report.

10 AOB KF is due to meet with NPo to discuss future plans for the PSQC meeting, and will provide feedback at the November meeting.

The meeting closed at 17:05.

PSQC - Chairs report 31st October 2019

 The IQPR was tabled for the committee. It was noted that the late arrival of the report provides minimal opportunity to read the information. It was noted that sign-off process often results in the paper being late. The committee asked if this could be reviewed to ensure the report is received in a timely manner  The committee received the risk register but it was noted his was not current and the committee has asked that an up to date version is shared for the November meeting to ensure items of relevance can be discussed, in line with good governance  The committee received the annual Child Death Overview Process Annual report (CDOP) FOR 2018-19. An increase of 5 deaths from the previous year has been reported. A significant number of

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deaths occurred in the neonatal period, and a number of these related to extreme prematurity. Maternal high BMI and consanguinity remain some of the key issues and work is underway to raise awareness  Children’s safeguarding - the L&D Hospital training compliance remains low at 77%- LCCG designated nurse is working with the Trust to improve compliance. LAC with initial health assessment completed performance is currently 40% of a target of 90%.a professional meeting has been arranged for 31st October at LBC to discuss performance  LDH quarterly quality report Q1- area of concern regarding staffing in maternity. The implementation of ‘Better Births’ places additional demands on the service to deliver continuity of care. This has seen a lower midwife to birth ratio. The Committee has asked this is raised at the next CQRM meeting.

Next Meeting: Thursday 28th November 2019, 15:15-17:15, Conference Room, Level 3 Arndale House

9

Primary Care Commissioning Committee (PCCC)

Date: Tuesday, 24th September 2019 Time: 1400-1600 Venue: Conference Room, Luton CCG, 3rd Floor, Arndale House, 37 The Mall, Luton, LU1 2LJ

In Attendance:

Name Job Title Practice/Organisation Phil Turner (PT) Chair Health Watch Luton Healthwatch Luton Gerry Taylor (GT) Corporate Director Public Health and Wellbeing Luton Borough Council Paul Lindars (PL) Associate Director Primary Care Development Luton CCG Chris Harvey (CT) Head of Quality [and in place of Jennie Russell) Luton CCG Dr Hetal Talati (HT) GP, PCN Clinical Director and Clinical Director Luton CCG Children and Primary Care Development Fiona Foster (FJF) Commissioning Support Officer (Minutes) Luton CCG Liz Cox (LC) Deputy Chief Finance Officer Luton CCG Sukeina Kassam (SK) Primary Care Development Manager Luton CCG Lloyd Denny (LD) CCG Board Lay Member (Chair) Luton CCG Nicky Poulain (NPo) Chief Operating Officer Luton CCG Pam Lewin (PLe) Contracts Manager Primary Care General Practice NHS England Apologies Dr Una Duffy (UD) GP Bell House Medical Centre Dr Peter Graves (PG) Chief Executive LMC Jennie Russell (JR) Deputy Director Quality and Nursing Luton CCG

1. Welcome, Apologies and Conflicts of Interests LD welcomed those present to the meeting and apologies were noted.

Conflict of Interests HT – Luton GP and Primary Care Network Clinical Director

In the absence of JR it was agreed that CH’s nursing clinical credentials were sufficient to ensure this meeting was quorate. 2. Minutes and actions from previous meeting 09.07.19 2.1 Item 4.2 [page 2] Minutes stated that “… some patients were concerned that they may not have a GP …” minutes should have stated that ‘… some patients were concerned that they may not have a specific Practice …”

2.2 Item 10.2 [page 4] Minutes stated that ‘Evexia’ will take over the contract which is currently being written …” minutes should have stated that ‘… ‘the contract will be novated to Evexia’ once they have completed their CQC registration…’

The remainder of the minutes were agreed accurate.

Matters Arising/Action Log 2.3 Action (011) : Dissemination of mid/low-risk Practice Highlight Report Information to this group – information to be disseminated going forward following each Primary Care Information Sharing Group Meeting

2.4 Action (012) : Finance papers – LC to prepare and disseminate relevant finance papers for inclusion with PCCC agenda and other associated papers prior to each PCCC meeting going forward 2.5 Action (013) : Comms – SK liaising with Comms Team and work ongoing in conjunction

Primary Care Commissioning Committee meeting | 14.03.19 Page 1 of 5

with BLMK relating to positive communication to patients via the ‘Our Practice is Changing’ campaign

2.6 Action (014) : Communication with Councillors – GT/NPo to share ‘Our Practice is Changing’ communication with Councillors to ensure positive and uniform messaging throughout Luton by the end of October 2019

2.7 Action (015/6) : Mahmood Aziz (lay PCCC member) – NPo updated that Mahmood Aziz did not wish to continue as a regular PCCC group member however he would be happy to chair PCCC meetings where LD is unavailable to attend. LD said this meeting must consist of a lay Board member/Deputy Chair and it was agreed that LD/NPo discuss further outside of this meeting

2.8 Action (017) : GP Resilience Programme – LMC have provided an update to Primary Care Leads within the last week and PL will circulate to this group 3. Primary Care Finance Report [No paper for this item] 3.1 LC confirmed that future finance paper will be available prior to PCCC meetings going forward

3.2 Primary Care Co Commissioning Budget shows slight underspend (as of Month 5, August 2019) of £225k connected to staffing associated with the formation of Primary Care Networks. Discussions currently ongoing with regard to how any underspend should be utilised

3.2 Although LCCG currently operating a recovery plan due to financial deficit it is anticipated that the contingency will not be used and this money can therefore be utilised to support the recovery (although this has not yet been signed off)

3.3 Delegated budget has proved difficult to manage as historically, NHSE, have operated different times in the year for charging and spending but these difficulties are being overcome and a more uniform approach will be adopted going forward

3.4 NPo asked for it to be noted that the hard work carried out by PL and the Primary Care Development Team has resulted in continuity of primary medical services for patients and stayed within the allocated financial envelope, for example, with Medina Road Medical Centre Caretaker and Sundon Park Health Centre list dispersal and she thanked PL and the team for their efforts 3.5 Primary Care budget for 2019-20 is £31.1M. Budgeted spend to month 5 is £12.8M with an actual spend at month 5 of £12.5M 3.6 Finance and Performance Committee will have the final decision relating to what to do with any underspend and this will be communicated to weekly FRG meetings and updated by LC/NPo at the next PCCC meeting 4. BLMK Primary Care Governance Paper [Paper Item 4 disseminated] 4.1 The Primary Care Strategy Group requested this item be tabled at PCCC in order to clearly set out (particularly to those who may be unaware) the decision-making responsibilities of PCCCs. Recommendations as to the responsibilities of each PCCC are set out in paper 4 which has been disseminated to this group

4.2 Point 3 of the Governance Paper shows a structure chart relating to where the Primary Care (PC) Leads Group fits in with the overall governance for PCN development, reporting directly to the Primary Care Strategy Group ensuring that BLMK system is working as uniformly as possible as a whole system

4.3 NPo suggested that as CCGs are member organisations a forum for primary medical services would be useful and must include colleagues from Public Health

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4.4 GT said it is unclear as to how the Primary Care Strategy Group links in with the Primary, Community and Social Care Transformation Board )PCSCTD) and that the Terms of Reference for the Primary Care Strategy group indicate a more ‘tactical’ approach to commissioning and it is important to start thinking about a more ‘transformational’ methodology working in conjunction with the (PCSCTB) and Clinical Commissioning Committee

4.5 NPo said that funding is allocated at ICS level to implement a PMS Strategy Group and how Primary Medical Services use it would constitute the tactical commissioning whereas ensuring Primary Medical Services are sufficiently enabled to work in a transformed way would suitably fit with the PCSCTB remit

4.6 LD said that as a group this PCCC must ensure it is very clear about the adherence to the responsibilities it has

4.6 No final decision has yet been taken relating to the April 2021 merger of all 3 CCGs 5. PCN Assessment Approach for BLMK [paper Item 5 and 5a disseminated] 5.1 PL updated the group advising that a sizeable volume of work is currently going in to this work. NHSE nationally have ring-fenced funds to the ICS to support Primary Care Networks (PCNs) and that the PCN Development Prospectus recently shared with Network Clinical Directors has been a useful tool to articulate the work to be done. CCGs are charged with ensuring a good support plan is in place with the ability to capitalize on ‘at-scale’ provision

5.2 This paper gives a timeline for the response for PCN development needs in BLMK for submission to NHSE in October this year. Network Clinical Directors have been asked to complete a ‘needs assessment’ in order to establish what support and resources they require and paper 5a shows how the Medics PCN as an example

5.3 As a result of the needs assessment completion PL advised that different emerging strengths within each PCN are showing and, equally, where PCNs need support

5.4 HT advised that there is much support available and a coordinated approach to what support is useful to adopt would be helpful

5.5 GT said she would like to see where the Local Authority can provide support and resources given that the provider portfolio now sits within her remit, for example, assistance with Social Prescribing or Adult Social Care

5.6 PL advised that whilst an emerging plan will be more established prior to the next Primary and Social Care Transformation Board as such a large volume of work is required in such a short space of time there is a risk that it could become General Practice focussed and lose sight of the fact that it is a whole system support

5.7 NPo said she felt pleased that Luton is intuitively discussing with partners across the BLMK patch as a whole rather than 3 separate CCGs and that continued efforts must be maintained and include key LBC and CCS teams ensuring that the focus is on the population served by a PCN and not just the on the needs of the PCN itself

5.8 LD asked what assurances could be given with regard to each of the 26 Practices remaining in their current PCN and what would happen if a ‘weak’ Practice within a PCN was identified?

PL replied that each Practice has a contractual extension within their GMS contract to do so however commissioners would need to agree any proposed move to another PCN.

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In terms of the identification of a ‘weak’ Practice, Practice performance is discussed at the regular Primary Care Information Sharing Group Meetings and the low/medium risk Practice highlight report will be disseminated to this group going forward showing which PCN they belong to. PCNs are more formal than the existing ‘Clusters’ and therefore the onus will be on the Practices within each PCN to support each other where possible with the overall accountability of the Network Clinical Director. 6. Estates Update, Premises Development Kingsway [paper Item 6 disseminated] 6.1 PL updated that the Conway Medical Centre is looking to move into the Kingsway Health Centre premises as there is spacial capacity which is not being fully utilised.

6.2 Following the proposed relocation it is hoped that the Conway Medical Centre will be able to re-open its patient list and LCCG will also see a reduction in costs as it will not need to pay Conway Medical Centre the notional rent on their current building.

6.3 The landlord of the Kingsway Health Centre (Nexus) is willing to carry out the necessary internal configuration at no cost however the current Kingsway lease will increase from the existing 14 years to 25 years.

6.4 The Medina Medical Centre Caretaker will move into the Kingsway premises until the caretaking is finished at which time the Conway Medical Centre would be phased in. The caretaking arrangements are for a period of 9 months, until July 2020.

6.5 This group was asked to approve the proposed project as it will deliver significant revenue savings to the CCG and lead to patient experience improvements and a significant increase in Practice resilience, enabling another Practice t open its list for new patient registrations.

6.6 DECISION : The Primary Care Commissioning Committee agreed item 6.5

Action (018) : PL to advise the F & P Committee for information of the decision of the PCCC relating to this proposal 7. Change of Boundary Approvals – Sundon Medical Centre [Paper Item 7 disseminated] 7.1 PLe updated that whilst virtual agreement had been granted by this Committee due to the speed with which the boundary changes happened the PCCC is asked to formally ratify the changes.

7.2 The boundaries changed due to the Practice being unclear as to what their boundaries were, together with the fact that approval to boundary changes should firstly have been sought by this Committee. Lessons have been learned from the process of list dispersal and the problems encountered should not happen in the future.

7.3 PL asked how NHSE list size payments and costs would affect Sundon Medical Centre given that their Harlington Branch has extended its boundary outside of the Luton area thereby increasing their list size. PLe said she would find this information out.

7.4 Action (019) : PLe to ascertain the effect of Harlington Branch additional patients on payments and costs to Sundon Medical Centre and report back to this group

7.5 DECISION : The Primary Care Commissioning Committee ratified the virtual agreement relating to the approval of Sundon Medical Centre boundary 8. List Closure Proposal – Medina Medical Centre Caretaker [Paper Item 8] 8.1 PLe updated that the Medina Medical Centre contract was handed back to NHSE by Dr Subramony and Mrs Pillai. A mutual termination date has been agreed which will come into effect on 30th September 2019.

8.2 Malzeard Road Medical Centre will caretake Medina Road Medical Centre until this

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time. In order to negate patients ‘Practice-hopping’ from the Kingsway Medical Centre when the caretaker moves into the same building, this group was asked for approval for the caretaker to temporarily close its list for the duration of the caretaking period (9 months).

8.3 LD asked how any decision to close the list, however temporarily, would affect patient choice. NPo replied that in situations such as these it is custom and practice to temporarily close lists as caretaking another Practice can be an unstable and unsettling period. Any challenges can easily be articulated if need be stressing that stability is paramount and that patients can be offered a choice of nearby Practices if they insist they wish to move from Kingsway Health Centre.

8.4 NPo said that as the Practice Group has now been taken over by Centene UK it would be useful to meet with Centene (Samantha Jones) prior to the end of their Kingsway and Bramingham Park contract

8.5 DECISION : The Primary Care Commissioning Committee approved Malzeard Road Medical Centre temporary list closure for the duration of their caretaking period of Medina Medical Centre 9. For Information – Virtual papers for ratification [Paper Item 9a and 9b] 9.1 Virtual ratifications granted by this Committee relating to Medina Medical Centre (Options for the future of the Medina Medical Centre Contract) and Medina Medical Centre (Chairs Action to agree recommendation for termination agreement to be sent and to confirm site for caretaker).

9.2 Due to the time constraints relating to the above 2 items both decisions were agreed virtually by this group and for completeness this Committee was asked to ratify both virtual decisions.

9.3 DECISION : The Primary Care Commissioning Committee approved the virtual ratifications relating to the Medina Medical Centre set out above in point 9.1

9.4 NPo asked for it to be noted that the Primary Care Team was to be thanked for the speed with which it acted in this case and the excellent way the volume of work was managed. 10 Any Other Business 10.1 HT asked whether she should continue to be a member of this group given her role (among others) as Primary Care Network Clinical Director. The group felt that her input was invaluable and therefore it was agreed that she should continue.

10.2 PT gave his apologies for the November PCCC meeting and advised that a colleague from Health Watch would attend in his place.

10.3 SK updated that she had received communication from the CQC relating to Dr Subramony’s CQC registration that a ‘Notice of decision to cancel Registration has now been issued’ (on Dr S. Subramony). Dr Subramony has received this decision in writing and has 28 days in which to appeal should he so wish. 10.4 LD gave his apologies for the November PCCC meeting and will liaise with NPo with regard to finding a suitable replacement.

Date of next meeting: Tuesday, 13th November 2019, Conference Room, Arndale House Thursday, 20th February 2019, Conference Room, Arndale House

Primary Care Commissioning Committee meeting | 14.03.19 Page 5 of 5

We are Luton

Draft Minutes of Luton Transformation Board Wednesday 18th September 2019 Luton CCG, Conference Room

Name Title Organisation Nicky Poulain NPo Chief Operating Officer Luton Clinical Commissioning Group Maud O’Leary MO Service Director Adult Social Care Luton Borough Council Dr SafiyaVirji SV Clinical Director Urgent Care & Luton Clinical Commissioning Group Primary Care Development Lewis Andrews LA AHP Board Member Luton Clinical Commissioning Group Gerald Zeidman GZ Chief Officer Bedfordshire LPC Liz Searle LSe Chief Executive Officer Keech Hospice Michelle Bradley MB Director ELFT Pat Lattimer PL Vice Chair Healthwatch Luton Peter Loomes PLo Interim Urgent Care Project Lead Luton Clinical Commissioning Group (Deputy for Caroline Capell) Clare Steward CS Programme Director Cambridgeshire Community Services (deputy for Anita Pisani) Martin Trinder MT Chief Executive Voluntary Works Jennis Cain JC Commissioning PA Luton Clinical Commissioning Group Apologies David Carter DC CEO Luton and Dunstable Hospital Dr Nina Pearson NP CCG Chair and GP Luton Clinical Commissioning Group Liz Cox LC Deputy Chief Finance Officer Luton Clinical Commissioning Group Gerry Taylor GT Corporate Director of Public Luton Borough Council Health & Wellbeing James Ramsay JR Medical Director Luton and Dunstable Hospital Fozia Irfan FI CEO The Bedfordshire and Luton Community Foundation (BLCF) Marilyn George MG Integrated Operations Manager Luton &Dunstable Hospital Colette McKeaveney CM Director Age Concern Dr Sahdev Swain SS RCGP Regional Ambassador RCGP Dr Peter Graves PG Chief Executive Beds and Herts LMC Ltd. Dave Tamarro DT Locality Lead EEAST Susannah Winter SW Head of IUC (Beds and Luton) Herts Urgent Centre (HUC) Trefor Evans TE Service Manager Virgin Care

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1. Welcome, introductions and apologies NPo welcomed everyone and the apologies were noted. 2. Minutes and actions from previous meeting on Wednesday 19th June2019 There were no amendments to the minutes, therefore marked as an accurate account of the meeting.

Conflicts of Interest: No conflicts of interest were declared.

Matters Arising NPo asked LA what the National Ambulance Service policy is trying to improve. LA replied that it is a national framework to provide system wide consistency in response for health care professionals requesting ambulance response. It aims to take out some of the ambiguity that currently occurs. The process will now ensure that a clinician has assessed a patient, thereby ensuring an appropriate response. There has been a lot of communications to general practices and also discussed with the A&E Delivery Board.

NPo asked MOL what impact this may have with residential and care homes. MOL stated she would welcome some targeted communications to care homes Action: Npo to check our local communications plan

PL mentioned that this was presented to the last GP members forum last week and have slides that he will share.

Action: PLO to share presentation to MOL Action: Carole G to be fully briefed by PLO re: care homes and do some bespoke communications

LSe said she was thinking about how the ambulance would affect end of life care and how it would work with the care co-ordinators in the services. AL stated the process will still be clinician to clinician the end of life care will each goes into hospital and ensure the information is updated. NPo stated it should be made clear to the care homes manager so that they are aware of the national policy where there is a scoring system.

MB asked about how Mental Health would impact on the service. LA stated it is not a forgotten cohort of patients when making a referral the patient will still be triaged national platform. 3. The NHS Long Term Plan Development – Luton place based plan. Npo stated she and MB had attended the Mental Health Programme Board and work from this board was feeding into the mental health section of the Luton Plan and she highlighted the work supporting the homelessness and rough sleepers. The Luton Plan is informed by the NHS long term plan with the primary aim to ensure health and wellbeing is joined up working with all partners. The next meeting will focus on ensuring the Luton Plan is supported and driven by all partners recognising the feedback from the Deloitts review in terms of being clear about measuring outcomes. 4. Winter Plan PLo set the context by stating that the system has been under sustained pressure throughout the summer which is less than ideal moving into a winter period. As an example 18 ambulances had arrived the previous day at L&D. Additionally contingency wards were still open which had been closed in previous years.

Members were asked to consider, what can be done differently to avoid the increasing rates of emergency admissions, what can organisations do, in a more detailed way and mitigate crisis care? Avoidance of patient deterioration earlier in the pathway will be key to the winter plan. There will be a

2 continuation of the ongoing promotion of NHS 111, directly booked appointments into clinics from NHS 111. The numbers of attendances to ED has remained relatively stable but the admissions are on the increase.

NPo outlined some key figures confirming this. For the L&D there is a 7.3% rolling increase in total non- elective broken down that is 0 length of stay - people that are staying anything over 2 hours and less than 24 hours that has increased by 8%. The +1 month length of stays is 6.1 less (it is the 0 length of stays) which will suggests that we have opportunity need some diagnostic and mentioned SV and Dr James Ramsey are doing some deep dive detailed work on this. Our rolling increase on the 12 months in A&E is under approx 1.5% up.

Action: CS asked whether we can share with our neighbours the benchmark

Key issues highlighted  ABI rehabilitation pathway remains an issue for delays out of hospital.  Care home market is extremely fragile and represents a real problem for winter  High number of short stay admissions provide an opportunity for admission avoidance  Brexit planning

PLo stated that we know what the problems are but how do we deal with that because that is the key to successful planning.

It was noted that there is a plethora of interventions to avoid conveyance to hospital, however, schemes are not widely understood or used consistently. LSe stated there is a Nero Rehab service with a Nero specialist nurse at the Physiotherapy Occupational Therapy. Action: NPo to review with Amanda Flower re ABI

NPo commented that Kate Sutherland (joint post with LBC and LCCG) is coordinating Alcohol detox with support with ELFT.

PLo agreed with MOL re system mitigation. What will be dropped in the event of a crisis? It may be that the system will need to aggressively prioritise certain elements of work. If this will lead to failure to maintain certain treatment targets, it will need AEDB agreement and acceptance.

GZ asked how many people appropriately attend A&E PLo stated about 46% is streamed to the UGPC which is staffed by GPs. While this is not called inappropriate it is an indicator of the acuity of the patient condition.

LA asked as a system are we doing for example a table top exercise where we run through a scenario of the worse case this winter what the impact for each individual agents where it will draw out where our risks mitigations are. PL to include this option in the Plan.

MB stated that over 80% of admissions beds are mental health patients and come from the ‘out of hours’ service and unless they are section under 136 they will go into A&E; what is recognised from shift patterns is when we get the clinical 24/7’s psychiatric liaison team queries that they will return to A&E. MB suggested stripping out the mental health part as the impact on the CRHT crises lines in relation to activity and physically health care plan and ELFT is a large cohort. It was noted there are nurses in the out of hours. Action: Npo to discuss with Loraine Rossati and MB to define the issue which we’re trying to solve.

PLO asked are we clear as a system that in the event of a crisis of demand that all parts of the system

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were aware of the required actions they should take to give the hospital some assurance of clearing bed pressure

LSe wanted everyone in the system to know what is available e.g. there are a number of services that would cover night-sitting out of hours that charities provide like Keech and age UK. Also LSe asked what we can do upstream for vulnerable people as they are likely to miss out in the winter, such as frail and elderly people as there are 700 on the register; can some resilience be put in place. How can we engage better? There are some ‘End of Life’ patients in the L&D which cannot be transferred.

PLo suggested having a focus core operational group sitting somewhere between an executive and A&E delivery board people who can make decision. This would need system agreement if it were deemed necessary.

The Winter Plan will be signed off by the local A&E delivery board and any suggestions would be helpful where they think their organisations are and to think what the mitigations are the issue. 5. New Community Pharmacy Contract Presentation GZ gave an overview of the contract. When the launch of the Community Pharmacist Consultation Service (CPCS) it was asked how can we move forward in community pharmacy in a different way. Having the dispensing side and a number of local commissioned services and a number of advanced national services such as the flu vaccination service. How can pharmacy are better integrated within the NHS and to be part of primary care and how to move forward and have a better understanding of where they are placed for future years. Slides inserted

Data collected will help to improve outcomes in public health and input into systems. The pharmacy integration funds which is money taken out of the global sum and is put into new services relating to prevention such as detection of undiagnosed CVD, Point of Care Testing to support efforts to tackle Antimicrobial resistance, Stop smoking referrals from secondary care, Support for PCN service specifications and routine monitoring of patients on repeat medication ensuring the medication is doing the correct job.

Medicines reconciliation service to ensure changes in medication in secondary care when patients are discharged into the community. There was a launch of a new service called TCAN this is when a patient is discharged from hospital the discharge could go to the GP however the pharmacy may have a copy of the prescription that has come directly from the GP or the patient, how do we know that this is the right medication to reduce risk of the right medication dispensed. TCAN will send electronically the prescription to the patients’ pharmacy, the patient will give verbal permission and the pharmacy will receive the medication that the patient has been discharged with. The pharmacy can refer back to the patients GP or L&D to ensure the patients safety; there will be an alert system set up that will show which patient it is (no details of the patient) just a referral. The GP will always be kept in the loop, this is a live system.

An advance service is where a patient has been given new medication the pharmacy can provide a service which is NMS (New Medicines Service) expansion to new conditions such as anticoagulation medication the public health is looking to expands this so the pharmacy that interaction and more time with the patient. There is also going to be a new service to improve access to palliative care medicines.

MURs to be phased out as Structured Medication Reviews carried out by clinical pharmacists working within PCNs are introduced to see whether the patient understands what their medicines is for and whether they are getting any side effects and whether the pharmacists need a conversation with their GP practices, although this service is going to be phased out. The MURs will be taken over by the GP practice by the clinical pharmacist in the some of the MUR work out of community pharmacy with full

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process from the department of health is this releases sometime in the pharmacy for the community pharmacy and with their team to take on the new clinical additional roles.

Pharmacy Quality Scheme (PQS) Criteria How can we be assured that what is happening to the pharmacy is done in a high standard. Some of the training by CPPE for pharmacists will be on Sepsis and assessment with risk mitigation; it is department of health funded, face to face as well as online.

Medicines Safety Audits complementing the GP QOF QI To compliment the QOF practice pharmacists will have to take part in number of new accordance Lithium, valproate, repeat of the NSAIDs and gastro-protection audit. The department of health stated there is a need to involve Primary Care Networks which will mean working with pharmacists and practitioners therefore an agreement needs to be put in place to demonstrate that in each PCN area to have a lead pharmacists in to make a decisions who that lead will be and no pharmacy will have preference treatment from that network.

The following slide described new services such as the CPCS – from October 2019, positions pharmacies as healthy living centres, prevention and treating minor conditions, major key role at the heart of the NHS an opportunity to start with the Community Pharmacy Consultation Service and to make case for further investment within the scheme to expand. There will change of use of practice spacing, in particular to improve automatic.

Enabling change • Exploring greater use of original pack dispensing to support automation • Proposing legislative changes that allow better use of skill mix and enable clinical integration of pharmacists • Exploring the impact of changes to funding and fee structures, including for different types of prescription

Reflections where we are now • The changes over the next five years will not be easy • All pharmacies under pressure • But community pharmacy has a way forward and a vision for the future

Conclusion • Community pharmacy has a clear vision for our future – set out in deal document • It is critical that pharmacies deliver • This means major changes for all pharmacies • A chance to put community pharmacy at the heart of primary care • Offering clinical support to the NHS

6. Any Other Business: NPo updated the committee re Integrated Care Providers; there is a new document just published for CCG’s roles where ICP are established.

BLMK system chief executive is having early discussions about a potential footprint for our ICS. Personalisation, population health and wider determents of health will all influence local decisions.

LSe mentioned that the Palliative Care consultant has gone on sabbatical leave therefore there is no cover so cannot hold MDT without a medical director NPo agreed to discuss with Carole Gillespie and CCS.

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Apologies received for October’s meeting Dr Safiya Virji Lewis Andrews

The next transformation board meeting will be :- Date: Wednesday 23rd October 2019. Venue: Conference Room, 3rd Floor Arndale House, The Mall, Luton, LU1 2LJ Time: 13:00-15:00 p.m.

Any issues or agenda items please forward to [email protected]

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