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Governing Body st Date: 1 September 2016 th st Report title: Chairs Report 11 July – 31 August 2016 Lead Clinician Cliff Richards, Chair Purpose: This report sets out some key areas of work, in addition to their usual duties, for the Chair since the last Governing Body meeting. The Governing Body is Note the contents of this report. asked to: Chair’s Report I give my apologies to Governing Body as at present I am installing my final exhibition at the University Central Lancashire for my Masters in Fine Art. The private view for this show is on the evening of Wednesday, 7 September and all are welcome.

I would like to inform the Governing Body that I have now stepped down as Chair of Cheshire and Merseyside Urgent Care network. I had given a commitment to initiate the network and after a year, now that the network is established I felt it was time to concentrate my limited resources within NHS Halton CCG.

I have been involved with Jan Snoddon, Chief Nurse in reviewing the clinical leadership of NHS Halton CCG, with discussions with the clinical leads, with the practice leads, with the membership as a whole and at Service Development Committee.

The focus of which is aligning our clinical leadership with the 6 One Halton themes with connecting our Commissioning Managers more closely with our clinical leaders, and producing a clinical leadership model which is strategically led, developmental and sustainable. Jan and I are soon to put the detail on this for final agreement.

The cultural manifesto, dealing with NHS Halton CCG's approach to sport, the arts, the environment and social value has now moved in 2nd phase with development of a written document. For the past year or so many developments have occurred or been enlivened by conversations around the cultural manifesto, however the time seems right to enhance our partnerships with a written document. If any Governing Body members want further information or to be more involved in this process please contact either myself or Dave Sweeney.

The key issue for the NHS at the present moment is sustainability particularly financial control. The key function of a the Governing Body over the next few years is to be informed of and guide NHS Halton CCG through the difficult decisions that are required throughout this period. Thus the Governing body will need clear line of sight through the sustainability agenda and the STP planning process.

Lastly a reminder of the AGM will be on the afternoon of 26 September and will take place within a Walk in the Park.

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Governing Body

st Date: 1 September 2016 th st Report title: Chief Officer’s Report: 7 July 2016 to 31 August 2016 Lead Clinician and/or Simon Banks, Chief Officer Lead Manager: Purpose: This report sets out some key areas of work, in addition to their usual duties, for the Chief Officer since the last Governing Body meeting. Recommendations: Note the contents of this report.

Chief Officer’s Report

Working with Service Providers

Bridgewater Community Healthcare NHS Foundation Trust

On 8th July 2016 we held a Board to Board with Bridgewater Community Healthcare NHS Foundation Trust. In addition to discussion about the developing Sustainability and Transformation Plan (STP), we discussed issues of service quality and the development of community services based around neighbourhood hubs in the borough.

5 Boroughs Partnership NHS Foundation Trust

On 1st August 2016 we held a Board to Board with 5 Boroughs Partnership NHS Foundation Trust. The meeting focused on the developing STP and the role of mental health services within it. There was also discussion over taking forward the recommendations of the Tony Ryan review.

North West Ambulance Service NHS Trust Strategic Partnership Board

On 4th August 2016 the Chief Officer attended the NWAS Strategic Partnership Board as the Accountable Officer representative from Merseyside CCGs. The meeting focused on performance in both Paramedic Emergency Services (PES) and Patient Transport Services (PTS). NHS Blackpool CCG work on behalf of all North West CCGs in regard to the contract management of NWAS.

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Commissioning in partnership with other organisations

Children’s Trust Board

The Chief Officer attended the Children’s Trust Board on 14th July 2016. The Board was organised and delivered in a different and more interactive format, based upon feedback from the young people, their carers, families and representative groups who participate in the meetings. It would appear that the transition between children’s services and adult services and preparations around the Special Educational Needs and Disability (SEND) Education, Health and Care (ECH) plans remain areas in which improvements can be made.

New Models of Care – Acute Care Collaboration Vanguard – Cheshire and Merseyside Women’s and Children’s Service Partnership

In the last month the Chief Officer has continued his work as Senior Responsible Officer for this New Care Models Acute Care Collaboration Vanguard. Activities connected with this work have included:

 Attending the launch of the Game Changer programme on 19th July 2016 – see http://www.widnesvikings.co.uk/article/50333/gamechanger.  Supporting the team to secure additional resources from the New Care Model’s team through a revised Value Proposition.  Preparing a submission for the Cheshire and Merseyside Sustainability and Transformation Plan (STP) and attending the fortnightly Steering Group from 10th August 2016.

Sustainability and Transformation Plan and Local Delivery System Plan

On 19th July 2016 the Chief Officer attended the Alliance Local Delivery System working group. On 4th August 2016 Dr Steve Cox, Clinical Chief Executive, NHS St Helens CCG stepped down from his role as Chair of the Alliance Local Delivery System (LDS) of which Halton is a part. The Chief Officer has now taken on this role, which is requiring an additional time commitment to prepare a LDS submission in draft for 1st September 2016 and finally by 30th September 2016 for the next iteration of the Cheshire and Merseyside Sustainability and Transformation Plan (STP). The Chief Officer is now also a member of the STP Steering Group, which meets fortnightly; in his capacity as SRO for the Vanguard programme (q.v). and as Chair of the Alliance LDS.

Strengthening Financial Performance and Accountability in the 2016/17

On 21st July 2016 NHS Improvement published Strengthening Financial Performance and Accountability in the 2016/17. The document was effectively as ‘reset’ for the NHS and outlined a wide-ranging seven-point set of actions for the NHS to take forward:

 allocating an extra £1.8 billion to trusts, with the aim set by NHS Improvement of cutting the

Page 2 of 5

combined provider deficit to around £250 million in 2016/17 and the ambition that, in aggregate, the provider position commences 2017/18 in run-rate balance.

 replaced national fines with trust-specific incentives linked to agreed organisation-specific published performance improvement trajectories, so as to kickstart a multi-year recovery and redesign of A&E and elective care.

 agreed 'financial control totals' with individual trusts and CCGs, which represent the minimum level of financial performance, against which their boards, governing bodies and chief executives must deliver in 2016/17, and for which they will be held directly accountable.

 introduced new intervention regimes of special measures which will be applied to both trusts and CCGs who are not meeting their financial commitments.

 set new controls to cap the cost of interim managers and to fast track savings from back office, pathology and temporary staffing.

 published the 2015/16 performance ratings for CCGs.

 launched a two-year NHS planning and contracting round for 2017/18-2018/19, to be completed by December 2016, and linked to agreed STPs.

The full document can be found at: https://improvement.nhs.uk/resources/strengthening-financial- performance-and-accountability-201617/

2016/17 A&E Improvement Plan

On 26th July 2016, following on from Strengthening Financial Performance and Accountability in the 2016/17, NHS Improvement, Association of Directors of Adult Social Services (ADASS) and NHS England wrote to all CCGs, providers and local authorities setting out the importance of improving performance and delivering NHS Constitution standards in respect of A&E. A copy of this letter is attached. The existing System Resilience Groups, which focused on urgent care as well as 18 weeks referral to treatment and the achievement of NHS Constitution Standards in regard to cancer waiting times, will be replaced by Local A&E Delivery Boards.

NHS England North Commissioners Event

On 28th July 2016 the Chief Officer attended a NHS North event that brought together all the CCGs in the North of England. The event, which was held in Leeds, looked at the opportunities and challenges faced by CCGs in 2016/17 and beyond.

Liverpool City Region NHS CCG Alliance

The Chief Officer and Chair attended this meeting on 3rd August 2016. The session, which was

Page 3 of 5

facilitated by David Fillingham from AQUA, explored how CCGs could work more closely together across the Liverpool City Region footprint.

Liverpool City Region Collaborative Leadership Group

The Chief Officer attended this meeting on 8th August 2016. The Group is chaired by Margaret Carney, Chief Executive, Sefton Council and is attended by CCGs and local authority Directors of Adult Social Services. The STP was the main agenda item at this meeting.

Assurance by NHS England

NHS England has published the outcome of NHS Halton CCG’s 2015/16 Assurance and the organisation has been rated as ‘Good’. A copy of this report and accompanying letter is attached to this report.

Focusing on quality

As part of routine operational business, clinicians and managers from NHS Halton CCG have been involved in a number of meetings that focus on the quality of services provided for Halton residents. These meetings have included quality boards that are associated with our main providers as well as the Merseyside Quality Surveillance Group, all of which occur monthly.

Being accessible and accountable to local communities

Disability Awareness Day

NHS Halton CCG was one of the corporate sponsors of the 25th Disability Awareness Day held in Walton Gardens on 10th July 2016. NHS Halton CCG had a stand at the event and the Chief Officer received a certificate of recognition on behalf of the organisation from the event organisers.

Halton People’s Health Forums

The Chief Officer attended two Halton People’s Health Forums on 12th July 2016 and 14th July 2016. These events discussed our future plans around One Halton and the key delivery workstreams.

Meeting with MPs

The Chair and Chief Officer met with Graham Evans MP and Derek Twigg MP on 15th July 2016. Both MPs have recently had low key visits to the Urgent Care Centres and were impressed with the services offered. We also briefed them both on our work within the STP and our closer working with NHS Warrington CCG.

Page 4 of 5

Well North

The Well North programme is evolving to support three distinct schemes based around Windmill Hill, Halton Brook and Halton Stadium. The Chief Officer chaired the Steering Group on 25th July 2016.

Developing our organisation and individuals

Governing Body Development Session

On 21st July 2016 we held a Governing Body Development Session that focused on our responsibilities in regard to safeguarding and also the Equality Act 2010. We also had a learning session on Information Governance.

Other key issues

The Chief Officer attended a meeting of the Nuffield Trust’s Commissioners Learning Network on 20th July 2016.

Page 5 of 5

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Group 1 (3)

Airedale NHS Foundation Trust Harrogate District NHS Foundation Trust Sheffield Children’s NHS Foundation Trust

Group 2 (16)

Barnsley Hospital NHS Foundation Trust Bradford Teaching Hospitals NHS Foundation Trust Calderdale and Huddersfield NHS Foundation Trust Doncaster and Bassetlaw NHS Foundation Trust Gateshead Health NHS Foundation Trust Lancashire Teaching Hospitals NHS Foundation Trust Mid Cheshire Hospitals NHS Foundation Trust North Tees and Hartlepool NHS Foundation Trust Northern Lincolnshire and Goole NHS Foundation Trust Northumbria Healthcare NHS Foundation Trust Salford Royal NHS Foundation Trust Sheffield Teaching Hospitals NHS Foundation Trust South Tees Hospitals NHS Foundation Trust South Tyneside NHS Foundation Trust The Newcastle upon Tyne Hospitals NHS Foundation Trust Wrightington, Wigan and Leigh NHS Foundation Trust

Group 3 (11)

Alder Hey Children’s NHS Foundation Trust Bolton NHS Foundation Trust Central Manchester University Hospitals NHS Foundation Trust City Hospitals Sunderland NHS Foundation Trust Countess of Chester Hospitals NHS Foundation Trust East Cheshire NHS Trust East Lancashire Hospitals NHS Trust Leeds Teaching Hospitals NHS Trust North Cumbria University Hospitals NHS Trust The Rotherham NHS Foundation Trust University Hospitals of Morecambe Bay NHS Foundation Trust

Group 4 (15)

Aintree University Hospital NHS Foundation Trust Blackpool Teaching Hospitals NHS Foundation Trust County Durham and Darlington NHS Foundation Trust Hull and East Yorkshire Hospitals NHS Trust Mid Yorkshire Hospitals NHS Trust Pennine Acute Hospitals NHS Trust Royal Liverpool and Broadgreen University Hospitals NHS Trust Southport and Ormskirk Hospitals NHS Trust St Helens and Knowsley Teaching Hospitals NHS Trust Stockport NHS Foundation Trust Tameside Hospital NHS Foundation Trust University Hospital of South Manchester NHS Foundation Trust Warrington and Halton Hospitals NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust York Teaching Hospital NHS Foundation Trust

Our ref: CMCDRC525 Cheshire & Merseyside Regatta Place Simon Banks Brunswick Business Park Chief Officer Summers Road NHS Halton CCG Liverpool 1st Floor L3 4BL Runcorn Town Hall [email protected] Heath Road 0113 825 2889 Runcorn WA7 5TD 11 July 2016

Dear Simon

Re: CCG Annual Assurance 2015/16

Thank you for meeting with us via teleconference on 29th March 2016 to discuss the CCG Assurance Annual Assessment for 2015/16. I am grateful to you and your team for the work you have done to prepare for the meeting and for the open and transparent nature of our discussions.

The enclosed document (Annex A) provides a brief summative assessment of the assurance meetings held over the last year against the assurance components in the 2015/16 CCG Assurance Framework, which informed the CCG’s 2015/16 annual headline rating. We have also summarised areas of strength and where improvement is needed. These will be used to inform how CCG support available in 2016/17 will be tailored to individual CCG needs.

A number of principles have been applied to the five component assessments to reach the annual headline assessments for 2015/16. It has also been agreed to describe the headline ratings in the 2016/17 language of outstanding, good, requires improvement and inadequate.

Therefore, the headline rating for NHS Halton CCG is Good. The principles used to reach this assessment are:  outstanding is applied where at least one component is outstanding and the others are all good.  good is applied if: o all components are good; or, o at least four components are rated as good (or good and outstanding) and one component is requires improvement, unless requires improvement is in the finance or planning components.  the headline is requires improvement if:

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ANNEX A – ASSURANCE SUMMARY 2015/16

Throughout the year, we have identified the following areas of strength, areas of challenge and improvement and considered the key actions required against the five components of the 2015/16 framework. This includes: The need for a long term plan to implement the Five Year Forward View; Confirmation of an agreed service development and improvement plan to implement the new mental health access standards; and clarification of the CCG’s progress on delegated primary care commissioning arrangements with NHS England.

Key Areas of Strength / Areas of Good Practice  The CCG has implemented a Cancer Patient Tracker system, focussing on pre- breach patients to avoid potential breaches occurring;  The CCG is developing a standardised pathway for Urology patients;  The CCG performance was under its 2015-16 C-Diff ceiling;  The financial performance of the CCG in meeting the 2015-16 Business Rules.  Leadership role for the Cheshire and Merseyside Urgent &Emergency Care Network  Leadership role for the Cheshire and Merseyside Maternity & Children’s Vanguard

Key Areas of Challenge  The restructure at the main acute Trust has been a challenge. However the CCG Lead has now been allowed to attend meetings to assist with Governance;  There is currently not a designated doctor in Halton for Safeguarding. However, a procurement exercise is currently underway, led by Liverpool CCG, for a Merseyside-Wide Service.  Delivery of Urgent Care

Key Areas for Improvement  The IAPT Recovery Ambition is currently the worst in the region. There is currently a piece of work being undertaken to investigate the reasoning behind patients reportedly not completing the treatment pathway and to improve waiting times;  The CCG is looking at work that can be done as a Mid Mersey footprint.  The CCG is to focus on improving the services for Looked After Children.

Development Needs and Agreed Actions  The CCG should consider the information in the 2016 360 Degree Stakeholder Feedback Survey and refine its Organisational Development Plan;  The CCG must ensure that there is a focus upon Mental Health. In particularly there needs to be a sustained improvement in performance against the IAPT metrics;  Given the increase in the number of Mental Health Metrics in 2016/17, the CCG should consider approaching other CCGs to create a virtual team to enable the commissioning of mental health on a larger footprint.

ASSURANCE COMPONENTS

Well Led Organisation (Assured as Good) Under this component of assurance the key areas for enquiry are strong and robust leadership; robust governance arrangements; actively involves and engages patients and the public and works in partnership with others, including other CCGs. We have 3 also looked at how the CCG secures the range of skills and capabilities it requires to deliver all of its commissioning functions, including effective use of support functions and getting the best value for money.

As part of the assessment of the CCG’s compliance with its statutory duties we have also considered the six statutory functions which NHS England has required a more detailed focus on in 2015/16 because of the complexity of the issues or the degree of risk involved. These are:

i. NHS Continuing Healthcare ii. Safeguarding of Vulnerable Patients iii. Equality and health inequalities iv. Learning disability v. Use of research vi. Special Educational Needs and Disabilities CCG Compliance of Statutory Duties: Transforming Care:  Performance has been hindered by transfers of patients from NHS Liverpool CCG, affected the Recovery Plan. Continuing Health Care (Previously Unassessed Periods of Care):  The plan is slightly off trajectory due to new cases received during the second Quarter of 2015/16; Equality and Health Inequality:  The CCG has an robust understanding of the inequality challenge locally and is taking concerted action to reduce these through: a. Range of JSNAs including full JSNA, Children, LAC, Older people and practice based JSNAs; b. Health inequalities work across practices; c. Work programmes to reduce variation in service provision and delivery across practices; d. Wellbeing approach to health; e. Partnership work with Public Health, the Viking and other organisation to improve engagement in wellbeing and health; f. Specific work locally to improve employment prospects for people with learning disabilities and mental health issues. Learning Disabilities:  The CCG has no Inpatient Service Users and is engaged in the transforming care board and the programmes of work for the board including commissioning plans for future models of care  In the Transforming Care Plan, the CCG has no Learning disability (LD) inpatient beds, as these were closed five years ago. There are plans in place for clients at risk of requiring admission and repatriation;

Safeguarding:  The CCG Designated Doctor retired during late 14/15 initially returning part time with the agreement that they would continue in the role. However, capacity became an issue. The procurement process has now commenced across the CCGs. The CCG has implemented the following risk mitigation:  There is experienced Designated Nursing support as part of the Mersey CCG service and has negotiated advice and support if required from local designated doctors;  Recruitment of a named GP with extra sessions and capacity for provision of support;  The LSCB is fully informed of the plans and are assured that this issue is management  The CCG in the process of completing Section 11 audit and NHSE Assurance assessment. 360 Degree Stakeholder Feedback Survey:  All but 1 of the areas within the Engagement Section has seen a reduction against the 2015 Survey;  A slight reduction in the proportion of respondent reporting that “the CCG communicates effectively on the commissioning decisions it makes” and “that the CCG will deliver continuous improvement in quality”;  There has been a reduction in the satisfaction ratings in all areas of the Overall Leadership of the CCG Section of the Survey;  The proportion of respondents having “Confidence in the leadership of the CCG to deliver improved outcomes for patients” reducing by 18% against the 2015 Survey;  The questions in the Clinical Leadership areas have also seen a reduction in the reported confidence levels;  The proportion of respondents having confidence that “When I have commented on the CCG’s plans and priorities I feel that my comments have been taken on board” has reduced by 20% compared with the 2015 Survey.

Delegated Functions (Assured as Good) Specific additional assurances have been required from CCGs with responsibility for delegated functions in 2015/16. This is in addition to the assurances needed for out-of- hours Primary Medical Services.

 The CCG had adopted Fully Delegated Primary Care Commissioning responsibilities for General Medical Services from 1st April 2015;  No material issues had been noted on the Delegated Functions Self- Certifications that had been received to date.

Financial Management (Assured as Good) We have monitored the CCG’s financial management and performance throughout the year, including looking at the quality of financial data submitted and how the CCG has managed its financial problems.

 It was noted that during the meeting that The CCG met the Business Rules in 2015/16; and  Is planning to do so for 2016/17.

The assessment was in line with the following nationally accepted criteria, as advised during the Regional Moderation process:

Performance category Assurance Rating Achieving or exceeding plan and 1% Assured as Good underspend Achieving or exceeding plan and < 1% Limited Assurance Requires underspend improvement Limited Assurance Requires Not achieving plan with underspend > 1% improvement Not achieving plan with underspend < 1% or Inadequate breakeven Achieving or over-performing against a Limited Assurance Requires deficit plan and reporting a deficit improvement Failing to deliver an underspend or Inadequate breakeven plan and in deficit Failing to deliver a deficit plan Inadequate

Performance (Assured as Good) We have reviewed how well the CCG has delivered improved services, maintained and improved quality, and ensured better outcomes for patients, including progress in delivering key Mandate requirements, NHS Constitution standards and Urgent Care.

Diagnostics:  The CCG achieved the Standard throughout the year.

52 Week Waiting Times:  The CCG reported one breach of the Standard in November 2015. The two local acute Trusts did not have any breaches of the Standard for the year.

62 Day Cancer:  The CCG failed to achieve the Standard in 8 months of the Year. This has been investigated but there does not appear to be any common theme or pattern.

MRSA:  The CCG had only its 1st confirmed breach in 2 years. Work is ongoing to determine if this was a hospital or community acquired infection. RTT:  The CCG has achieved the Standard throughout the year.

Dementia:  The CCG was achieving the ambition as at the end of Quarter 3.

Improving Access to Psychological Therapies (IAPT)  The CCG was marginally under the Access ambition as at the end of Quarter 3;  The CCG was not achieving the Recovery ambition as at the end of Quarter 3.

Care Programme Approach:  The CCG achieved the Standard throughout the year.

Mixed Sex Accommodation:  As at the end of February 2016, there have been five breaches in the year. All of them were at Warrington & Halton Hospitals NHS Foundation Trust. All of the breeches have been investigated (RCA) and relate to CCU and ITU and have action plans in place

Planning (Assured as Good) The assurance of CCG plans is a continuous process, covering annual operational plans and related plans such as those relating to System Resilience Groups, the Better Care Fund, and longer term strategic plans including progress in implementing the Five Year Forward View. This component also considers progress in moving providers from paper-based to digital processes and the extent to which NHS number and discharge summaries are being transferred digitally across care settings to meet the ambition for a paperless NHS.

 The CCG has submitted an Operational Plan, in accordance with the National Expectations, including a financial plan that meets the 2016/17 Business Rules;  The Better Care Fund Plan was Fully Approved.  The System Resilience Group Winter Plan was assured as Good.

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NHS England INFORMATION READER BOX

Directorate Medical Operations and Information Specialised Commissioning Nursing Trans. & Corp. Ops. Commissioning Strategy Finance

Publications Gateway Reference: 05544 Document Purpose Report Document Name CCG Assurance Annual Assessment 2015/16 Author CCG Planning and Assessment National Team Publication Date 21 July 2016 Target Audience CCG Clinical Leaders, CCG Accountable Officers, NHS England Regional Directors, NHS England Directors of Commissioning Operations, Patients and public, all CCG stakeholders Additional Circulation #VALUE! List Description NHS England conducts an annual performance assessment of CCGs. This report provides the assurance rating for each CCG.

Cross Reference 0 Superseded Docs CCG Assurance Annual Assessment 2014/15 (if applicable) Action Required N/A

Timing / Deadlines N/A (if applicable) Contact Details for CCG Planning and Assessment National Team further information [email protected] 0 Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet.

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CCG assurance annual assessment 2015/16

Publications Gateway reference number:

Version number: 1.0

First published: 21 July 2016

Prepared by: CCG Planning and Assessment National Team

Classification: OFFICIAL

This document can be made available in alternative formats, such as easy read or large print, and may be available in alternative languages, upon request. Please contact 0300 311 22 33 or email [email protected]

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1 Annual assessment 2015/16

1.1 Introduction NHS England conducts an annual performance assessment of CCGs. The assurance framework for 2015/16 assessed CCGs against five components of assurance. The criteria for assessing each component during the year are set out in the CCG assurance framework. The year-end component assessment balances an overview of the CCG’s performance during the year with the level of risk it is carrying forward in to the next year.

CCGs may be assessed in four categories: outstanding, good, requires improvement and inadequate. The principles used to create headline assessments from the five components of assurance are:

 outstanding is applied where at least one component is outstanding and the others are all good;

 good is applied if o all components are good; or o at least four components are rated as good (or good and outstanding) and one component is requires improvement, unless requires improvement is in the finance, planning or well led component;

 the headline is requires improvement if o four components are rated as good (or good and outstanding) and the finance, planning or well led components are assessed as requires improvement or inadequate; o there is more than one requires improvement component rating; and o no more than one component is assessed as inadequate;

 A CCG is inadequate overall if o more than one component is rated as inadequate; o it already has directions (under section 14.z.21 of the NHS Act 2006, as amended) in force.

The table below shows the assurance rating of each CCG. Further details of assurance outputs may be available for public review by the CCG itself.

NHS England provides an annual survey of CCG partners and a summary of the results, the CCG 360 stakeholder survey 2015/16, is published alongside this report.

2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions NHS Airedale, Requires Requires Wharfedale and Good Good Good Good improvement improvement Craven CCG Requires Requires Requires Requires Requires NHS Ashford CCG Good improvement improvement improvement improvement improvement NHS Aylesbury Vale Good Good Good Good Good Good CCG NHS Barking and Requires Requires Requires Requires Good Inadequate Dagenham CCG improvement improvement improvement improvement Requires Requires Requires Requires Requires NHS Barnet CCG Good improvement improvement improvement improvement improvement NHS Barnsley CCG Good Good Good Good Good Good NHS Basildon and Requires Requires Requires Requires Requires Good Brentwood CCG improvement improvement improvement improvement improvement NHS Bassetlaw CCG Outstanding Outstanding Good Good Good Good NHS Bath and North Requires Requires Requires Requires Requires Good East Somerset CCG improvement improvement improvement improvement improvement NHS Bedfordshire Requires Requires Requires Inadequate Good Inadequate CCG improvement improvement improvement Requires Requires Requires Requires NHS Bexley CCG Good Good improvement improvement improvement improvement NHS Birmingham Requires Requires Requires Good Outstanding Good Crosscity CCG improvement improvement improvement

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions NHS Birmingham Requires Requires Requires South and Central Good Outstanding Good improvement improvement improvement CCG NHS Blackburn with Requires Requires Good Good Good Good Darwen CCG improvement improvement Requires Requires NHS Blackpool CCG Good Good Inadequate Good improvement improvement NHS Bolton CCG Good Good Good Good Good Good NHS Bracknell and Good Good Good Good Good Good Ascot CCG NHS Bradford City Good Good Good Good Good Good CCG NHS Bradford Good Good Good Good Good Good Districts CCG Requires Requires Requires NHS Brent CCG Good Good Good improvement improvement improvement NHS Brighton and Inadequate Inadequate Good Good Inadequate Inadequate Hove CCG Requires Requires Requires Requires Requires NHS Bristol CCG Good improvement improvement improvement improvement improvement Requires Requires Requires NHS Bromley CCG Good Good Good improvement improvement improvement

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions Requires NHS Bury CCG Good Good Good Good Good improvement NHS Calderdale CCG Good Good Good Good Good Good NHS Cambridgeshire Requires Requires and Peterborough Inadequate Inadequate Good Inadequate improvement improvement CCG Requires NHS Camden CCG Good Good Good Good Good improvement NHS Cannock Chase Requires Requires Requires Good Good Good CCG improvement improvement improvement NHS Canterbury and Requires Requires Requires Good Good Good Coastal CCG improvement improvement improvement NHS Castle Point and Requires Good Good Good Good Good Rochford CCG improvement NHS Central London Requires Good Good Good Good Good (Westminster) CCG improvement NHS Central Good Good Good Good Good Good Manchester CCG NHS Chiltern CCG Good Good Good Good Good Good NHS Chorley and Requires Good Good Good Good Good South Ribble CCG improvement NHS City and Good Good Good Good Good Good Hackney CCG

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions NHS Coastal West Requires Requires Requires Good Good Good Sussex CCG improvement improvement improvement Requires Requires Requires Requires Requires Requires NHS Corby CCG improvement improvement improvement improvement improvement improvement NHS Coventry and Requires Requires Requires Inadequate Inadequate Inadequate Rugby CCG improvement improvement improvement Requires NHS Crawley CCG Good Good Good Good Good improvement Requires Requires Requires NHS Croydon CCG Good Good Inadequate improvement improvement improvement Requires Requires NHS Cumbria CCG Inadequate Good Inadequate Inadequate improvement improvement Requires NHS Darlingon CCG Good Good Good Good Good improvement NHS Dartford, Requires Requires Requires Requires Gravesham and Good Inadequate improvement improvement improvement improvement Swanley CCG NHS Doncaster CCG Good Good Good Good Good Good NHS Dorset CCG Good Good Good Good Good Good NHS Dudley CCG Outstanding Outstanding Good Outstanding Good Good NHS Durham Dales, Requires Easington and Good Good Good Good Good improvement Sedgefield CCG

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions Requires NHS Ealing CCG Good Good Good Good Good improvement NHS East and North Requires Good Good Good Outstanding Good Hertfordshire CCG improvement NHS East Lancashire Outstanding Outstanding Good Good Good Good CCG NHS East Requires Requires Requires Leicestershire and Good Good Good improvement improvement improvement Rutland CCG NHS East Riding of Requires Requires Requires Requires Good Good Yorkshire CCG improvement improvement improvement improvement NHS East Requires Requires Requires Good Good Good Staffordshire CCG improvement improvement improvement NHS East Surrey Requires Inadequate Inadequate Good Inadequate Inadequate CCG improvement NHS Eastbourne, Requires Requires Requires Hailsham and Good Good Good improvement improvement improvement Seaford CCG NHS Eastern Requires Requires Requires Good Good Inadequate Cheshire CCG improvement improvement improvement Requires Requires Requires NHS Enfield CCG Inadequate Good Inadequate improvement improvement improvement

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions Requires NHS Erewash CCG Good Good Good Good Good improvement NHS Fareham and Requires Requires Requires Requires Good Inadequate Gosport CCG improvement improvement improvement improvement NHS Fyle and Wyre Outstanding Outstanding Good Good Good Good CCG NHS Gloucestershire Requires Good Good Outstanding Good Good CCG improvement NHS Great Yarmouth Requires Requires Requires Good Inadequate Good and Waveney CCG improvement improvement improvement NHS Greater Requires Requires Requires Good Good Good Huddersfield CCG improvement improvement improvement NHS Greater Preston Requires Good Good Good Good Good CCG improvement Requires Requires Requires Requires NHS Greenwich CCG Good Inadequate improvement improvement improvement improvement NHS Guildford and Requires Requires Requires Requires Good Good Waverley CCG improvement improvement improvement improvement NHS Halton CCG Good Good Good Good Good Good NHS Hambleton, Requires Requires Requires Richmond and Whitby Good Good Good improvement improvement improvement CCG

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions NHS Hammersmith Requires Good Good Good Good Good and Fulham CCG improvement Requires NHS Hardwick CCG Good Good Good Good Good improvement Requires Requires Requires NHS Haringey CCG Good Good Good improvement improvement improvement NHS Harrogate and Outstanding Outstanding Good Good Good Good Rural District CCG Requires Requires Requires Requires Requires NHS Harrow CCG Good improvement improvement improvement improvement improvement NHS Hartlepool and Stockton-On-Tees Outstanding Outstanding Good Good Good Good CCG NHS Hastings and Requires Good Good Good Good Good Rother CCG improvement Requires Requires NHS Havering CCG Inadequate Good Good Inadequate improvement improvement NHS Herefordshire Requires Requires Inadequate Inadequate Inadequate Inadequate CCG improvement improvement NHS Herts Valleys Requires Requires Requires Requires Requires Good CCG improvement improvement improvement improvement improvement

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions NHS Heywood, Requires Middleton and Good Good Good Good Good improvement Rochdale CCG NHS High Weald Requires Good Good Good Good Good Lewes Havens CCG improvement Requires Requires Requires NHS Hillingdon CCG Good Good Good improvement improvement improvement NHS Horsham and Requires Good Good Good Good Good Mid Sussex CCG improvement Requires NHS Hounslow CCG Good Good Good Good Good improvement Requires Requires Requires NHS Hull CCG Good Good Good improvement improvement improvement NHS Ipswich and Requires Requires Requires Good Inadequate Good East Suffolk CCG improvement improvement improvement NHS Isle of Wight Requires Requires Requires Requires Good Good CCG improvement improvement improvement improvement NHS Islington CCG Good Good Good Good Good Good NHS Kernow CCG Inadequate Inadequate Good Inadequate Inadequate Inadequate Requires Requires Requires NHS Kingston CCG Good Good Good improvement improvement improvement NHS Knowsley CCG Good Good Good Good Good Good

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions Requires NHS Lambeth CCG Good Good Good Good Good improvement NHS Lancashire Requires Requires Good Good Good Good North CCG improvement improvement NHS Leeds North Good Good Good Good Good Good CCG NHS Leeds South Good Good Good Good Good Good and East CCG NHS Leeds West Good Good Good Good Good Good CCG NHS Leicester City Requires Requires Requires Requires Good Good CCG improvement improvement improvement improvement Requires Requires Requires NHS Lewisham CCG Good Good Good improvement improvement improvement NHS Lincolnshire Requires Requires Requires Requires Good Good East CCG improvement improvement improvement improvement NHS Lincolnshire Requires Requires Requires Good Good Good West CCG improvement improvement improvement NHS Liverpool CCG Good Good Good Good Good Good Requires Requires Requires NHS Luton CCG Good Good Good improvement improvement improvement NHS Mansfield and Requires Good Good Good Good Good Ashfield CCG improvement

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions Requires NHS Medway CCG Inadequate Good Good Inadequate Inadequate improvement Requires Requires Requires NHS Merton CCG Good Good Inadequate improvement improvement improvement Requires Requires Requires NHS Mid Essex CCG Good Good Good improvement improvement improvement NHS Milton Keynes Requires Requires Requires Requires Requires Good CCG improvement improvement improvement improvement improvement Requires Requires Requires Requires Requires NHS Nene CCG Good improvement improvement improvement improvement improvement NHS New Devon Requires Requires Requires Inadequate Good Inadequate CCG improvement improvement improvement NHS Newark and Requires Good Good Good Good Good Sherwood CCG improvement NHS Newbury and Good Good Good Good Good Good District CCG NHS Newcastle Outstanding Outstanding Good Good Good Good Gateshead CCG Requires NHS Newham CCG Good Good Good Good Good improvement NHS North and West Good Good Good Good Good Good Reading CCG

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions NHS North Requires Good Good Good Good Good Derbyshire CCG improvement NHS North Durham Requires Requires Good Good Good Good CCG improvement improvement NHS North East Requires Requires Requires Good Good Good Essex CCG improvement improvement improvement NHS North East Hampshire and Good Good Good Good Good Good Farnham CCG NHS North East Requires Requires Good Good Good Good Lincolnshire CCG improvement improvement NHS North Requires Requires Requires Inadequate Inadequate Inadequate Hampshire CCG improvement improvement improvement NHS North Kirklees Requires Good Good Good Good Good CCG improvement NHS North Requires Requires Requires Requires Good Good Lincolnshire CCG improvement improvement improvement improvement NHS North Requires Good Good Good Good Good Manchester CCG improvement NHS North Norfolk Requires Good Good Good Good Good CCG improvement NHS North Somerset Requires Inadequate Inadequate Good Inadequate Inadequate CCG improvement

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions NHS North Requires Requires Requires Requires Good Inadequate Staffordshire CCG improvement improvement improvement improvement NHS North Tyneside Requires Inadequate Good Inadequate Good Inadequate CCG improvement NHS North West Requires Good Good Good Good Good Surrey CCG improvement NHS Northumberland Requires Inadequate Good Inadequate Good Inadequate CCG improvement Requires NHS Norwich CCG Good Good Good Good Good improvement NHS Nottingham City Requires Requires Requires Good Good Good CCG improvement improvement improvement NHS Nottingham Requires Good Good Good Good Good North and East CCG improvement NHS Nottingham Requires Good Good Good Good Good West CCG improvement Requires NHS Oldham CCG Good Good Good Good Good improvement NHS Oxfordshire Good Good Good Good Good CCG Good NHS Portsmouth Requires Requires Requires Good Good Good CCG improvement improvement improvement

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions Requires Requires Requires Requires NHS Redbridge CCG Good Inadequate improvement improvement improvement improvement NHS Redditch and Requires Requires Requires Requires Good Good Bromsgrove CCG improvement improvement improvement improvement Requires Requires Requires NHS Richmond CCG Good Good Inadequate improvement improvement improvement Requires Requires NHS Rotherham CCG Good Good Good Good improvement improvement Requires NHS Rushcliffe CCG Good Good Good Good Good improvement NHS Salford CCG Outstanding Outstanding Good Outstanding Good Outstanding NHS Sandwell and West Birmingham Outstanding Outstanding Good Outstanding Good Good CCG NHS Scarborough Requires Requires Requires Requires Good Good and Ryedale CCG improvement improvement improvement improvement Requires Requires NHS Sheffield CCG Good Good Good Good improvement improvement Requires NHS Shropshire CCG Inadequate Inadequate Inadequate Inadequate Inadequate improvement NHS Slough CCG Good Good Good Good Good Good Requires Requires Requires NHS Solihull CCG Good Good Good improvement improvement improvement

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions Requires Requires Requires Requires Requires NHS Somerset CCG Good improvement improvement improvement improvement improvement NHS South Cheshire Requires Inadequate Good Inadequate Good Inadequate CCG improvement NHS South Devon Requires Inadequate Inadequate Good Inadequate Inadequate and Torbay CCG improvement NHS South East Staffordshire and Requires Requires Requires Good Good Good Seisdon Peninsula improvement improvement improvement CCG NHS South Eastern Requires Requires Requires Requires Good Inadequate Hampshire CCG improvement improvement improvement improvement NHS South Requires Requires Inadequate Good Inadequate Inadequate Gloucestershire CCG improvement improvement NHS South Kent Requires Requires Requires Requires Good Good Coast CCG improvement improvement improvement improvement NHS South Requires Requires Requires Good Good Good Lincolnshire CCG improvement improvement improvement NHS South Requires Good Good Good Good Good Manchester CCG improvement NHS South Norfolk Requires Requires Requires Requires Good Good CCG improvement improvement improvement improvement

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions NHS South Reading Good Good Good Good Good Good CCG NHS South Sefton Requires Requires Good Good Good Good CCG improvement improvement NHS South Tees Requires Good Good Good Good Good CCG improvement NHS South Tyneside Requires Good Good Good Good Good CCG improvement NHS South Requires Requires Requires Good Good Good Warwickshire CCG improvement improvement improvement NHS South West Requires Requires Requires Good Good Good Lincolnshire CCG improvement improvement improvement NHS South Requires Requires Requires Good Good Good Worcestershire CCG improvement improvement improvement NHS Southampton Requires Good Good Good Good Good CCG improvement Requires Requires Requires Requires NHS Southend CCG Good Good improvement improvement improvement improvement NHS Southern Requires Requires Requires Good Good Good Derbyshire CCG improvement improvement improvement NHS Southport and Requires Requires Inadequate Good Inadequate Inadequate Formby CCG improvement improvement

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions Requires NHS Southwark CCG Good Good Good Good Good improvement Requires NHS St Helens CCG Inadequate Good Inadequate Good Inadequate improvement NHS Stafford and Requires Requires Requires Good Good Good Surrounds CCG improvement improvement improvement Requires Requires Requires Requires NHS Stockport CCG Good Good improvement improvement improvement improvement NHS Stoke On Trent Requires Requires Requires Requires Good Inadequate CCG improvement improvement improvement improvement NHS Sunderland Requires Good Outstanding Good Good Good CCG improvement NHS Surrey Downs Requires Requires Inadequate Good Good Good CCG improvement improvement NHS Surrey Heath Requires Requires Good Good Good Good CCG improvement improvement Requires Requires Requires NHS Sutton CCG Good Good Good improvement improvement improvement Requires NHS Swale CCG Good Good Good Good Good improvement Requires Requires Requires Requires NHS Swindon CCG Good Good improvement improvement improvement improvement

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions NHS Tameside and Good Good Good Good Good Good Glossop CCG NHS Telford and Requires Good Good Good Good Good Wrekin CCG improvement Requires Requires Requires Requires NHS Thanet CCG Good Good improvement improvement improvement improvement Requires Requires Requires Requires Requires NHS Thurrock CCG Good improvement improvement improvement improvement improvement NHS Tower Hamlets Requires Good Good Good Good Good CCG improvement Requires Requires NHS Trafford CCG Good Good Good Good improvement improvement NHS Vale of York Requires Requires Inadequate Inadequate Inadequate Inadequate CCG improvement improvement Requires Requires NHS Vale Royal CCG Good Good Good Inadequate improvement improvement Requires NHS Wakefield CCG Good Good Good Good Good improvement NHS Walsall CCG Inadequate Inadequate Good Inadequate Inadequate Inadequate NHS Waltham Forest Requires Good Good Good Good CCG Good improvement NHS Wandsworth Requires Requires Requires Requires Good Good CCG improvement improvement improvement improvement

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions Requires Requires NHS Warrington CCG Good Good Good Good improvement improvement NHS Warwickshire Requires Requires Requires Good Inadequate Good North CCG improvement improvement improvement NHS West Cheshire Requires Requires Inadequate Good Inadequate Inadequate CCG improvement improvement NHS West Essex Requires Requires Requires Requires Good Good CCG improvement improvement improvement improvement NHS West Hampshire Requires Requires Requires Requires Good Inadequate CCG improvement improvement improvement improvement Requires NHS West Kent CCG Good Good Good Good Good improvement NHS West Lancashire Good Good Good Good Good Good CCG NHS West Requires Good Good Good Good Good Leicestershire CCG improvement NHS West London Requires Good Good Good Good Good (K&C & QPP) CCG improvement NHS West Norfolk Requires Requires Requires Requires Good Good CCG improvement improvement improvement improvement NHS West Suffolk Requires Requires Requires Good Good Good CCG improvement improvement improvement

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2015/16 components of assurance Headline Delegated CCG Well led Finance Performance Planning rating functions NHS Wigan Borough Good Good Good Good Good Good CCG Requires NHS Wiltshire CCG Good Good Good Good Good improvement NHS Windsor, Ascot and Maidenhead Good Good Good Good Good Good CCG Requires Requires Requires NHS Wirral CCG Good Good Inadequate improvement improvement improvement NHS Wokingham Good Good Good Good Good CCG Good NHS Wolverhampton Outstanding Outstanding Good Outstanding Good Good CCG NHS Wyre Forest Requires Good Good Good Good Good CCG improvement

GOVERNING BODY

st Date: 1 September 2016 Report title: NHS St Helens CCG Financial Recovery Consultation Lead Clinician and/or Simon Banks, Chief Officer Lead Manager: Purpose: The purpose of this paper is to inform the Governing Body of the consultation currently being undertaken by NHS St Helens Clinical Commissioning Group (CCG) on proposals that are designed to address their projected £12.5m deficit in 2016/17. The consultation has attracted significant interest in the national and local media and amongst patient groups, think-tanks and professional bodies. The Governing Body is Review the proposals, how we became aware of them and asked to: consider a response by NHS Halton CCG.

This Report supports the following CCG Strategic Objectives Three: To deliver improvements in the quality of the health and care services accessed by the people of Halton within the resources available to us and our partner organisations.

Four: To deliver all of our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place.

Commissioning Plan Implications Not applicable. Financial Implications The proposal to pause non-urgent referrals by NHS St Helens CCG, if carried through, may have had a detrimental impact on NHS Halton CCG and our financial position. Our shared provider of acute services, St Helens and Knowsley Teaching Hospitals NHS Foundation Trust, may have increased the rate at which non-St Helens residents are treated and, given we pay for the activity delivered by the Trust, this could have increased our over-performance and our financial deficit.

Page 1 of 4

Equality and Diversity and Human Rights Throughout the development of this paper and the policies and processes cited NHS Halton CCG has:  Given regard to the need to reduce inequalities between patients in access to, and outcomes from healthcare services and to ensure services are provided in an integrated way where this might reduce health inequalities.

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NHS St Helens CCG Financial Recovery Consultation

NHS St Helens Clinical Commissioning Group (CCG) is currently consulting on four key proposals that are designed to address their projected £12.5m deficit in 2016/17. The consultation has attracted significant interest in the national and local media and amongst patient groups, think-tanks and professional bodies. The proposals that NHS St Helens CCG are consulting on include:

Minor Ailments/Over the counter medicines

NHS St Helens CCG is proposing to stop providing over the counter/ minor ailment medicines for short-term and self-limiting conditions such as painkillers, cough and cold remedies, antihistamines and some skin conditions. This will not affect medicines which need to be prescribed by a doctor. NHS St Helens CCG currently spends over £1 million a year paying for widely available, over the counter medicines.

Gluten Free Products

A decision was taken 30 years go to include gluten-free foods on prescription, when there was limited availability of gluten free foods to buy. Today the availability of gluten-free foods has increased dramatically and they are found in all major supermarkets and health food shops.

NHS St Helens CCG is proposing to stop providing gluten-free unless there are specific circumstances whereby a dependent patient could be at risk of dietary neglect. Last year NHS St Helens CCG spent £103,000 (plus additional costs for processing the items).

Specialist Fertility Services

NHS St Helens CCG is proposing to stop routinely commissioned specialist fertility services by placing restrictions on age referral criteria. The programme proposed will suspend access to the pathway for anybody aged 37 and under (therefore a two-year suspension) but leave access to anybody aged over 37 who meets all the existing criteria of the local policy. Anyone aged 37 – 39 will qualify for 2 cycles of IVF. Anyone aged over 40 will qualify for one cycle.

Patients who have already commenced IVF treatment will be allowed to continue but no new referrals will be accepted after the proposed implementation date.

Pausing non-urgent referrals

NHS St Helens CCG is proposing to pause (temporarily suspend) non-urgent referrals to hospital for a maximum four month period. Hospital referrals are one of the CCG’s biggest areas of financial pressure and currently activity in the hospital exceeds the budget NHS St

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Helens CCG receives. NHS St Helens CCG believes that requesting a four month pause of all non-urgent treatment over the winter months there will be a number of additional benefits in addition to financial recovery:

 It will support hospitals during the busy winter period when there is a marked increase in patients requiring urgent treatment.  It will enable hospitals to concentrate on treating patients who require urgent referrals, suspected cancer and referrals for sick children.  It will reduce the risk of an operation being cancelled during the busy winter months when there are less non-urgent beds available in hospitals.

Referrals for any clinically urgent referrals, suspected cancer and referrals for sick children will not be included and will be referred as normal. Any decision not to refer will be made in agreement by the patient and GP.

Patients and public can have their say on these proposals on-line between Monday 1st August 2016 and Wednesday 5th October 2016 (inclusive) via an online survey https://www.surveymonkey.co.uk/r/ZZ7G5ZV.

Implications for NHS Halton CCG

NHS Halton CCG was not formally notified of any of the proposals that NHS St Helens CCG are consulting upon. We became aware of the proposals on 9th August 2016 through the national and regional media.

NHS Halton CCG, as part of our own Recovery and Sustainability Plan, are exploring whether we should continue to provide over the counter/ minor ailment medicines and gluten free products. We are not currently exploring any change to our commissioning of specialist fertility services, which follows National Institute for Health and Clinical Excellence (NICE) guidance.

The proposal to pause non-urgent referrals by NHS St Helens CCG was withdrawn on 11th August 2016 following extensive local, regional and national political and media coverage. If carried through it may have had a detrimental impact on NHS Halton CCG and our financial position. Our shared provider of acute services, St Helens and Knowsley Teaching Hospitals NHS Foundation Trust, may have increased the rate at which non-St Helens residents are treated and, given we pay for the activity delivered by the Trust, this could have increased our over-performance and our financial deficit.

The Governing Body is asked to review the proposals, how we became aware of them and consider a response.

Page 4 of 4

Integrated Governance Committee 13th July 2016

Agenda Item Key Issue: Action: CCG Item No: Ref: Datix Risk Ref: 3 Committee Committee analysed all risks, noted Qtr. 1 updates and refined risk Understand how PPGs and 23, 26 IGC 16-16 Risks definitions as appropriate. Practices engage with public 362, 364, regarding IT systems 365 The level of public engagement relating to IT strategy (risk 362) was discussed. 5 IG Working Committee received IG report for period 1st April – 27th May 2016, IGC 17-16 Group Update and approved 2016/17 Improvement Plan to underpin Version 14 of national IG Toolkit. It was noted that a new electronic system U- Assure will be adopted by the CCG to integrated information risk management. 6 Declarations of The Committee noted the annual refresh of declarations was Standards of Business Conduct to IGC 18-16 Interest Update underway with a number of practices outstanding for 16/17. Revised be updated, and audit of statutory guidance on managing conflicts of interest to be declarations to ensure consistency incorporated into Standards of Business Conduct Policy. undertaken. 8 Communication The Committee recommended approval of the Strategy for 2016-16 Strategy to be presented to 39 IGC 20-16 & Engagement and agreed Year 1 Action Plan Governing Body for ratification Strategy 9 Integrated The Integrated Governance Report for Qtr. 1 period covering FOI, IGC 21-16 Governance Incidents and PALS activity was noted. Analysis of 21 complaints Report was noted and further information relating to breakdown of category of complaints to be included in future reports. 10 I,M&T Working Qtr. 1 activity for 2016/17 noted with digital road map approval being 362,364 IGC 22-16 Group Update highlighted. Technology bids had been submitted for end of June deadline. 11 Disclosure of Committee noted new requirement for UK Pharmaceutical IGC 23-16 Transfers of companies to publicly disclose details of certain benefits in kind Page 1 of 2

Agenda Item Key Issue: Action: CCG Item No: Ref: Datix Risk Ref: Value known as transfers of value to individuals organisations to enable further transparency to the relationship between companies. Database public from 1st July 2016. There will be an internal process established to ensure CCG Gifts, Hospitality and Sponsorship Register reflects information held on public database.

Key Issues Report Date Prepared by: Angela Delea 23rd August 2016 Verified by: Simon Banks 24th August 2016 NOTE: A copy of the approved Minutes from this Meeting or any papers referenced in this Key Issues Report will be made available to the Governing Body on request to the Committee Chair

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NHS Halton CCG Communications and Marketing Strategy 2016-2019

1. Introduction

It is well documented the NHS has recently been through a period of unprecedented change, and it will continue to face many challenges over the next five years and beyond. Every day the NHS in Halton helps people to stay healthy, recover from illness and live independent and fulfilling lives. Effective communication can help support patients to stay healthy and restore or retain confidence during challenging times.

This strategy sets out how NHS Halton CCG intends to communicate with patients, members, staff, stakeholders and the local population. The overall aim of this Communications Strategy is to support the CCG’s five year strategy and to capitalise on its recent success to continue enhancing the organisation’s reputation as the leader of the local NHS system.

The strategy will support the organisation’s strategic objectives and will set-out how we will:

 Communicate with our stakeholders  Continue to build the reputation of NHS Halton CCG and mitigate against times of challenge and change  Strengthen our working relationships with partnership organisations to reduce duplication, improve best practice and ensure smooth cooperation and collaboration on a much wider footprint  Communications will support the CCG workforce in their daily activities

2. Who we are

NHS Halton Clinical Commissioning Group (CCG) is the leader of the NHS in our area. We are responsible for the planning and purchasing of health services for the people who are registered with the 16 GP practices in Halton.

This includes:

 Elective hospital care  Rehabilitation care  Urgent and emergency care  Most community health services  Mental health and learning disability services  Prescribing  GP services (from 1st April 2015)

Despite residents living for longer, the local population is living a greater proportion of their lives with an illness or health problem that limits their daily activities. There are also significant differences in how long people live across the borough. The NHS Five Year Forward View sets out how the health service needs to change to address the widening gaps in the health of the population, quality of care and increased financial pressures.

We recognise collaboration will be key to achieving this. Collaboration requires individuals, communities and organisations to work together to bring about meaningful change and achieve the best possible outcome. Communications will play an important role in enabling and supporting these conversations to take place. It will also help to maintain public confidence by ensuring stakeholders, including the public, are kept informed of our activities openly and transparently.

3. Organisational Vision and Values

The organisation has an overarching vision of:

“To involve everybody in improving the health and wellbeing of the people of Halton” This vision is supported by a set of values and behaviours which are listed below and will be threaded throughout all of our communications.

Partnership We will work collaboratively with our practices, local people, communities and with other organisations with whom we share a common purpose.

Openness We will undertake to deliver all business within the public domain unless there is a legitimate reason for us not to do so.

Caring We will place local people, patients, carers and their families at the heart of everything we do.

Honesty We will be clear in what we are able to do and what we are not able to do as a commissioning organisation.

Leadership We will be role models and champions for health in the local community.

Quality We will commission the services we ourselves would want to access.

Transformation We will work to deliver improvement and real change in care

We will also ensure our communication closely follows and supports the NHS values,1 which will demonstrate our:

 Professionalism  Clarity

1 www.england.nhs.uk/about/our-vision-and-purpose/  Respect  Accessibility  Straightforwardness

4. Current Situation

NHS Halton CCG is now in its fourth year of being a statutory organisation. During that period it has worked hard to establish a strong organisational identity and culture, and is widely respected among regional partners and NHS organisations. 2015 was a landmark year for the organisation and it is now beginning to build a national reputation for being progressive and innovative.

Our successes to-date include organising and obtaining a Guinness World Record; being shortlisted for and winning several national awards including a HSJ Award, building a growing following on social media and establishing a strong and identifiable brand that is widely trusted and respected amongst public and patients.

Developing the strategy The strategy was developed through a series of methods which included undertaking surveys and holding focus groups with staff and representatives from member practices. From this research we were able to evaluate how well we have communicated with our key audiences and set-out specific and measurable goals for the next period. The CCG 360o stakeholder survey is one of the key methods we measure our engagement and communication with practices and the key themes have been considered in developing this strategy and will also be one of the evaluation methods.

The strategy will support the organisational objectives set-out in the 5 year Sustainability and Transformation Plan, the One Halton Health and Wellbeing Operational Plan and will be closely aligned to the Consultation and Engagement Strategy.

5. Risk Analysis

A number of areas have been identified as being ‘weaknesses or threats’. This has been measured through consultation with staff and stakeholders.

Strengths Weaknesses

Established Governing Body with high Continuously changing environment level of strategic expertise and a varied skill set. Increasing demands on staff

Good relationships with partner and A small communications team provider communication teams Our internal communication channels Highly productive and skilled workforce need further development

Skilled and knowledgeable communication resource

Established communication channels

Opportunities Threats

Continue to further enhance clinical Political challenge and further change engagement between provider and commissioner organisations. Loss of public and clinician confidence. Strengthen working relationships with partners and providers Diverse and competing demands on time to undertake the necessary work. Modify & refine our communication channels to ensure they are future proof Financial challenges

Continue to build our national reputation Major incidents and Serious Untoward via marketing and PR opportunities Incidents

Consideration has been given to overcoming these threats below

Financial Challenges The organisation faces real financial challenges over the next three years, which could impact on the decisions we make. Communication will be key to ensuring these messages are conveyed openly and clearly with assurance and sensitivity.

Provider Performance Provider performance reflects on the CCG and its reputation. By working with our providers we can ensure they flag up potential risks. Horizon scanning within the organisation can also ensure the communications team is advised and can prepare for potential issues as early as possible.

Business Continuity The Business Continuity Plan outlines how the CCG will respond in the event of an emergency or major incident and contains action cards, which outlines the roles and responsibilities of the communications team. Having well developed crisis communication plans in place will ensure the CCG is as prepared as possible - in particular handling the media, managing communication with staff and where appropriate coordinating responses with partner organisations and providers.

Governance Strong governance arrangements can reduce many of the risks that could face an organisation and impact negatively on its reputation, such as conflicts of interest, data breaches and irregularity. Ensuring staff are aware of and fully understand the protocols will help to reduce potential risks.

Press Relations Building strong relations with our local media is key to ensuring the success of this strategy. We will ensure we are proactive in our approach to journalists and respond in a timely and appropriate manner to reactive enquiries.

Partnership Working Many of our challenges outlined will be more effectively met with effective and robust partnerships. We will need to ensure there is an open and constant dialogue with our partners and providers to enable communication activity to be as joined up as possible. This will include:  Working with other commissioners to ensure there is clarity about who will lead on proactive and reactive communications on areas of shared responsibility  Collaborating more closely with other commissioners and provider organisations, to maximise the impact of communications and deliver on a much wider footprint, particularly around key projects such as One Halton, Alliance Local Delivery System and Sustainability and Transformation Plans  Ensuring that changes to structures or working arrangements do not present reputational risks.

6. Audiences

Building effective and supportive relationships with our key stakeholders is critical to the success of this strategy and will reduce duplication in the system. We will communicate clearly and to professional standards, using methods which are appropriate to the audience.

Our audiences include:

 Staff  CCG Governing Body  Member practices  Patients and public  MPs  Local council members  Healthwatch Halton  NHS England  Collaborating CCGs  Partner and provider organisations  Health Forum  Patient Participation Groups  Health and Wellbeing Board  Third sector and patient support groups (via local CVS organisations)  Local Overview and Scrutiny Committee  Local Medical Committees  Local Pharmacy Committees  Local Chamber of Commerce  Housing Trusts and other public sector organisations  Local Social Enterprises

We recognise this list is extensive and audiences, or the level of audience involvement (especially for patients and public), may vary depending on the project. For example, if the CCG was considering redesigning one of the services it commissions, we would need to communicate with patients and public but the level of involvement could be extremely varied from existing service users, who would be involved in discussions about what the new service could look like but the rest of the population would be made aware of the new service via the press, website, leaflet or face-to-face. However, a campaign such as Examine Your Options, which aims to reduce inappropriate attendances at A&E by providing positive alternatives, will communicate on a much wider scale.

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STATEMENT OF COMPLIANCE

NHS Halton Clinical Commissioning Group has undertaken a self-assessment against the NHS England Core Standards for EPRR (v4.0).

Following self-assessment, and in line with the definitions of compliance stated below, the organisation declares itself as demonstrating Substantial compliance against the EPRR Core Standards.

Compliance Level Evaluation and Testing Conclusion

Arrangements are in place that appropriately addresses all the core Full standards that the organisation is expected to achieve. The Board has agreed with this position statement.

Arrangements are in place however they do not appropriately address Substantial one to five of the core standards that the organisation is expected to achieve. A workplan is in place that the Board has agreed.

Arrangements are in place however they do not appropriately address six Partial to ten of the core standards that the organisation is expected to achieve. A workplan is in place that the Board has agreed. Arrangements in place do not appropriately address 11 or more core standards that the organisation is expected to achieve. A work plan has Non-compliant been agreed by the Board and will be monitored on a quarterly basis in order to demonstrate future compliance.

The results of the self-assessment were as follows:

Number of applicable Standards rated as Standards rated as Standards rated as standards Red1 Amber2 Green3 35 0 3 32

2 1 Not complied with but Not complied with and not in evidence of progress and in an 3 an EPRR work plan for the next Fully complied with EPRR work plan for the next 12 12 months months

Where areas require further action, this is detailed in the attached EPRR Core Standards Improvement Plan and will be reviewed in line with the organisation’s EPRR governance arrangements.

I confirm that the above level of compliance with the EPRR Core Standards has been or will be confirmed to the organisation’s Governing Body.

Simon Banks Accountable Emergency Officer, NHS Halton Clinical Commissioning Group

01/09/2016 01/09/2016 Date of Governing Body meeting Date signed

Emergency Preparedness, Resilience and Response (EPRR) Core Standards Improvement Plan

EPRR Core Standards 2015 - Improvement Plan - Action Taken

Organisation: NHS Halton Clinical Commissioning Group

Plan owner: Simon Banks, Accountable Emergency Officer

Core Improvement required to achieve Standard Core Standard description Action taken to achieve compliance Completed compliance reference 16 Those on-call must meet identified Further attendance at training events required Additional training to be offered following Yes (Simon Banks) competencies and key knowledge development of LHRP training plan (Mar-16) and skills for staff Pandemic Flu 3 Organisations have undertaken a To attend an exercise LHRP Exercise to be held on w/c 11th April Yes (Exercise Bluebird: pandemic influenza exercise or have 2016 for all NHS (Mar/Apr-16) Julie Holmes and Lucy one planned in the next six months Reid)

EPRR Core Standards 2016 - Improvement Plan

Organisation: NHS Halton Clinical Commissioning Group

Plan owner: Simon Banks, Accountable Emergency Officer

Core Improvement required to Standard Core Standard description Action to deliver improvement Action Owner Deadline achieve compliance Reference Effective arrangements are in place to respond to the risks the Approved Severe Weather 8 organisation is exposed to, Plan and Pandemic Flu Approved plans in place. Angela Delea 30-Nov-16 appropriate to the role, size and (Communicable Diseases) Plan. scope of the organisation… Preparedness is undertaken with Evidence of consultation with the full engagement and co- external stakeholders. Exercise BCP and IRP once BCP 13 operation of interested parties and Angela Delea 31-Mar-17 Undertake exercise of BCP and upgrade completed stakeholders (internal and external) IRP. who have role in the plan and

Page 1 of 2 Emergency Preparedness, Resilience and Response (EPRR) Core Standards Improvement Plan

Core Improvement required to Standard Core Standard description Action to deliver improvement Action Owner Deadline achieve compliance Reference securing agreement to its content. Arrangements include a training plan with training needs analysis Evidence of general staff Staff awareness training for BC and ongoing training of staff training. and EPRR 34 Angela Delea 31-Mar-17 required to deliver the response to Evidence of BCP and IRP Exercise BCP and IRP once BCP emergencies and business exercises upgrade completed continuity incidents

Page 2 of 2 NHS Core Standards Requirements and Evidence for NHS Halton CCG - 2016 Return

CORE STANDARD - DUTY CLARIFYING INFORMATION EVIDENCE OF ASSURANCE EVIDENCE PROVIDED Governance 1.Organisations have a director level None • Ensuring accountable emergency Simon Banks accountable emergency officer who is officer's commitment to the plans and responsible for EPRR (including giving a member of the executive business continuity management) management board and/or governing 2.Organisations have an annual work Lessons identified from your organisation body overall responsibility for the LHRP work plan 2016-17 under programme to mitigate against and other partner organisations. Emergency Preparedness Resilience consultation until end Sep-16. CSU identified risks and incorporate the NHS organisations and providers of NHS and Response, and Business work plan submitted. lessons identified relating to EPRR funded care treat EPRR (including Continuity Management agendas (including details of training and business continuity) as a systematic and • Having a documented process for Debriefing process incorporated into exercises and past incidents) and continuous process and have procedures capturing and taking forward the trust planning. improve response. and processes in place for updating and lessons identified from exercises and maintaining plans to ensure that they emergencies, including who is Organisation assurance framework. reflect: responsible. - the undertaking of risk assessments • Appointing an emergency requirements reviewed at governing and any changes in that risk preparedness, resilience and response body. ass essment(s) (EPRR) professional(s) who can - lessons identified from exercises, demonstrate an understanding of EPRR EPRR and Business Continuity emergencies and business continuity principles. functions commissioned from incidents • Appointing a business continuity Midlands and Lancashire CSU - restructuring and changes in the management (BCM) professional(s) (MLCSU). organisations who can demonstrate an understanding - changes in key personnel of BCM principles. - changes in guidance and policy. • Being able to provide evidence of a 3. Organisations have an overarching Arrangements are put in place for documented and agreed corporate framework or policy which sets out emergency preparedness, resilience and policy or framework for building expectations of emergency response which: resilience across the organisation so CCG BC and IR plan contains a policy preparedness, resilience and response. • Have a change control process and that EPRR and Business continuity statement in respect of Business version control issues are mainstreamed in processes, Continuity and Incident response • Take account of changing business strategies and action plans across the BC and IR plans in place which objectives and processes organisation. include version control and annual • Take account of any changes in the • That there is an appropriate budget review arrangements organisations functions and/ or and staff resources in place to enable Reviewed and updated April 2016. organisational and structural and staff the organisation to meet the . changes requirements of these core standards. MLCSU provide advice and support, training and annual reports and reviews of plans.

• Take account of change in key suppliers This budget and resource should be Plans held on intranet and contractual arrangements proportionate to the size and scope of • Take account of any updates to risk the organisation. Monthly EPRR brief sent to CCG by assessment(s) MLCSU • Have a review schedule • Use consistent unambiguous Budget held within Corporate budget. terminology, • Identify who is responsible for making sure the policies and arrangements are updated, distributed and regularly tested; • Key staff must know where to find policies and plans on the intranet or shared drive. • Have an expectation that a lessons identified report should be produced following exercises, emergencies and /or business continuity incidents and share for each exercise or incident and a corrective action plan put in place. • Include references to other sources of information and supporting documentation 4.The accountable emergency officer After every significant incident a report Annual report to the board following will ensure that the Board and/or should go to the board/governing body or approval from IG Committee (Apr- Governing Body will receive as appropriately delegated governing group 16). appropriate reports, no less frequently Must include information about the Assurance documents signed off by than annually, regarding EPRR, organisations position in relation to the board (Sep-16). including reports on exercises NHS England core standards self undertaken by the organisation, assessment significant incidents, and that adequate resources are made available to enable the organisation to meet the requirements of these core standard Duty To Assess Risk 5. Assess the risk, no less frequently Risk assessments should take into Being able to provide documentary CCG BC and IR plans updated than annually, of emergencies or account community risk registers and at evidence of a regular process for annually and any additional threats business continuity incidents occurring the very least include reasonable worst- monitoring, reviewing and updating and and risks incorporated. which affect or may affect the ability of case scenarios for: approving risk assessments Risk take into account within the the organisation to deliver its functions. • severe weather (including snow, • Version control Business Continuity Plan .

heatwave, prolonged periods of cold • Consulting widely with relevant internal Any local risks additional to generic weather and flooding); and external stakeholders during risk risks would be identified within the • staff absence (including industrial evaluation and analysis stages plans. action); • Assurances from suppliers which Risks assessed to health via the • the working environment, buildings and could include, statements of LHRP and sub groups. equipment (including denial of access); commitment to BC, accreditation, MLCSU attends LHRP. • fuel shortages; business continuity plans. Strategic Group. NHS E attends • surges and escalation of activity; • Sharing appropriately once risk LRF groups on behalf of CCG. • IT and communications; assessment(s) completed Threats to CCG identified within the • utilities failure; BIA. • response a major incident / mass casualty event • supply chain failure; and 6. There is a process to ensure that the • associated risks in the surrounding area LHRP attended by MLCSU. risk assessment(s) is in line with the (e.g. COMAH and iconic sites) LRF attended by NHS E on behalf of organisational, Local Health Resilience CCG. Partnership, other relevant parties, There is a process to consider if there are MLCSU provides monthly EPRR brief community (Local Resilience Forum/ any internal risks that could threaten the to CCG. Borough Resilience Forum), and performance of the organisation’s national risk registers. functions in an emergency as well as external risks e.g. Flooding, COMAH sites etc.

7. There is a process to ensure that the Other relevant parties could include Risks considered within CCG and risk assessment(s) is informed by, and COMAH site partners. PHE etc. cascaded appropriately. Corporate Risk consulted and shared with your Register and Board Assurance Framework organisation and relevant partners. updated by risk owner and reviewed by appropriate committee quarterly. Risks affecting external agencies cascaded via LHRP representation. Duty to maintain BC and IR plans 8. Effective arrangements are in place Incidents and emergencies (Incident Relevant plans: BC and IR plans in place which to respond to the risks the organisation Response Plan (IRP) (Major Incident • demonstrate appropriate and sufficient are aligned with to NHS Core is exposed to, appropriate to the role, Plan)) equipment (inc. vehicles if relevant) to standards for BC. size and scope of the organisation, and Corporate and service level Business deliver the required responses Plans reviewed and updated April there is a process to ensure the likely Continuity (aligned to current nationally • identify locations which patients can 2016. extent to which particular types of recognised BC standards) be transferred to if there is an incident Part of NHS England command and emergencies will place demands on Severe Weather (heatwave, flooding, that requires an evacuation; control structure to respond to Major your resources and capacity. snow and cold weather) • outline how, when required (for mental Incidents. Pandemic Influenza health services), Ministry of Justice Have arrangements for (but not Mass counter measures (e.g. mass approval will be gained for an

necessarily have a separate plan for) prophylaxis or mass vaccination evacuation; All plans covering Mass Casualties, some or all of the following Surge and Escalation Management (inc. • take into account how vulnerable vaccination, infectious diseases, (organisation dependent) (NB, this list links to appropriate clinical networks e.g. adults and children can be managed to weather related events part of both is not exhaustive): see next column Burns, Trauma and Critical Care) avoid admissions, and include LHRP and LRF generic planning. Infectious Disease Outbreak appropriate focus on providing CCG represented at LHRP by Utilities, IT and Telecommunications healthcare to displaced populations in MLCSU and at LRF by NHS E. Failure rest centres; • include arrangements to co-ordinate and provide mental health support to patients and relatives, in collaboration with Social Care if necessary, during and after an incident as required; • make sure the mental health needs of patients involved in a significant incident or emergency are met and that they are discharged home with suitable support • ensure that the needs of self- presenters from a hazardous materials or chemical, biological, nuclear or radiation incident are met. • for each of the types of emergency listed evidence can be either within existing response plans or as stand alone arrangements, as appropriate. 9. Ensure that plans are prepared in Aim of the plan, including links with plans All plans reviewed and updated line with current guidance and good of other responders Being able to provide documentary annually practice which includes: • Information about the specific hazard or evidence that plans are regularly Integrated Governance Committee contingency or site for which the plan has monitored, reviewed and systematically reviews EPRR in Oct and Apr been prepared and realistic assumptions updated, based on sound assumptions: each year. • Trigger for activation of the plan, • Being able to provide evidence of an All plans reviewed against current including alert and standby procedures approval process for EPRR plans and guidance and good practice • Activation procedures documents Version control in place • Identification, roles and actions • Asking peers to review and comment References included (including action cards) of incident on your plans via consultation response team • Using identified good practice • Identification, roles and actions examples to develop emergency plans (including action cards) of support staff • Adopting plans which are flexible, including communications allowing for the unexpected and can be • Location of incident co-ordination centre scaled up or down (ICC) from which emergency or business • Version control and change process continuity incident will be managed controls • Generic roles of all parts of the • List of contributors organisation in relation to responding to • References and list of sources emergencies or business continuity • Explain how to support patients, staff incidents and relatives before, during and after an • Complementary generic arrangements incident (including counselling and of other responders (including mental health services). acknowledgement of multi-agency working) • Stand-down procedures, including debriefing and the process of recovery and returning to (new) normal processes • Contact details of key personnel and relevant partner agencies • Plan maintenance procedures (Based on Cabinet Office publication Emergency Preparedness, Emergency Planning, Annexes 5B and 5C (2006)) 10. Arrangements include a procedure Enable an identified person to determine for determining whether an emergency whether an emergency has occurred On-call Standards and expectations are CCG part of Mid Mersey On Call or business continuity incident has - Specify the procedure that person set out Group providing 24/7 on call occurred. And if an emergency or should adopt in making the decision • Include 24-hour arrangements for response. Contained within plans business continuity incident has - Specify who should be consulted alerting managers and other key staff. including triggers. Mutual aid occurred, whether this requires before making the decision considered in plans. changing the deployment of resources - Specify who should be informed once or acquiring additional resources. the decision has been made (including clinical staff) 11. Arrangements include how to Decide: Prioritised functions within plans as continue your organisation’s prioritised - Which activities and functions are part of BIA. BIA updated on review in activities (critical activities) in the event critical respect of risk reduction objectives of an emergency or business continuity - What is an acceptable level of service and tasks incident insofar as is practical. in the event of different types of emergency for all your services - Identifying in your risk assessments in what way emergencies and business continuity incidents threaten the performance of your organisation’s functions

functions, especially critical activities 13. Preparedness is undertaken with CCG staff involved in BIA process, the full engagement and co-operation Specifiy who has been consulted on the awareness raising. of interested parties and key relevant documents/ plans etc. stakeholders (internal and external) who have a role in the plan and securing agreement to its content 14. Arrangements include a debrief Explain the de-briefing process (hot, local Debrief Process included in plans process so as to identify learning and and multi-agency, cold) at the end of an inform future arrangements incident. Command and Control 15. Arrangements demonstrate that Organisation to have a 24/7 on call rota in Explain how the emergency on-call rota CCG part of Mid Mersey On Call there is a resilient single point of place with access to strategic and/or will be set up and managed over the Group providing 24/7 on call response. contact within the organisation, capable executive level personnel short and longer term. Rota administration undertaken by of receiving notification at all times of MLCSU. Call Centre operation an emergency or business continuity provided by Office Link. On Call Pack incident; and with an ability to respond developed by MLCSU and issued Jul- or escalate this notification to strategic 16. and/or executive level, as necessary. 16. Those on-call must meet identified NHS England published competencies Training is delivered at the level for CCG has attended training session competencies and key knowledge and are based upon National Occupation which the individual is expected to delivered by NHS E. (Accountable skills for staff. Standards . operate (ie operational/ bronze, tactical/ Emergency Officer, Director of silver and strategic/gold). for example Commissioning and Service Delivery strategic/gold level leadership is and Director of Transformation). delivered via the 'Strategic Leadership in a Crisis' course and other similar courses. 17. Documents identify where and how This should be proportionate to the size Arrangements detail operating Command centre within plan, decision the emergency or business continuity and scope of the organisation. procedures to help manage the ICC (for logging included in plan. incident will be managed from, ie the example, set-up, contact lists etc.), Incident Co-ordination Centre (ICC), contact details for all key stakeholders how the ICC will operate (including and flexible IT and staff arrangements information management) and the key so that they can operate more than one roles required within it, including the control/co0ordination centre and role of the loggist . manage any events required. 18. Arrangements ensure that National JESIP decision making decisions are recorded and meetings model included in plan

are minuted during an emergency or business continuity incident. 19. Arrangements detail the process for Sample sitreps and crips in plan completing, authorising and submitting situation reports (SITREPs) and/or commonly recognised information pictures (CRIP) / common operating picture (COP) during the emergency or business continuity incident response. Duty to communicate with public 22. Arrangements demonstrate warning Arrangements include a process to inform Have emergency communications Communications function delivered by and informing processes for and advise the public by providing response arrangements in place the CCG. emergencies and business continuity relevant timely information about the • Be able to demonstrate that you have Strategic input provided by MLCSU. incidents. nature of the unfolding event and about: considered which target audience you NHS E comms would support out of - Any immediate actions to be taken by are aiming at or addressing in hours. responders publishing materials (including staff, Input to web site managed by CCG. - Actions the public can take public and other agencies) - How further information can be • Communicating with the public to obtained encourage and empower the community - The end of an emergency and the to help themselves in an emergency in return to normal arrangements a way which compliments the response Communications arrangements/ of responders protocols: • Using lessons identified from previous - have regard to managing the media information campaigns to inform the (including both on and off site development of future campaigns implications) • Setting up protocols with the media for - include the process of communication warning and informing with internal staff • Having an agreed media strategy - consider what should be published on which identifies and trains key staff in intranet/internet sites dealing with the media including - have regard for the warning and nominating spokespeople and 'talking informing arrangements of other heads'. Category 1 and 2 responders and other • Having a systematic process for organisations. tracking information flows and logging information requests and being able to deal with multiple requests for information as part of normal business processes. • Being able to demonstrate that

publication of plans and assessments is part of a joined-up communications strategy and part of your organisation's warning and informing work. 23. Arrangements ensure the ability to • Have arrangements in place for Other systems in place, mobile communicate internally and externally resilient communications, as far as telecoms, email, iPad available, during communication equipment reasonably practicable, based on risk. remote access available through VPN. failures Information Sharing – Mandatory requirements 24.Arrangements contain information These must take into account and include Where possible channelling formal Information sharing protocol in place sharing protocols to ensure appropriate DH (2007) Data Protection and Sharing – information requests through as small with Cheshire and Mersey and communication with partners. Guidance for Emergency Planners and as possible a number of known routes. providers. Responders or any guidance which • Sharing information via the Local supersedes this, the FOI Act 2000, the Resilience Forum(s) / Borough Data Protection Act 1998 and the CCA Resilience Forum(s) and other groups. 2004 ‘duty to communicate with the • Collectively developing an information public’, or subsequent / additional sharing protocol with the Local legislation and/or guidance. Resilience Forum(s) / Borough Resilience Forum(s). • Social networking tools may be of use here. Co-operation 25. Organisations actively participate in Attendance at or receipt of minutes from NHS E represents on strategic LRF or are represented at the Local relevant Local Resilience Forum(s) / Group. Resilience Forum (or Borough Borough Resilience Forum(s) meetings, Resilience Forum in London if that meetings take place and appropriate) membership is quorate. 26. Demonstrate active engagement • Treating the Local Resilience MLCSU attends LHRP and and co-operation with other category 1 Forum(s) / Borough Resilience all issues communicated to CCG and 2 responders in accordance with Forum(s) and the Local Health the CCA Resilience Partnership as strategic level 27. Arrangements include how mutual NB: mutual aid agreements are wider groups Via command and control and NHS aid agreements will be requested, co- than staff and should include equipment, • Taking lessons learned from all England ordinated and maintained. services and supplies. resilience activities 30. Arrangements demonstrate how Examples include completing RITREP’s , • Using the Local Resilience Forum(s) / Via command and control. SITREP organisations support NHS England cascading of information, supporting Borough Resilience Forum(s) and the included within IR plans locally in discharging its EPRR mutual aid discussions, prioritising Local Health Resilience Partnership to

functions and duties activities and/or services consider policy initiatives 33. Arrangements are in place to • Establish mutual aid agreements LHRP attended by MLCSU on behalf of ensure attendance at all Local Health • Identifying useful lessons from your CCG. Resilience Partnership meetings at a own practice and those learned from director level collaboration with other responders and strategic thinking and using the Local Resilience Forum(s) / Borough Resilience Forum(s) and the Local Health Resilience Partnership to share them with colleagues • Having a list of contacts among both Cat. 1 and Cat 2. responders with in the Local Resilience Forum(s) / Borough Resilience Forum(s) area Training and Exercising 34. Arrangements include a training • Staff are clear about their roles in a plan Taking lessons from all resilience Training plan for staff in place as part of plan with a training needs analysis and • Training is linked to the National activities and using the Local Resilience BC/IRP development. ongoing training of staff required to Occupational Standards and is relevant Forum(s) / Borough Resilience deliver the response to emergencies and proportionate to the organisation Forum(s) and the Local Health Strategic training provided in 2016 by and business continuity incidents type. Resilience Partnership and network NHS E. • Training is linked to Joint Emergency meetings to share good practice Response Interoperability Programme

(JESIP) where appropriate • Being able to demonstrate that people • Arrangements demonstrate the responsible for carrying out function in provision to train an appropriate number the plan are aware of their roles of staff and anyone else for whom training would be appropriate for the • Through direct and bilateral purpose of ensuring that the plan(s) is collaboration, requesting that other Cat effective 1. and Cat 2 responders take part in • Arrangements include providing training your exercises to an appropriate number of staff to ensure that warning and informing arrangements are effective • Refer to the NHS England guidance and National Occupational Standards For Civil Contingencies when identifying 35. Arrangements include an ongoing • Exercises consider the need to validate training needs. All exercises are offered to on call exercising programme that includes an plans and capabilities personnel. exercising needs analysis and informs • Arrangements must identify exercises future work. which are relevant to local risks and meet • Developing and documenting a

the needs of the organisation type and of training and briefing programme for staff other interested parties. and key stakeholders • Arrangements are in line with NHS England requirements which include a • Being able to demonstrate lessons six-monthly communications test, annual identified in exercises and emergencies table-top exercise and live exercise at and business continuity incidents have least once every three years. been taken forward • If possible, these exercises should involve relevant interested parties. • Programme and schedule for future • Lessons identified must be acted on as updates of training and exercising (with part of continuous improvement. links to multi-agency exercising where • Arrangements include provision for appropriate) carrying out exercises for the purpose of ensuring warning and informing arrangements are effective • Communications exercise every 6 36. Demonstrate organisation wide months, table top exercise annually and Commissioning manager - Primary (including on call personnel) live exercise at least every three years Care and Head of Medicines appropriate participation in multi- Management attended pandemic flu agency exercises. exercise (Apr-16). 37. Preparedness ensures all incident On call managers required to evidence commanders (on call directors and on call training as part of mandatory managers) maintain a continuous training required and agreed with PDRs. personal development portfolio demonstrating training and/or incident /exercise participation. Business Continuity Deep Dive DD1. Organisation has undertaken a  The organisation has undertaken a risk  Updated Business Impact Assessment Business Impact Analyses completed by Business Impact Analysis. based Business Impact Assessment of  Corporate Risk Register each functional team. services it delivers, taking into account the resources required against staffing, Corporate Risk Register reflects key premises, information and information systems, supplies and suppliers. operational risks to CCG and mitigated  The organisation has identified appropriately. interdependencies within its own services rd and with other NHS organisations and 3 party providers.  Risks identified through the Business Impact Assessment are present on the organisational Corporate Risk Register.

DD2. Organisation has explicitly  The organisation has identified their  Business Continuity Plan explicitly Key functions listed in Business identified its Critical Functions and set Critical Functions through the Business details the Critical Functions Continuity Plan and the Recovery Time  Minimum Tolerable Periods of Impact Assessment. Business Continuity Plan explicitly Objective is identified. Disruption for these. Maximum Tolerable Periods of Disruption outlines all organisations functions and have been set for all organizational the maximum tolerable period of functions - including the Critical Functions. disruption DD3. There is a plan in place for the  The organisation has an up to date plan  An organisation wide Business CCG Business Continuity Plan ratified organisation to follow to maintain critical which has been approved by its Continuity Plan that has been updated in by Governing Body in May 2016. functions following a disruptive event. Board/Governing Body that will support the last 12 months and agreed by the staff to maintain critical functions and Board/Governing Body restore lost functions. The plan outlines roles and responsibilities for key staff and includes how a disruptive event will be communicated both internally and externally. DD4. Within the plan there are  The plan details arrangements in place to  Detail within the Plan that explicitly Actions to consider in the event of a arrangements in place to manage a maintain critical functions during disruption makes reference to shortage of fuel and transport disruption/fuel emergency are shortage of fuel and heating oil. to fuel. These arrangements include both its impact on the business included in the Business Continuity road fuel and where applicable heating Plan. Corporate Risk Register reflects fuel. key operational risks to CCG and mitigated appropriately.

DD5. The Accountable Emergency  EPRR Framework 2015 requirement, NHS E will provide this assurance to Officer has ensured that their page 17. CCGs through Provider Trusts EPRR organisation, any providers they Core Standards submissions. commission and any sub-contractors have robust business continuity planning Requirement for providers to have arrangements in place which are aligned to ISO 22301 or subsequent guidance robust BC plans is incorporated into the which may supersede this. standard NHS contract and is part of conditions precedent to contracts.

Service Development Committee 13th July 2016

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: There was a Hot Topic discussion which centered around the It was agreed that further Hot Topic following topics; discussions would take place at the August meeting which would cover;  Dermatology Growth and Variation  End of Life Care  St Helens Rota  Gastro  Out of Hours, UC 24 Contract & GP Access  End of Life Care

Dermatology Growth and Variation Martin Stanley presented a report on dermatology growth and ACTION – Further report to be developed variation, to enable discussion around the options available to by Clinical Leads and Commissioners and HOT TOPIC reduce the variation in practice and reduce the level of activity brought back to October SDC, identifying being undertaken in the acute sector. Within Halton there are options/potential service specification. significant variations between referral rates - this could be due to the individual patient profile within practices, or a specialist interest in a practice allowing them to manage more patients locally. Overall, spend on dermatology is high. Dermascopes are being conducted (excisions of skin), and being sent away, but then still removing even if non-malignant.

Opportunity for potentially implementing a ‘Prior Approval Scheme’ – asking permission before taking off? Potential £100k saving to be made? Or implementing a community based service to undertake procedures (non-cancerous). St Helens already have a community based dermatology service.

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Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref:

Discussion around difficulty/risks of splitting cancer/non cancer into community service; how to handle the potential volume of referrals – would be a full time job - who could provide this service? What incentives are there for practices – some feel they would only be breaking even. Also subject has been to SDC previously and didn’t make any progress? Issue around liability – much higher for GP’s; needs to be cost effective. Could we utilise the free treatment rooms at UCC currently not being utilised? Another option is to tighten up HOT TOPIC the contract - referral for review/opinion only.

Opportunity for federated GP’s to work together - model to evidence how deliver/manage spend. Concerns re: risk of lack of clinical support and training - risk of GP undertaking without specialist community services to link into like in St Helens – would need to build that - develop a specification looking at other areas with services already in place e.g. STH.

St Helens Rota Historical agreement from around the time of the PCT ending – aim to create a single point of access to deflect admissions. When the providers at the time pulled out of the contract Halton Practices started using St Helen’s Rota and a small contract was created, which has historically remained in place. Value of around £18k. Not used by Runcorn GPs – or widely by Widnes GPs, and recommendation to Committee is Action: Concerns regarding delays getting that we end the contract and make contact with Whiston SAE through to Whiston to be raised at CQPG directly - advantages of doing so include ability to speak meeting. Page 2 of 7

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: directly with clinician who will be admitting your patient, reduce delays of ambulance being dispatched, reduces risk in mis communication of information. Some concerns raised regarding delays some GPs experiencing around using calling Whiston directly.

Agreement from Committee to end contract (only 2 in group in favour of keeping, consensus in favour of ending contract).

Out of Hours, UC 24 Contract & GP Access HOT TOPIC Currently overlap between practices finishing cover at 630pm, OOH (at the UCC) cover ending at 10pm and then UC 24 then doing 24 hours – basically we are paying twice for the period 630pm to 10pm. This could potentially be resolved if the UCC was staffed by teams from our Practices, and would also meet the expectation for 7 day working – which although hasn’t been implemented yet, is still an expectation. This could be ACTION: Information to be sent in advance met through GP’s in their Federations coming together via the about the current service currently, along care centres. Not only financial incentive, but also quality with the proposal – plus financial incentives – the Bridgewater doctors currently staffing the implications and then further discussion to UCC’s are not local and have no real input into the patients – be had at PLT. SV/MOC it is also an unsustainable model.

£1.8 - £2mill investment has been agreed for covering doctors in the UC24; but so far we don't have a coming together of our doctors within local practices – need to formalise this for 2017 recruitment. Currently being covered by doctors outside of Halton area. OOH contracts is practice based contract - to be retendered early 2017. We need to commit to being part of Page 3 of 7

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: that – to be discussed at next PLT as part of open discussion around involvement in UCC.

WHHFT Anaemia Pathway WHHFT have brought in a new Anaemia Pathway, want to roll out 1st August – aim is to avoid admissions to hospital, through the appropriate support. CR has brought to SDC for discussion and approval. MOC queried Flow Chart 4 – potentially could result in a lot of expenditure if the patient is referred to multiple teams for multiple tests – not likely, but is a potential risk.

General agreement from group, but JS to query flow chart 4, and to also double check regarding contradictions with ‘Consult and Consultant Policy’ Guidance.

End of Life Care – Deferred to August’s Hot Topics 5 Paediatric Update provided to Committee on progress of the ACTION: Escalation through Executive Speech & implementation of a single integrated SALT service. Management Team to liaise with Halton Language Unfortunately the specification is not ready to share yet. The Borough Council to confirm way forward. Verbal service will pool both Local Authority and CCG funding into a pooled budget to enable a truly integrated service. Unfortunately there have been a number of delays – the first delay was caused when the Local Authority went out and commissioned the service with two new providers - Together Trust and Communicate; and the CCG had already commissioned Bridgewater – having 3 individual providers caused a lot of problems (as expected), therefore the integrated service work was resurrected. They revamped the service specification and everything was moving along Page 4 of 7

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: smoothly; unfortunately they have now encountered another problem – the Local Authority now want to include the opportunity to review year on year the funding and pull funding out due to LA cuts. This has huge impacts in terms of flexibility of the service, as would need to revisit the spec each time to look for cost savings each time - if funding is removed, staff may have to be made redundant then who is responsible for redundancy costs?

By pooling the budget they had thought it ring fenced it from cuts , and as only a 2 year contract should be able to commit to a robust service, aimed at improving school readiness (Halton is currently 2nd from the bottom nationally).

6 Draft The Committee noted a report from Helen Moir, Halton Telehealthcare Borough Council on the draft Telehealthcare Strategy Strategy currently in development. Main aim of this strategy is to SDC 25-16 increase independent living within the community, within a tight fiscal policy. The Policy outlines the key drivers/work streams, and how these will be taken forwards. The strategy will save money in the long term, but the team haven’t been able to find any definitive evidence to support this, so they are sourcing this evidence locally and will bring it back in a year's time (both in terms of savings and evidencing outcomes). Currently monitoring blood pressures, Monday to Friday, of 2,800, and aiming to increase by 2% (3000). Also working with Liverpool City Region around supporting the implementation of extra care technology into Care Homes - cameras, tablet monitoring etc.

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Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: 7 Health David King, Halton Borough Council presented an update on ACTION: Further discussions to be had re: Improvement his team’s current work around improving the response rates ways to take forward offer. Services to Bowel Cancer Screening and the benefits, both in terms of SDC 26-16 cost savings and potential lives saved this could bring. DK offered to expand this opportunity out to other practices (currently working within 8 of the 16 Halton practices); and potentially link in with One Halton work.

8 Risk Register The Committee received a verbal update from the Chair that the risks are currently being updated from the Governing Body development session and will be being brought back to SDC next month. 9 Any Other The Committee were asked to consider value of holding an Business additional meeting in August, as a number of items for the agenda have already been identified – agreement by group – date set 10th August. The Committee approved an additional meeting in August. 10 Practice Leads  Consultant to Consultant Referrals – Warrington Policy, Feedback STHK Policy similar. Martin Stanley to share copies of the policies with Sarah Vickers, who is to arrange distribution to Practice Managers.  NHS Halton CCG are involved in a £3.3mill Enterprise & Employment funding scheme whereby employers employ individuals who've been unemployed and/or on long term benefits – especially those with a learning disability/mental health illness. Any practices who would be interested in working with these individuals let us know. Great opportunity to support someone back into work – empower them to gain some skills/experience.  We’ve also developed a paper on the work we’ve done as Page 6 of 7

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: a CCG to bid for £7mill to the Liverpool City Region on “DWP and areas of burden” (MSK/MH/LD) to extend our existing MSK work.

Key Issues Report Date Prepared by: Hilary Southern 14/07/16 Verified by: Mick O’Connor 02/08/16 NOTE: A copy of the approved Minutes from this Meeting or any papers referenced in this Key Issues Report will be made available to the Governing Body on request to the Committee Chair

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Service Development Committee 10th August 2016

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: There was a Hot Topic discussion which centered around the Further report outlining potential hub following topics; configuration with a view to enabling use of Aristotle in primary care for peer review,  Sustainability and primary care: and potential implementation of Map of - How do we use Aristotle Medicine to be developed by Clinical Leads - How can we reduce variation and Commissioners and brought back to - Role of map of medicine October SDC, identifying options/potential - Referral management schemes service specification. SVi / MOC  Gastro

The chair outlined the presentations given at the members GPs and Clinical Leads to take discussion HOT TOPIC forum which was held 1 week earlier. These presentations back in particular around Map of medicine / covered the current financial challenge facing the CCG, the referral management. To be discussed role of primary care providing solutions to both the next SDC – GP Reps. sustainability of the CCG, and Primary care. The forum also introduced the data held in Aristotle to the members, and potential uses of this data; and gave an overview of the future local NHS configurations within the borough i.e. multispecialty community providers / accountable care organisations – and the role of primary care hubs in developing these. At the members forum it was agreed that these topics would be brought to this SDC for further discussion between member practices once they had had the opportunity to explore within their individual practice teams. Page 1 of 6

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: Discussions took place within the group around the above areas and the outcome was as follows :

Practices felt that Map of Medicine would be a useful tool, but were unsure if the use of Map would be consistent and unsure how this could be addressed

Practices were generally against a formal referral management scheme, preferring to possibly use Map of medicine but as above no solution as to how this would take place

Debate took place around working together / peer review and using Aristotle to reduce variation in primary care in both clinical care and referrals / admissions. There was no clear view from practices about the organisational structure of hubs, and how effective peer review could be facilitated.

4 Clinical The Committee noted the Clinical Leadership Model report Leadership presented by CR & JS: Model (Verbal) The report identified that the CCG currently has 25 clinical lead roles (including 2 strategic clinical leads)

Current spend on these clinical lead roles is £250k

Some clinical lead roles have a lot of activity to undertake, with others less so.

There is not a consistent approach to payment of clinical Page 2 of 6

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: leads, with some claiming for role only, some adding expenses and some potentially not claiming. Information on what is being claimed for is again not consistent.

The report proposed that the role of a clinical lead within Halton (excluding the urgent care and safeguarding specific leads) be redefined – with this new clinical lead role operating across the works streams aligned with One Halton.

The works streams are currently defined as:  Children and families  Generally Well  Long term conditions  Mental Health  Older people, disabilities and aging well  Enabler groups – such as IM&T etc

The strategic clinical leads along with the CCG Clinical chair would agree workplans.

Members agreed that:  Practice clinical lead role be strengthened  To align a small number of clinical leads to the One Halton work streams  Revise the role of strategic clinical lead as above  Create a new generic lead role as an introductory role to learn about the business of the CCG  Agreed to introducing a clinical lead ‘pool’ for ad-hoc work. Page 3 of 6

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: 5 RCAT ‘The Damian Nolan, Halton Borough Council and Dr Neil Martin, Recommendation to continue service Future’ Report provided a report on an interim model scheme, ‘Rapid Clinical Monday to Friday to be taken to BCF board (SDC 29-16) Assessment Team’, which has been in place for 4 months. to agree funding. DN The report presents the data for the first 10 weeks of the scheme.

So far have handled 49 referrals – of them 48 were definite ‘otherwise would be going to hospital’. Of those 48, in the end 42 did not require hospital admission. Three case studies provided to highlight the different diagnosis arrived at in avoiding hospital admission.

Paper brought to SDC with three options for consideration 1) interim model continues 2) increase the service to 7 days a week 3) Cease the service

Discussion had around more referrals received from Widnes than Runcorn at the start of the scheme. Confirmed all practices were notified of scheme. There is also still capacity within the service to pick up more referrals. Unable to say exactly how much financial saving was made in preventing hospital admission, due to potential readmission after prevention.

Other benefit to scheme is the educational benefits of sharing skills with other professionals in the community – not picked up in the paper – the Professor did a lot of training. This element will be expanded if the process continues.

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Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: Definite agreement that scheme should not be ceased (option 3). All in agreement with option 1 – bit early for option 2. Need to see it over winter first and increase capacity.

Funding comes from Better Care Fund. Care Home Support.

The Committee noted the report and agreed to support Option 1 – to continue service Monday – Friday. . 6 Children’s ADHD The Committee noted the contents of a report presented by SDC 30-16 Anne Doyle, Assistant Director of Children’s Services, Bridgewater Community Trust on a proposed ‘Coordination and Assessment Journey’ Pathway. Aimed at streamlining the journey for children within services and also moving into adult services. Currently the focus is on diagnosis not access services. Aim was to develop a single point of access, one form and one approach about support rather than diagnosis.

The committee supported this approach.

7 Commissioning The Committee received the Q1 Commissioning Intentions Intentions Qrt 1 Report – there are a number of gaps due to annual leave; (SDC 31-16) however it is a live document so these gaps are constantly being filled and updated. Only one red referring to concerns around the monitoring of BCF pooled budget and how closely CCG monitors the spend of this budget – but a lot of assurances have been put into place to mitigate risks associated with these concerns. Issue was discussed at Joint team meeting last Friday and concerns may now be fully resolved. Page 5 of 6

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: 8 Risk Register The Committee noted the Risk Register and Q1 positions: Revamp Risk ID 372 – bring back to SDC 17,37,68, (SDC 32-16) in September 369,372,  Risk ID 17 – Reduce to 6 Unlikely.  Risk ID 37 – discussion re: low score ‘rare’ – do have a separate one related to sustainability and financial implications. But not national policy. More clarification around wording – JS to revise.  Risk ID 68 – Agreed.  Risk ID 369 – Agreed. Risk around recruiting of staff – they slightly behind, but not majorly concerned.  Risk ID 372 – New Risk – not sure concerns and assurances are at a strong enough level – JS to speak to SMc – need to reflect other CCG delays.

Key Issues Report Date Prepared by: Hilary Southern 11/08/16 Verified by: Mick O’Connor 25/08/16 NOTE: A copy of the approved Minutes from this Meeting or any papers referenced in this Key Issues Report will be made available to the Governing Body on request to the Committee Chair

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QUALITY COMMITTEE 21st July 2016

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: 3 Risks The Committee noted the Risk Register with agreed All QC 26-16 recommendations as follows:

Risk ID 39 – To be reviewed and agreed at Sept QC Meeting Risk ID 47/376 – Merge quality elements of Risk ID 376 into Risk ID 47, then amend 376 into financial risk and move to P&F Committee for oversight. Risk ID 56/ 371 – Proposed new Risk to be merged with existing Risk 56. Close Risk ID 371. Risk ID 60 – Agreement from issue to leave where it is for now until EMIS is in place. IM&T provide update at IGC. Risk ID 62 – Stalled therefore score has been increased to 12 – update due at Sept QC Meeting after next Stroke Board. Risk ID 64 – Plan in place, but needs refining. Updated Risk to be brought to Sept QC meeting. Risk ID 377 – New Risk agreed by Committee

4 Quality Strategy The Committee approved the revised Quality strategy; Document to be formatted and added to 47/376/62 QC 27-16 which had been refreshed early (due 2017) due to a number CCG Intranet and public facing website. of new reports and updates in guidance e.g. 5 Year Forward View etc. The majority of the document remains the same including the intervention measures. 5 Draft Patient The Committee discussed the draft Patient Experience Final version to be brought back in 39 Experience Strategy, and made a number of recommendations including: September for approval. Page 1 of 7

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: Strategy  Under National Reviews section include statement QC28-16 around MAZARS and Southern Health  Also under Accountability suggestion to add in Healthwatch link – to include how feed in the views of local people 6 Provider Quality The Committee noted the Quality Dashboard – April 2016. 47/62/376 Performance No major performance issues noted – two cases of Report community acquired MRSA in Halton (first for four years). QC 29-16 WHHFT, as of next Thursday the level of surveillance will be reduced to routine, as agreed by the QSG. Mixed Sex Accommodation breaches are still an area for concern, and there have been a further two breaches since the report; along with a 62 day Cancer breach.

Future of the report is uncertain – not sustainable; no Trust can afford to keep gathering the data in this way; and all the data is being collected in another form already therefore duplicating the work. E.g. through national audits. Also included in the paper, for noting by the Committee, was a copy of the Contract Performance Notice letter sent to Bridgewater 8th July re: their Safeguarding Service and their Looked after Children’s Service.

The Serious Incidents Report provided by the CSU was included for noting by the Committee – not what was agreed, so is a work in progress – currently only provides figures. The CCG is going to be bringing the management of Serious Incidents in-house from end of August. Our Performance management of SI's is currently the best across the North - but unable to evidence that here in this reports. Page 2 of 7

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: 3767 CQPG Reports CQPG Reports were received from Bridgewater main area of 47/62/376 QC 30-16 concern safeguarding see below, and Warrington key area remain cancer targets, A&E performance issues but have been taken off enhanced surveillance at QSG. Verbal update provided in relation to St Helens & Knowsley. No major areas of concern; on-going safeguarding issues within Bridgewater. 8 Safeguarding The Committee noted the Safeguarding Children and Adults 47 Quarterly Report Quarterly update (Quarter 4) report for noting. The report QC 31-16 focussed on the following areas: 1.) Bridgewater Community Trust Safeguarding Continues to have limited assurance with both Adults and Policy Children’s – support has been offered but has been declined. QC 32-16 Issues re: training, strategy, supervisions and quality schedule. In regards to Looked After Children percentage Management of compliance levels are low and heading for a 0% rating. Allegations Policy Have also recently taken in an additional service from Alder QC 33-16 Hey which came with problems and may have had impact. 2.) 5BP Limited assurance on Children's due to Q3 information being missing. Also gaps around supervision re: MH (CAMS service not routinely linked into proactive supervision). Received Red in Q4 from previous Amber – this relates to the missing data and this is expected within next quarters submission. 3.) St Helens & Knowsley Consistent, strong reasonable assurance. Only issue is around level 2 training particularly Children’s. However they have always had a trajectory in place and are meeting this trajectory. Page 3 of 7

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref:  Alder Hey – Currently Reasonable Assurance. Liverpool CCG issued them a Performance notice in Q2 due to low training figures.  Liverpool Women’s – Currently Reasonable Assurance  Warrington – on-going issues in getting Safeguarding updates from Warrington CCG – some issue re JS to contact John Wharton and assurance.level request information on the trust

AD also asked for guidance from Committee re: future STHK reporting, as this is now responsibility of St Helens CCG. Committee agreed report should be separate to Safeguarding reports produced by AD and team and should be provided by the coordinating commissioners designated nurses.

6) Management of Allegations Policy The Committee noted and approved the revised policy. Main changes bringing in Care Act Changes (mainly around use of terminology).

7) Safeguarding Policy The Committee noted and approved the revised policy. .

8) Care Homes quality and Adult Safeguarding Unit reporting JS to discuss with Integrated Unit The committee noted it was sometime since these reports and Sue Wallace Bonner presentation had been received and as the September committee is to be of information to the committee a themed review of care home and domiciliary care quality and safety these reports would be useful. Page 4 of 7

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: 9 MMWG Summary The Committee noted the Summary report and approved 47 & APC the recommendations as follows: Recommendations QC 34-16  Sacubitril/valsartan (Entresto) was approved (Chairs action) as a temporary red statement by APC on 4th Quality Initiative May. Now been amended to an amber statement. Cost Outcomes template provided showing how cost will increase over QC 35-16 time – take up may not be as quick as expected, but will monitor.  Melatonin M/R – Felt couldn’t agree to retain within a service we haven’t got – and as it isn’t a dangerous drug – an amber initiative supports prescribing in area currently, and prevents access issues.  CNS Formulary – Anti Psychotics to remain Red for Halton  Care Home Update – clinical reviews going really well – just hitting some delays in getting the med reviews from GPs. Aim of reducing unnecessary prescribing in older people.

The Committee noted and approved the summary report of achievements for the 2015-16 Practice Prescribing Quality Initiative Outcomes Scheme and agreed that it had been a fair process and agreed the recommended next steps, as detailed in the report regarding payment.

JS highlighted that MOC, AB and DH, although able to join in conversations had a conflict of interest and could not take part in any voting.

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Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: 10 Healthwatch The Committee were provided with a copy of Heathwatch’s 47 Annual Report Annual Report 2015-16 for noting. QC 36-16 The Committee noted the contents of the report. 11 SEND Strategy The Committee approved Halton’s SEND Strategy, which Owen Ashworth to look over it – for 47 QC 37-16 has been sent to all providers for their feedback. The suggestions how he would present it – Committee was asked if they were comfortable with the link it to CCG SEND webpage. strategy’s approach. Aim is around engaging young people in their own planning - vision of what they want to do. General discussion had around the strategy.

12 SEND Guidelines The Committee approved Halton’s SEND Guidance for 47 QC 38-16 Professionals. 13 Draft The Committee approved the draft Halton Borough Council 47 Personalisation & & NHS Halton CCG’s Personalisation & Personal Budget Personal Budgets Policy for approval. The CCG will be paying money for the Policy health portions of the personalised budgets and therefore QC 39-16 needed to approve the processes within the policy. Currently relates to 12 children within the Borough.

15 Flu Performance The Committee were provided with a copy of Halton’s Flu 47 Report Vaccination Report for noting. QC 40-16 The Committee noted the contents of the report. 16 Halton Haven The Committee were provided with a copy of Halton Haven’s 47 Hospice CQC CQC Report for noting. Report QC 41-16 The Committee noted the contents of the report. 17 National Cancer The Committee noted the National Cancer Patient 47 Patient Experience Experience Survey Report. Felt 56% was not a great Page 6 of 7

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref: Survey Results response rate, but in general the sample size of 167 was QC 42-16 quite low. Also disappointing that only 53% said that there was always or nearly always enough staff on duty. The lower than average 58% of patients responding that they though GPs and nurses did everything they could to support them was disappointing too. In general not a bad report – but a lot of room for improvement.

Key Issues Report Date Prepared by: Hilary Southern 22/07/16 Verified by: Jan Snoddon 25/07/16 NOTE: A copy of the approved Minutes from this Meeting or any papers referenced in this Key Issues Report will be made available to the Governing Body on request to the Committee Chair

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Primary Care Commissioning Committee 19th July 2016

Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref:

3 Conflicts of Jan Snoddon had designed a workshop around the new, JS and HS to review DoI process and Interest Training revised ‘Conflicts of Interest Guidance’ – what it means, how process of recording/publishing breaches PCC 14-16 we might use it, and how we might keep it in mind while we look to what the rest of the year looks like in terms of what we are going to work on.

Key changes:  Requirement to have 3 lay members – Halton is achieving this as currently has 4  Nominate a DoI Guardian - David Merill, Audit Committee Chair has agreed to take on this role  Gifts, Hospitality & Sponsorship Register changes  Anonymised Breaches to be published  Annual audit to be undertaken – this has been written into our audit plan

The Committee then broke into three sub groups to work on a number of case studies. This helped the committee to consider how it would need to plan ahead to enable good clinical input in service design whilst avoiding procurement and reputational challenges.

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Agenda Item Key Issue: Action: CCG Item Ref: Datix No: Risk Ref:

4 Topics for PCCC Leigh Thompson led a discussion on CCG Priority Areas – Work to be undertaken on direction of travel Focus Clinical Areas of Focus; this looked at: for Primary Care – how it aligns to clinical (Verbal) areas of work and the strategic direction. What plans we have ccurrently and whether we need a Bring back to September meeting for further clinical strategy in order to drive the right agenda forwards for discussion and agreement. PCCC over the next 2 years.

It was agreed that it was important to address variation and Second part of work is to agree the best practice and identifying the areas of focus would allow measures/variations - once have agreed this to be measured and addressed. intentions. Build the dashboard/plans.

Key Issues Report Date Prepared by: Hilary Southern 22nd July 2016 Verified by: Ingrid Fife & Jan Snoddon 27th July 2016 NOTE: A copy of the approved Minutes from this Meeting or any papers referenced in this Key Issues Report will be made available to the Governing Body on request to the Committee Chair

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Performance and Finance Committee Tuesday 26th July 2016

No Item Key Issue Action CCG BAF/Risk Register Combined The Combined Performance Report informed the Committee of the current Performance Report financial position at Month 3 up until the end of June. Committee asked to (PF 17-16) note Business Rules should be green, and QIPP amber.

Position for first three months is an overspend of £1.3 million. Out of area placements taking longer than expected to get resolved. Acute spend still the biggest figure – half of the total budget at £1.1 mill. Two providers, Warrington and St Helens. We are still forecasting to break even and meet NHSE rules at this point. The main factors will be where we come in on QIPP – little reserves left – aside from contingency and ring fenced funding – everything else went into contract settlements.

Summary of acute contract positions provided – Warrington has biggest YTD 3 variance at £419k. All overspend is currently being challenged with Warrington – they have been charging us A&E attendances when these should be blocked as part of UCC. CCG not paid them any over performance charges so far and nor will we. SB updated the Committee that he met with NHSE Improvement on 22nd July and discussed Warrington issues – they are aware of a variety of performance issues including problems around the implementation of the Lorenzo system. NHSE were clear that Providers should not be expecting Commissioner to pay for activities generated in this way, and therefore being bankrupted. NHSE agreed they would intervene if necessary.

Medicines Management team are on track to deliver their QIPP target of £1m. Resource allocation – consistent. Better payment code way above

No Item Key Issue Action CCG BAF/Risk Register 95% target.

Financial position in 2016/17 is clearly extremely challenging. Corporate The Committee received the Corporate Performance Report. Performance Report (PF 18-16) Areas highlighted included;

Cancer Activity ACTION: MS and JS to 5 breaches in May. 1 raised at breaches meeting. 2 cases outcome of MDT formally request referred for surgery – Consultant surgeon spoke to patient and decision information or invoke changed and Radiotherapy put forward for treatment but no further invest financial penalties. done. 1 patient surgery delayed as hadn’t stopped taking meds before surgery – 2nd Aug will find out if had been told to stop or not. Unable to get the data before the meeting - Warrington share the data up front re: pathways; but St Helens won’t tell any more than the number of breaches, until you attend the meeting. Discussion around whether there is any 4 contractual lever to enable us to see this information in advance – could we withhold money (1%), unless get this info in advance? Also need to think about how to monitor cancer breaches and waits now SRGs are being abolished (replaced by A&E delivery boards now and cancer not included in them).

Ambulance Response Times NWAS missed times 6 months in a row. Increase in activity and turnaround times. 5mins longer in may this year than last, although have improved from peak times. 12.5% increase in activity here. Discussed at SRG – agreed to find extra funding – to be discussed with Dave Sweeney re: funding.

Dementia Diagnosis Rates Declined since April – given an increased prevalence figure. Above national

No Item Key Issue Action CCG BAF/Risk Register average still, and improvement seen in June. Work with i5 will identify additional patients (in secondary care but don’t feature in primary care). Second part of work is focused on those patients who don’t have a formal diagnosis but show patterns of admissions and behaviour which match those who do or go on to have – therefore look at them and get an early/earlier diagnosis. Two practices running the pilot currently. Sits with P&F currently – under Recovery Plan. Can’t get bloods from residents in care homes, so not on dementia register – this is needed by QAF – so can’t be on the register. Self-set CCG target. Potential costs around i5 in making links with Memory Clinic.

Psychological Therapies Recovery Rate IAPT Recovery Rate remains below 50% - contract performance notice has been issued to 5BP. Actions listed in report. Emergency Readmissions – no May update yet from CSU.

MRSA – 1 Case Community acquired – reported through Quality Committee.

Seen 300 additional non electives go through Warrington and 17 additional A&E attendances. Also query regarding A&E one group have disappeared and moved into more expensive code. Couple of 100 every month – in April/May none – in Warrington. Coding issue. 300% increase in BB02’s (Resuscitation).

Contracts Update The Committee noted the contracts update – month 2 over performance (PF 19-16) identified of £553k (4%) above planned position. Variance predominantly in three Trusts. Aristotle, new Business Intelligence tool will pull out 5 exceptional items now. Fluctuations – spike in two independent hospitals Spire Cheshire and Fairfield Hospital – activity had dropped off in outpatients and ortho cases – seems to be coming back now. Hopefully as MSK pilot

No Item Key Issue Action CCG BAF/Risk Register rolls out will come back in line with plan.

Royal Liverpool – spike due to low volume, high cost (vascular) patients (diabetics/amputations). Long stay critical care patients - cost a lot. Always expect them to happen. Countess also spiking – Halton sends majority of patients there.

STH – Under performance on A&E and electives. Not UCC causing it. Main pressure point is elective activity. Real referrals going through. Neuro rehab unit – couple of long stay patients still in there. Using more beds than paid for. High user of them. Didn’t buy enough beds, and are actually a high user.

WHHFT – Month two £0.25m variance, pressures in A&E, non-electives and critical care – total almost £0.5m. Key issues as listed on page 5. Meeting held on 22nd July to discuss and review activities. Cash figure will come down – they are working on it – if they fail financial control total they get nothing.

Plastic Surgery STHK – Looking at anything they shouldn’t be doing (e.g. dermatology services), anything with higher referral rates. Discussions being had at SDC – a lot going on want to take out.

Recovery & The Committee noted verbal update from Jacqui Ireland, Head of Recovery Copy of paper to be Sustainability and Simon Banks, Chief Officer. Paul Brickwood and Simon Banks met with brought to next P&F (Verbal) NHSE to go through Combined performance report and shared JI’s Committee meeting. 7 Sustainability update report.

Halton position is concerning – challenge to deliver required financial position at year end. Adopt voluntary recovery stance. Sent a number of

No Item Key Issue Action CCG BAF/Risk Register docs to support including CCG improvement manual. During meeting Claire Duggan said if Halton can do it then they will.

Recovery plan to be delivered by 2017/18. Basically stay out of financial distress as long as possible; but the cost of activity growth is crippling. Scale of the challenge is we can’t invest in primary care if in turn around – acute sector reorganisation.

Avoiding formal direction from NHSE, but have been given a number of ‘Go away and do’, as follows: 1) Contractual management – pay to plan Referral Management 2) Referral management system (like currently in place in Warrington) – Centre/Incentivise We already looking at MAP of Medicine but if don’t start implementing through PMS Premium it soon it will be part of formal direction given to us. – plan to be worked 3) Redesign needs to accelerate – strategic Accountable Care System, up. Paper to go jobs etc. Paper to go to GB in September. through SDC. 4) Meds Management – Robust plan but they asked are all providers are on board and responding to us and talking to LR and team. Pan Mersey team chaired by Liverpool CCG – they much more laissez faire than us. STP Level discussion needed. 5) Nuclear options – what take out/stop doing?

NHSE currently steering us – not formal directions as yet – but could happen very quickly. We are voluntarily declaring where we are – created breathing room. Need to up some of schemes in the recovery plan. Key clinical leads and staff behind plan.

In report – looked at underlying financial position. Identified £9mill QIPP – included is 1% ring fenced (£2mill) – so takes down to £7mill. Identified where money been spent – 13/14 to 16/17 secondary care, community,

No Item Key Issue Action CCG BAF/Risk Register prescribing and MH all gone up. Community due to UCC. Now identified list of efficiencies/opportunities.

Achieved Q1 target (£1mill). But a lot was around moving money out of reserves. Prescribing on target, Primary Care and community have achieved little bits. Monitoring fortnightly. PIDs to decommission and change. But we meet most back end of year - £1mill Q2, 2.4 Q3, etc.

Big schemes pathways are only just starting to be implemented. Massive risks - everything remains red until on the ground being delivered. Full year effect is £7.2 mill. Meet this year, then meet 1% next year, then meet 1% surplus 2017-18 – puts us back in line. Budget Book Budget Book brought to P&F Committee for information – currently in 8 process of getting sign off from budget holders – minor changes over who is budget holder for certain areas. Halton Haven MIAA Review Report on Halton Haven Hospice brought for noting – initially Undertake the review, Report (PF 21-16) presented to EMT on 22nd July. A few changes have been made - better then next year make described how created some of the tables in the report; and also set up a decision on template to be produced on a monthly basis for them to complete. Good recurrent/non report – identified main issues and pressure points in organisational financial recurrent. Timeframe stewardship. They have taken on board recommendations and agreed to for review – Oct/Dec them all. Pressures have been growing – although are making money on need to be negotiating 9 their fundraising, and increases in lottery expected (due to canvassers). contract. Legacies are falling and non recurrent windfall is dwindling. Have more HCAs in place of nurses – looking at pay rates of nursing. Altering bed base from 12 to 10. Overall not much they can do to cut costs in this area – shut down recycling centre etc. – small changes against recurrent problem. Need proper recovery plan and reserve planning (e.g. half million plan). The CCG is the core bulk of incoming income, then strong fundraising – mainly windfalls. Fixed costs predominantly.

No Item Key Issue Action CCG BAF/Risk Register Brought to P&F for decision re: long term future:  Do we continue to fund?  Do we stop funding – in effecting ‘Letting them fall over’?  Do we encourage them to join with another Hospice?

LT – Agreed at EMT to recommend a proposal of non recurrent funding for this financial year whilst a review of Hospice position with EoL services is undertaken, JS to take through LTC group. Opportunity to move services out of the hospital and direct to the hospice instead – include the costs/income. Loss of specialist palliative care team – more important than just the bricks and mortar – find a way to sort this in the long term. It is not an option to not support.

Have given them £100k non recurrent this year already to ensure maintain operationally stable. No additional resources. Risk Register (PF 22- The Committee discussed the risks contained in the Corporate Risk 44,45,63,66 16) Register. Risk ID 44 – Agreed Risk ID 45 – Don’t close as still deemed a risk, due to current Warrington 10 CCG working closely and may need to invest to do more. Also gaps in assurance around Primary Care. Risk ID 63 – Agreed Risk ID 66 – Agreed

Key Issues Report Date Prepared by: Liz Walker, Committee Administrator 28/07/16 Verified by: Simon Banks, Committee Chair 28/07/16

Governing Body

st Date: 1 September 2016 Report title: Review of Standards of Business Conduct including management of conflicts of interest Lead Clinician and/or Jan Snoddon Chief Nurse Lead Manager: David Merrill, Chair – Audit Committee

Purpose: To present to the Governing Body for approval the reviewed and fully updated in line with new statutory guidance Standards of business Conduct for the CCG

The Governing Body is 1. note the amendments asked to: 2. approve the policy 3. agree the appointment of the Conflicts of Interest Guardian for the CCG

This Report supports the following CCG Strategic Objectives (delete as appropriate) One: To commission services which continually improve the health and wellbeing of Halton residents

Three: To develop plans which will deliver improvements in local health services whilst making efficiency savings

Four: To deliver all of our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place

Five: To develop into a high-performing organisation, working with our partners to deliver a joined- up approach to commissioning wherever possible

Seven: To develop the skills, knowledge and competence of our workforce to create a high- performing team

Commissioning Plan Implications affects all commissioning and other decisions Financial Implications Does this require financial support? No

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If Yes - Is there currently a budget for this? No/Yes If No - please indicate if this has been discussed with and has the sign off, of the CCG finance department

Board Assurance Framework and Corporate Risk Register Does this report link to either the Board Assurance Framework (BAF) or Corporate Risk Register (CRR) or both? YES

If Yes - please state: affects all risks within the BAF

 the corresponding reference number.

 state level of assurance this paper provides? (None/Limited/Significant/High )

If No - does this paper raise a risk to be considered please liaise with the relevant BAF and CRR Leads and confirm here that this has been raised.

National Policy, Guidance, Standards, Targets or Legislation

Equality and Diversity and Human Rights What are the identified equality implications across protected characteristics? No

Are these implications mitigated in your plan? Yes/No – (if Yes please escalate this issue)

Background

NHS Halton CCG approved in April 2016 an updated and reviewed Standards of Business conduct policy following a review by NHS England further updated statutory guidance on Managing Conflicts of Interest – statutory guidance for CCGs was published in June 2016. This guidance supersedes the previous guidance The effective management of conflicts of interest is essential in safeguarding the CCG legally and from a reputational perspective. It is also essential in ensuring the trust of local people in the actions and decisions taken by the CCG

Process for updating

The Chief Nurse working with the Deputy Chair/Audit committee chair reviewed the guidance once published together with the current Standards of business conduct and agreed the additions and amendments to be made to ensure the policy was complaint with statutory

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guidance. The policy presented for approval is the completed article and is ready for approval by the Governing Body.

Amendments made to the document are:

 additional clarification of conflicts with broader descriptors  additional clarifications on roles and responsibilities including extra roles such as Primary Care Commissioning Committee chair and conflict of Insets Guardian  greater clarity in relation to gift, hospitality and sponsorship  greater clarity regarding requirement during contracting or procurement processes  amendments to declaration template  amendments to hospitality and gifts declaration template  amendments to publication template for declaration of interests and hospitality register  a template for recording minutes in committees were conflicts are being actively managed  template for publication of conflicts and how these have been managed  templates for declaring conflicts in contracting or procurement processes and for publishing all such decisions  inclusion of a flow chart highlighting the key processes for declarations of interest etc.

The Governing body is also asked to note that within this Improvement and Assessment process in this year Mersey Internal Audit Agency (MIAA) will during Quarter four carry out an audit review which will be utilised in final decision and need to be included within the Annual Report/Governance Statement

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STANDARDS OF BUSINESS CONDUCT (incorporating Managing Conflicts of Interest Policy)

Policy Author(s) Jan Snoddon, Chief Nurse

Accountable Manager(s) Simon Banks, Chief Officer Jan Snoddon, Chief Nurse

Ratified by (Committee) Governing Body th Date Ratified 6 October 2016 Target Audience All CCG Staff Review Date January 2018 Unless new guidance has been issued

Revision Date Version Brief Description of Change No January 2015 2 Inclusion of the term contractors and volunteers Updated forms in Appendices D & E Updates from Managing Conflicts of Interest guidance 2014 statutory guidance January 2016 3 Incorporating Bribery Act 2010 October 2016 4 Updated in line with Managing Conflict of Interest: Revised Statutory Guidance for CCGs published by NHSE June 2016

To be read in conjunction with:  Counter Fraud Policy  Whistle Blowing Policy  Disciplinary Policy  Code of Conduct for NHS Managers (October 2002)  Standards of Business Conduct (HSG (93) 5)  Induction Procedure  Procurement Policy  CCG Standing Orders and Standing Financial Instructions  RCGP & NHS Confederation’s ‘Managing Conflicts of Interest’ briefing paper, (September 2011)  Monitor - Substantive guidance on the Procurement, Patient Choice and Competition Regulations (December 2013)  http://www.legislation.gov.uk/uksi/2013/500/contents/made  The Bribery Act 2010  Managing Conflicts of Interest – Revised Statutory Guidance for CCGs (June 2016)  CCG Pharmaceutical Industry Policy  NHSE Guidance

Contents

1.0 Introduction 3

2.0 Purpose 4

3.0 Roles and responsibilities 4

4.0 Conflict of Interest (Definition & Management) 8

5.0 Bribery Act 2010 15

6.0 The Legal Position 15

7.0 Gifts 16

8.0 Hospitality 16

9.0 Commercial sponsorship 17

11..0 Non - Adherence to this Policy 19

12.0 Consultation, approval and ratification process 19

13.0 Dissemination and Implementation 20

14.0 Document Control 20

15.0 Monitoring compliance and effectiveness 20

16.0 Associated Documentation 20

Appendices

Appendix A Short guide for Managers 22

Appendix B Short guide for Staff 23

Appendix C Declaration of interest CCG members and employees 24

Appendix D Declaration of interest checklist 26

Appendix E Template for recording minutes 29

Appendix F Procurement checklist 31

Appendix G Procurement Declaration template 32 Appendix H Procurement decisions and contact awarded template 33 Appendix I Register of interest template for publication 34 Appendix J Declaration of gift and hospitality 35 Appendix K Register of gifts and hospitality for publication 36 Appendix L Register of Procurement decisions and contracts 37 awarded for publication Appendix M Process flow Chart 38

1.0 Introduction

NHS Halton Clinical Commissioning Group (CCG) is mindful of the necessity to conduct its business in keeping with the highest ethical standards. The CCG makes extensive reference to this subject in its Constitution, Scheme of Reservation and Delegation, Standing Orders and Standing Financial Instructions.

This policy document builds on these written standards whilst reflecting;

 Health Service Guidelines issued by the NHS Management Executive in 1993 HSG (93) 5  The Code of Conduct for NHS Managers (October 2002)  The 2012 guidance from the National Commissioning Board in relation to Managing Conflict of Interest in CCGs and the Professional Standards Authority Standards for Members of NHS Boards and Clinical Commissioning Group Governing Bodies in England (November 2012, Managing Conflicts of Interest: Statutory Guidance for CCGs June 2016

Managing Conflicts of Interest: Statutory guidance for CCGs published in June 2016 provides clear guidance to CCGs to ensure conflicts of interest are managed appropriately and assurance is available on the effectiveness of processes in CCGs. The guidance is issued as statutory guidance under sections 14O and 14Z8 of the National Health Service Act 2006 (as amended by the Health and Social Care Act 2012) (“the Act”). This means that CCGs must have regard to such guidance with the onus on them to explain any non-adherence. When a CCG seeks to take on delegated or joint commissioning responsibilities, the Audit Committee Chair and Accountable Officer will be required to provide direct formal attestation to NHS England that the CCG has complied with all appropriate guidance. Subsequently, this attestation will form part of an annual certification. CCG approaches to management of conflicts of interest will also be considered on an on-going basis as part of CCG Improvement and Assessment Framework 2016/2017. .

This guidance also builds on guidance issued by other national bodies, in particular Monitor’s guidance on the Procurement, Patient Choice and Competition Regulations, and guidance issued by GP professional bodies such as the British Medical Association (BMA), the General Medical Council (GMC) and the Royal College of General Practitioners (RCGP).

The latest statutory guidance outlines a number of additional requirements on the CCG to ensure compliance legally these are described below

 Recommendation that CCGs have a minimum of three lay members

 The introduction of a Conflicts of interest guardian who will be an important point of contact for any conflicts of interest queries or issues (which is expected to be audit committee chair)

 A requirement for CCGs to include a robust process for managing breaches within their policies and for anonymised details of the breach to be published on the CCG website for the purpose of learning and development.

 Strengthened provisions around decision-making when a member of the governing body, or committee or sub-committee is conflicted;

 Strengthened provisions around the management of gifts and hospitality, including the need for prompt declarations and a publicly accessible register of gifts and hospitality;

 A requirement for CCGs to include an annual audit of conflicts of interest management within their internal audit plans and to include the findings of this audit within their annual end-of-year governance statement;

 A requirement for all CCG employees, governing body and committee members and practice staff with involvement in CCG business, to complete mandatory online conflicts of interest training, which will be provided by NHS England. The online training will be supplemented by a series of face-to-face training sessions for CCG leads in key decision-making roles.

The Bribery Act introduced a new corporate offence of failure to prevent bribery by persons associated with a commercial organisation (this includes NHS bodies), with a potential defence if the commercial organisation could show that it had adequate procedures in place to prevent bribery from occurring. Any senior management or board member who consents or connives in any active or passive bribery offence would, together with the organization, be liable for the corporate offence.

In summary, the Bribery Act 2010 exposes individuals who commit or connive in bribery offences to imprisonment of up to 10 years, and/or unlimited fines. It exposes commercial organisations to unlimited fines, unless the commercial organization could demonstrate that it had adequate procedures in place to prevent bribery from occurring.

In considering the application of this policy or procedure the CCG will ensure that members, staff or patients will not be discriminated against or treated differently on account of any subjective bias in relation to the six pillars of equality and diversity: race, disability, gender, age, sexual orientation, religion/belief.

Where nationally agreed terms and conditions change or differ from locally agreed policies, the nationally agreed terms and conditions will take precedence.

2.0 Purpose

The purpose of this policy is to provide guidelines for members, staff, and contractors and to their work on behalf of or employment with the CCG, and how they conduct their business in a fair, equitable, open and transparent way.

The CCG places the utmost importance upon the impartiality and honesty of all working for the CCG and expects them to use public funds in a responsible fashion ensuring best value for money. In all matters the service to patients and clients will remain the focus of our activities.

Clinical Commissioning Groups (CCGs) manage conflicts of interest as part of their day-to-day activities. Effective handling of such conflicts is crucial for the maintenance of public trust in the commissioning system. Importantly, it also serves to give confidence to patients, providers, and Parliament and tax payers that CCG commissioning decisions are robust, fair, and transparent and offer value for money. The CCG must also ensure it complies with the expectations of the Bribery Act 2010.

The aims of this guidance are to;  Safeguard clinically led commissioning, whilst ensuring objective investment decisions

 Enable commissioners to demonstrate that they are acting fairly and transparently and in the best interests of their patients and local populations.

 Uphold confidence and trust in the NHS.

 Support commissioners to understand when conflicts (whether actual or potential) may arise and how to manage them if they do.

 Be a practical resource and toolkit and web links to case studies to help the CCG and its staff identify conflicts of interest and appropriately manage them

 Ensure the CCG operates within a legal framework but without being bound by over- prescriptive rules that risk stifling innovation;

3.0 Roles and responsibilities

3.1 Chief Officer

The Accountable Officer has overall accountability for the CCG’s management of conflicts of interest. CCGs should identify a team or individual within their organisation, such as the CCG’s governance lead, with responsibility for:

 The day-to day management of conflicts of interest matters and queries;

 Maintaining the CCG’s register(s) of interest and the other registers referred to in this Guidance;

 Supporting the Conflicts of Interest Guardian to enable them to carry out the role effectively (see paragraph 67 onwards);

 Providing advice, support, and guidance on how conflicts of interest should be managed; and

 Ensuring that appropriate administrative processes are put in place

The Chief Officer, as the Accountable Officer is responsible for ensuring that this policy is brought to the attention of all members, employees, contractors and volunteers, and those systems and procedures are put in place for ensuring that this policy is effectively implemented and reported to the Audit Committee, this responsibility will be delegated to the Chief Nurse as outlined below. In addition, the Chief Officer is responsible for ensuring that the organisation is impartial and honest in the conduct of its business, and that all employees should remain above suspicion.

3.2 Chief Nurse

The Chief Officer will delegate responsibility for the effective operation of this policy to the Chief Nurse. This delegation will include ensuring that appropriate systems and procedures and reporting mechanisms as set out above are in place. Through this individual and her team, the CCGs will provide clear guidance to staff, governing body and committee members, and GP member practices on what might constitute a conflict of interest, including examples of possible conflicts and situations in which a conflict may arise. This may be achieved through training and wide promotion of the CCG’s policy on conflicts of interest management,

3.3 Lay Members Lay members play a critical role in CCGs, providing scrutiny, challenge and an independent voice in support of robust and transparent decision-making and management of conflicts of interest. They chair a number of CCG committees, including the Audit Committee and Primary Care Commissioning Committee. By statute, CCGs must have at least two lay members (one of whom must have qualifications, expertise or experience such as to enable the person to express informed views about financial management and audit matters and serve as the chair of the audit committee19; and the other, knowledge of the geographical area covered in the CCG’s constitution such as to enable the person to express informed views about the discharge of the CCG’s functions. In light of lay members’ expanding role in primary care co-commissioning, we strongly recommend that all CCGs consider increasing this requirement within their constitution to a minimum of three lay members on their governing body. NHS Halton CCG has four Lay Member roles.

3.4 Conflict of Interest Guardian To further strengthen scrutiny and transparency of CCGs’ decision-making processes, all CCGs should have a Conflicts of Interest Guardian (akin to a Caldicott Guardian). This role should be undertaken by the CCG audit chair, provided they have no provider interests, as audit chairs already have a key role in conflicts of interest management. They should be supported by the CCG’s Chief Nurse (lead for Governance), who should have responsibility for the day-to-day management of conflicts of interest matters and queries. The CCG lead for Governance should keep the Conflicts of Interest Guardian well briefed on conflicts of interest matters and issues arising.

The Conflicts of Interest Guardian should, in collaboration with the CCG’s governance lead:

 Act as a conduit for GP practice staff, members of the public and healthcare professionals who have any concerns with regards to conflicts of interest;

 Be a safe point of contact for employees or workers of the CCG to raise any concerns in relation to this policy;

 Support the rigorous application of conflict of interest principles and policies;

 Provide independent advice and judgment where there is any doubt about how to apply conflicts of interest policies and principles in an individual situation;

 Provide advice on minimising the risks of conflicts of interest.

Whilst the Conflicts of Interest Guardian has an important role within the management of conflicts of interest, executive members of the CCG’s Governing Body have an on-going responsibility for ensuring the robust management of conflicts of interest, and all CCG employees, governing body and committee members and member practices will continue to have individual responsibility in playing their part on an ongoing and daily basis

3.5 Primary Care Commissioning Committee Chair The primary care commissioning committee must have a lay chair and lay vice chair. To ensure appropriate oversight and assurance, and to ensure the CCG audit chair’s position as Conflicts of Interest Guardian is not compromised, the audit chair should not hold the position of chair of the primary care commissioning committee. This is because CCG audit chairs would conceivably be conflicted in this role due to the requirement that they attest annually to the NHS England Board that the CCG has:

 Had due regard to the statutory guidance on managing conflicts of interest; and

 Implemented and maintained sufficient safeguards for the commissioning of primary care.

CCG audit chairs can however serve on the primary care commissioning committee provided appropriate safeguards are put in place to avoid compromising their role as Conflicts of Interest Guardian. Ideally the CCG audit chair would also not serve as vice chair of the primary care commissioning committee. However, if this is required due to specific local circumstances (for example where there is a lack of other suitable lay candidates for the role), this will need to be clearly recorded and appropriate further safeguards may need to be put in place to maintain the integrity of their role as Conflicts of Interest Guardian in circumstances where they chair all or part of any meetings in the absence of the primary care commissioning committee chair.

3.6 Managers It is the responsibility of line managers to ensure that they comply with the Code of Conduct for NHS Managers (October 2002). http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publications Policy and Guidance/DH_4005410

It is the responsibility of all managers to ensure that CGG members and their staff (including contractors and volunteers) have received an induction which includes reference to all Policies and Codes of Conduct to ensure that they are familiar with the agreed processes and procedures as identified within this Policy.

It is the responsibility of the line manager to ensure that appropriate action and risks are assessed where an employee, contractor or volunteer has raised any issue in accordance with this policy or where an issue has come to the notice of the line manager. All risks must be recorded on the CCGs Risk Assessment Form (Appendix A).

A short guide is attached at Appendix A to support members and managers in their decision making.

The Bribery Act 2010 is a piece of UK legislation which the CCG must comply with. All areas of the CCG are responsible for consideration of and compliance with the Bribery Act, where appropriate, as a matter of ‘business as usual’ e.g. when considering development and review of policies and procedures; undertaking appropriate due diligence on those we employ and do business with; ensuring appropriate contract clauses are in use; ensuring appropriate tender documentation is in use etc. Compliance with the Act is required based on the level of risk to the CCG, and proportionate procedures should be put in place accordingly.

3.7 All Members, Employees, Contractors and Volunteers Members on CCG business and Staff are expected to follow the highest standards in business conduct and accountability. The NHS Codes of Conduct and Standards of Business Conduct for NHS Staff HSG (93) 5 require you to declare all situations where you (or a close relative or associate) have a controlling interest in a business (such as a private company, public organisation, other NHS organisation or voluntary organisation) or in any other activity which may compete for an NHS contract to supply goods or service to the CCG. The CCG has adopted a set of rules on declaration of hospitality and gifts, and declaration of interests in suppliers and potential suppliers to the CCG. These rules set out circumstances in which hospitality and interests must be declared.

4.0 Conflict of interest For the purposes of Regulation 6 [National Health Service (Procurement, Patient Choice and Competition) (No.2) Regulations 2013], a conflict will arise where an individual’s ability to exercise judgment or act in their role in the commissioning of services is impaired or influenced by their interests in the provision of those services

Conflict of interest occurs where an individual’s ability to exercise judgement, or act in a role is, could be, or is seen to be impaired or otherwise influenced by his or her involvement in another role or relationship. In some circumstances, it could be reasonably considered that a conflict exists even when there is no actual conflict. In these cases it is important to still manage these perceived conflicts in order to maintain public trust.

Conflicts of interest can arise in many situations, environments and forms of commissioning, with an increased risk in primary care commissioning, out-of-hours commissioning and involvement with integrated care organisations, as clinical commissioners may here find themselves in a position of being at once commissioner and provider of services. Conflicts of interest can arise throughout the whole commissioning cycle from needs assessment, to procurement exercises, to contract monitoring.

Interests can be captured in four different categories:

Financial interests: This is where an individual may get direct financial benefits from the consequences of a commissioning decision. This could, for example, include being:

 A director, including a non-executive director, or senior employee in a private company or public limited company or other organisation which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations.

 A shareholder (or similar ownership interests), a partner or owner of a private or not-for-profit company, business, partnership or consultancy which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations.

 A management consultant for a provider.

This could also include an individual being:  In secondary employment (see paragraph 56-57);

 In receipt of secondary income from a provider;

 In receipt of a grant from a provider;

 In receipt of any payments (for example honoraria, one-off payments, day allowances or travel or subsistence) from a provider;

 In receipt of research funding, including grants that may be received by the individual or any organisation in which they have an interest or role; and

 Having a pension that is funded by a provider (where the value of this might be affected by the success or failure of the provider).

Non-financial professional interests: This is where an individual may obtain a non-financial professional benefit from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. This may, for example, include situations where the individual is:

 An advocate for a particular group of patients;

 A GP with special interests e.g., in dermatology, acupuncture etc.

 A member of a particular specialist professional body (although routine GP membership of the RCGP, British Medical Association (BMA) or a medical defence organisation would not usually by itself amount to an interest which needed to be declared);

 An advisor for the Care Quality Commission (CQC) or the National Institute for Health and Care Excellence (NICE);

 A medical researcher.

 GPs and practice managers, who are members of the governing body or committees of the CCG, should declare details of their roles and responsibilities held within their GP practices.

Non-financial personal interests: This is where an individual may benefit personally in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit. This could include, for example, where the individual is:

 A voluntary sector champion for a provider;

 A volunteer for a provider;

 A member of a voluntary sector board or has any other position of authority in or connection with a voluntary sector organisation;

 Suffering from a particular condition requiring individually funded treatment;

 A member of a lobby or pressure group with an interest in health.

Indirect interests: This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision (as those categories are described above) for example, a:

 Spouse / partner

 Close relative e.g., parent, grandparent, child, grandchild or sibling;

 Close friend;

 Business partner.

 A declaration of interest for a “business partner” in a GP partnership should include all relevant collective interests of the partnership, and all interests of their fellow GP partners (which could be done by cross referring to the separate declarations made by those GP partners, rather than by repeating the same information verbatim).

Whether an interest held by another person gives rise to a conflict of interests will depend upon the nature of the relationship between that person and the individual, and the role of the individual within the CCG

For a commissioner, a conflict of interest may therefore arise when their judgment as a commissioner could be, or be perceived to be, influenced and impaired by their own concerns and obligations as a provider. In the case of a GP involved in commissioning, an obvious example is the award of a new contract to a provider in which the individual GP has a financial stake. However, the same considerations, and the approaches set out in this guidance, apply when deciding whether to extend a contract.

There will be occasions where an individual declares an interest in good faith but, upon closer consideration, it is clear that this does not constitute a genuine conflict of interest. The individual who has designated responsibility for maintaining the registers of interest should provide advice on this and decide whether it is necessary for the interest to be declared

There will be occasions where the conflict of interest is profound and acute. In such scenarios (such as where an individual has a direct financial interest which gives rise to a conflict, e.g., secondary employment or involvement with an organisation which benefits financially from contracts for the supply of goods and services to a CCG) it is likely that CCGs will want to consider whether, practically, such an interest is manageable at all. If it is not, the appropriate course of action may be to refuse to allow the circumstances which gave rise to the conflict to persist. This may require an individual to step down from a particular role and/or move to another role within the CCG. CCGs should ensure that their HR policies, governing body and committee terms of reference and standing orders are reviewed to ensure that they enable the CCG to take appropriate action to manage conflicts of interest robustly and effectively in such circumstances

Examples of situations which might constitute a constitute a conflict of interest are;

 a perception of wrongdoing, impaired judgement or undue influence can be as detrimental as any of them actually occurring;

 if in doubt, it is better to assume the existence of a conflict of interest and manage it appropriately rather than ignore it; and  for a conflict of interest to exist, financial gain is not necessary.

To ensure effective management of conflicts of interest NHS Halton CCG will

 Maintain appropriate registers of interests;

 Publish or make arrangements for the public to access those registers;

 Make arrangements requiring the prompt declaration of interests by the persons specified (members and employees) and ensure that these interests are entered into the relevant register;

 Make arrangements for managing conflicts and potential conflicts of interest (e.g. developing appropriate policies and procedures);

 Appoint a Conflict of Interest Guardian as a point of contact for any conflicts of interest issues or queries.

 Ensure all staff received appropriate conflict of interest training in line with statutory guidance

 Implement a robust process for managing any conflict of interest breaches with a process to publish anonymised details of any breaches on the CCG website and

 Have regard to guidance published by NHS England and Monitor in relation to conflicts of interest.

Section 14O is supplemented by the procurement specific requirements set out in the National Health Service (Procurement, Patient Choice and Competition) (No.2) Regulations 2013. In particular, regulation 6 requires the following:

 CCGs must not award a contract for the provision of NHS health care services where conflicts, or potential conflicts, between the interests involved in commissioning such services and the interests involved in providing them affect, or appear to affect, the integrity of the award of that contract; and

 CCGs must keep a record of how it managed any such conflict in relation to NHS commissioning contracts it enters into. (As set out in section 4 below, details of this should also be published by the CCG.)

An interest is defined for the purposes of regulation 6 as including an interest of the following:  a member of the commissioner organisation;  a member of the governing body of the commissioner;  a member of its committees or sub-committees or committees or sub-committees of its governing body; or  an employee.

Appendices 6/7/8 and 12 provide appropriate documentation through which the CCG will record conflicts management and publish procurement decisions

4.1 Conflicts of interest can be managed by:

4.1.1 Doing business appropriately- working to Nolan Principals. If commissioners get their needs assessments, consultation mechanisms, commissioning strategies and procurement procedures right from the outset, then conflicts of interest become much easier to identify, avoid and/or manage, because the rationale for all decision-making will be clear and transparent and should withstand scrutiny;

4.1.2 Being proactive, not reactive. Commissioners should seek to identify and minimise the risk of conflicts of interest at the earliest possible opportunity, for instance by:

 considering potential conflicts of interest when electing or selecting individuals to join the governing body or other decision-making bodies;  ensuring individuals receive proper induction and training so that they understand their obligations to declare conflicts of interest.  establishing and maintaining registers of interests, and agreeing in advance how a range of possible situations and scenarios will be handled, rather than waiting until they arise;

4.1.3 Assuming that individuals will seek to act ethically and professionally, but may not always be sensitive to all conflicts of interest. Rules should assume people will volunteer information about conflicts and, where necessary, exclude themselves from decision-making, but there should also be prompts and checks to reinforce this.

4.1.4 Being balanced and proportionate. Rules should be clear and robust but not overly prescriptive or restrictive. They should ensure that decision-making is transparent and fair, but not constrain people by making it overly complex or cumbersome.

4.1.5 Openness. Ensuring early engagement with patients, the public, clinicians and other stakeholders, including local Healthwatch and Health and Wellbeing Boards, in relation to proposed commissioning plans.

4.1.6 Responsiveness and best practice. Ensuring that commissioning intentions are based on local health needs and reflect evidence of best practice – securing ‘buy in’ from local stakeholders to the clinical case for change.

4.1.7 Transparency. Documenting clearly the approach taken at every stage in the commissioning cycle so that a clear audit trail is evident;

4.1.8 Securing expert advice. Ensuring that plans take into account advice from appropriate health and social care professionals, e.g. through clinical senates and networks, and draw on commissioning support, for instance around formal consultations and for procurement processes;

4.1.9 Engaging with providers. Early engagement with both incumbent and potential new providers over potential changes to the services commissioned for a local population;

4.1.10 Creating clear and transparent commissioning specifications that reflect the depth of engagement and set out the basis on which any contract will be awarded;

4.1.11 Following proper procurement processes and legal arrangements, including even-handed approaches to providers;

4.1.12 Ensuring sound record-keeping, including up to date registers of interests; and

4.1.13 A clear, recognised and easily enacted system for dispute resolution.

4.2 Maintaining a register of interests

4.2.1 Statutory requirements The CCG must maintain one or more registers of interest of: the members of the group, members of its governing body, members of its committees or sub-committees of its governing body, and its employees. CCGs must publish, and make arrangements to ensure that members of the public have access to these registers on request. The process to register interests is outlined with this policy

The CCGs must make arrangements to ensure individuals declare any conflict or potential conflict in relation to a decision to be made by the group as soon as they become aware of it, and in any event within 28 days. CCGs must record the interest in the registers as soon as they become aware of it.

CCGs must ensure that, when members declare interests, this includes the interests of all relevant individuals within their own organisations (e.g. partners in a GP practice), who have a relationship with the CCG and who would potentially be in a position to benefit from the CCG’s decisions.

When entering an interest on its register of interests, the CCG must ensure that it includes sufficient information about the nature of the interest and the details of those holding the interest

The CCG will need to ensure that, as a matter of course, declarations of interest are made and regularly confirmed or updated.

This includes the following circumstances:

On appointment: Applicants for any appointment to the CCG or its governing body should be asked to declare any relevant interests. When an appointment is made, a formal declaration of interests should again be made and recorded.

At meetings: All attendees should be asked to declare any interest they have in any agenda item before it is discussed or as soon as it becomes apparent. Even if an interest is declared in the register of interests, it should be declared in meetings where matters relating to that interest are discussed. Declarations of interest should be recorded in minutes of meetings.

Quarterly: CCGs should have systems in place to satisfy themselves on a quarterly basis that their register of interests is accurate and up to date.

On changing role or responsibility: Where an individual changes role or responsibility within a CCG or its governing body, any change to the individual’s interests should be declared.

On any other change of circumstances: Wherever an individual’s circumstances change in a way that affects the individual’s interests (e.g. where an individual takes on a new role outside the CCG or sets up a new business or relationship), a further declaration should be made to reflect the change in circumstances. This could involve a conflict of interest ceasing to exist or a new one materialising.

4.2.2 Process for declaration of interest see flow chart Appendix M Individual’s must declare/register any interests with the Chief Finance Officer, Chief Nurse or Chief Officer either on appointment or subsequently as outlined above or whenever such interests are gained. The individual must not engage in such interests without the written approval of the Chief Officer, which will not be unreasonably withheld. If an individual thinks they should make a declaration they should discuss the matter with their manager who will provide further guidance.

Appendix C provides a copy of the template for declaration of interests and Appendix D provides an checklist for completion of declarations to ensure these are completed appropriately

Failure to declare may result in appropriate action which for employed staff may include disciplinary action. Declarations of interest should be made through the formal process (Datix or declaration of interest form) and submitted to the Head of Corporate Governance. This declaration will be reviewed by the Chief Nurse and any management processes agreed with the Chief Officer. The CCG member/member of staff/contractor/volunteer will then be informed of these management arrangements.

Failure to complete a declaration or follow management arrangements can and will lead to proportionate appropriate action being taken by the CCG to ensure full compliance with statutory requirements

It is the responsibility of members and staff, contractors and volunteers to ensure that they are not placed in a position which risks, or appears to risk, conflict between their private interests and their NHS duties.

This primary responsibility applies to all staff although certain categories are more likely to be exposed due to the nature of their job, e.g.: a) Those who directly order goods using NHS resources b) Those who are involved in the process of competitive tendering c) Those who indirectly commit NHS resources by the prescription of medicines or influence prescribing d) Those staff who may have an interest in a private nursing home and who are involved with the discharge of patients to residential facilities

Employees should be mindful that there is strong evidence that health professionals are influenced by sponsorship whilst believing themselves not to be. It is also the responsibility of staff to ensure that they do not abuse their official position for personal gain or to the benefit of family or friends. Neither should they seek to advantage or foster private business, or other interests, in the course of their official duties.

Publication of registers CCGs are required to publish the register(s) of interest and register(s) of gifts and Hospitality, referred to above, and the Register of procurement decisions described below, in a prominent place on the CCG’s website.

In exceptional circumstances, where the public disclosure of information could give rise to a real risk of harm or is prohibited by law, an individual’s name and/or other information may be redacted from the publicly available register(s). Where an individual believes that substantial damage or distress may be caused, to him/herself or somebody else by the publication of information about them, they are entitled to request that the information is not published. Such requests must be made in writing. Decisions not to publish information must be made by the Conflicts of Interest Guardian for the CCG, who will seek appropriate legal advice where required, and the CCG will retain a confidential un-redacted version of the register(s).

All persons who are required to make a declaration of interest(s) or a declaration of gifts or hospitality will be made aware that the register(s) will be published in advance of publication. This should be done by the provision of a fair processing notice that details the identity of the data controller, the purposes for which the registers are held and published, and contact details for the data protection officer. This information should additionally be provided to individuals identified in the registers because they are in a relationship with the person making the declaration.

The register(s) of interests (including the register of gifts and hospitality) will be published as part of the CCG’s Annual Report and Annual Governance Statement. A web link to the CCG’s registers is acceptable. Templates for these publications are within the appendices of this policy Appendix I and J

5. Bribery Act The Bribery Act 2010 which came into force on 1st July 2011 deals with bribery only, not other white collar crime. The CCG can be liable for failing to prevent a person from bribing on behalf of their organization. The CCG must evidence adequate procedures to preventing Bribery. The procedures are dependent on the Bribery risk and must be applied following the six principals:

1. Proportionality 2. Top level commitment 3. Risk assessment 4. Due diligence 5. Communication] 6. Monitoring and Review

All members of the CCG must be mindful of the requirements of the Bribery Act 2010 and the potential consequences of non-adherence which could lead to legal action being taken against the CCG.

6.0 The Legal Position Under the Prevention of Corruption Acts 1906 and 1916 it is an offence for employees to corruptly accept gifts or consideration as an inducement or reward for:

 doing, or refraining from doing, anything in their official capacity

 showing favour or disfavour to any person in their official capacity

N.B. Under the 1916 Act, any money, gift or consideration received by an employee in public service from a person or organisation holding or seeking to obtain a contract will be deemed by the courts to have been received corruptly unless the employee proves the contrary.

7.0 Gifts A 'gift' is defined as any item of cash or goods, or any service, which is provided for personal benefit, free of charge or at less than its commercial value.

All gifts of any nature offered to CCG staff, governing body and committee members and individuals within GP member practices by suppliers or contractors linked (currently or prospectively) to the CCG’s business should be declined, whatever their value. The person to whom the gifts were offered should also declare the offer to the team or individual who has designated responsibility for maintaining the register of gifts and hospitality so the offer which has been declined can be recorded on the register.

Gifts offered from other sources should also be declined if accepting them might give rise to perceptions of bias or favouritism, and a common sense approach should be adopted as to whether or not this is the case. The only exceptions to the presumption to decline gifts relates to items of little financial value (i.e., less than £10) such as diaries, calendars, stationery and other gifts acquired from meetings, events or conferences, and items such as flowers and small tokens of appreciation from members of the public to staff for work well done. Gifts of this nature do not need to be declared to the team or individual who has designated responsibility for maintaining the register of gifts and hospitality, nor recorded on the register.

Any personal gift of cash or cash equivalents (e.g. vouchers, tokens, offers of remuneration to attend meetings whilst in a capacity working for or representing the CCG) must always be declined, whatever their value and whatever their source, and the offer which has been declined must be declared to the team or individual who has designated responsibility for maintaining the register of gifts and hospitality and recorded on the register.

8.0 Hospitality A blanket ban on accepting or providing hospitality is neither practical nor desirable from a business point of view. However, individuals should be able to demonstrate that the acceptance or provision of hospitality would benefit the NHS or CCG.

Modest hospitality provided in normal and reasonable circumstances may be acceptable, although it should be on a similar scale to that which the CCG might offer in similar circumstances (e.g., tea, coffee, light refreshments at meetings). A common sense approach should be adopted as to whether hospitality offered is modest or not. Hospitality of this nature does not need to be declared to the team or individual who has designated responsibility for maintaining the register of gifts and hospitality, nor recorded on the register, unless it is offered by suppliers or contractors linked (currently or prospectively) to the CCG’s business in which case all such offers (whether or not accepted) should be declared and recorded.

There is a presumption that offers of hospitality which go beyond modest or of a type that the CCG itself might offer, should be politely refused. A non-exhaustive list of examples includes:  Hospitality of a value of above £25; and  In particular, offers of foreign travel and accommodation.

There may be some limited and exceptional circumstances where accepting the types of hospitality referred to in this paragraph may be contemplated. Express prior approval should be sought from a senior member of the CCG (e.g. the CCG governance lead or equivalent) before accepting such offers, and the reasons for acceptance should be recorded in the CCGs register of gifts and hospitality. Hospitality of this nature should be declared to the team or individual who has designated responsibility for maintaining the register of gifts and hospitality, and recorded on the register, whether accepted or not. In addition, particular caution should be exercised where hospitality is offered by suppliers or contractors linked (currently or prospectively) to the CCG’s business. Offers of this nature can be accepted if they are modest and reasonable but advice should always be sought from a senior member of the CCG (e.g. the CCG governance lead or equivalent) as there may be particular sensitivities, for example if a contract re-tender is imminent. All offers of hospitality from actual or prospective suppliers or contractors (whether or not accepted) should be declared and recorded.

9.0 Commercial sponsorship CCG staff, governing body and committee members, and GP member practices may be offered commercial sponsorship for courses, conferences, post/project funding, meetings and publications in connection with the activities which they carry out for or on behalf of the CCG or their GP practices. All such offers (whether accepted or declined) must be declared so that they can be included on the CCG’s register of interests, and the team or individual designated by the CCG to provide advice, support, and guidance on how conflicts of interest should be managed should provide advice on whether or not it would be appropriate to accept any such offers. If such offers are reasonably justifiable and otherwise in accordance with this statutory guidance then they may be accepted. CCGs should consider whether they wish to adopt a system of prior approval for acceptance of such sponsorship from a member of the CCG with appropriate seniority.

Notwithstanding the above, acceptance of commercial sponsorship should not in any way compromise commissioning decisions of the CCG or be dependent on the purchase or supply of goods or services. Sponsors should not have any influence over the content of an event, meeting, seminar, publication or training event. The CCG should not endorse individual companies or their products. It should be made clear that the fact of sponsorship does not mean that the CCG endorses a company’s products or services. During dealings with sponsors there must be no breach of patient or individual confidentiality or data protection legislation. Furthermore, no information should be supplied to a company for their commercial gain unless there is a clear benefit to the NHS. As a general rule, information which is not in the public domain should not normally be supplied.

10.0 Declaration of offers and receipt of gifts and hospitality

A draft template for declaring gifts and hospitality is annexed at Annex J All hospitality or gifts declared must be promptly transferred to a register of gifts and hospitality that all CCGs should maintain. This should include any gifts and hospitality declared in meetings. A template gifts and hospitality register for use by CCGs is annexed at Annex K. This should contain the following information:  Recipient’s name;  Current position(s) held by the individual (within the CCG);  Date of offer and/or receipt;  Details of the gifts of hospitality  The estimated value of the gifts or hospitality  Details of the supplier/offeror (e.g. their name and the nature of their business); Details of previous gifts and hospitality offered or accepted by this offeror/ supplier;  Details of the officer reviewing/approving the declaration made and date;  Whether the offer was accepted or not; and  Reasons for accepting or declining the offer

Conference or Educational support: staff must obtain permission from their line manager to attend conferences or educational meeting sponsored by commercial concerns. The line manager will agree appropriateness of the support and will ensure that the decision is made in a transparent and unconditional way. The line manager will then ensure that ALL attendance at events with commercial support will be recorded via the Chief Nurse who will present a report to the Audit Committee twice a year. The list of commercially sponsored events will be published as part of the governance committee papers. The CCG expects that educational speakers provided through commercial sponsorship will be chosen carefully and in line with their knowledge rather than affiliations. NHS Halton CCG expects that staff will treat the identity of the CCG (logo etc.) with appropriate respect and will expect that all use of the identity is agreed with a line manager. (See Pharmaceutical Industry Policy)

Declaration of Interests: CCG Members involved in CCG business and all Staff, contractors and volunteers must declare any financial interests they (or a close relative or friend) have in any company, public sector organisation, other NHS employer, voluntary organisation or other body which may compete for an NHS contract to supply either goods or services. A particular area of potential conflict is when NHS staff holds a self-beneficial interest in private care homes or hostels. Staff should declare such interests either on commencing appointment or on acquisition. Declarations of interest forms are accessed via the Datix system – Log in to datix and put the following address in: https://halton.datix.thirdparty.nhs.uk/Live/index.php?action=addnew&level=2&module=PAL.

The CCG holds both a register of declarations (Appendix) and a register of gifts, hospitality and sponsorship received (Appendix E for an example). These registers are monitored via the Integrated Governance Committee and reported to the Audit Committee.

Preferential Treatment in Private Transactions: Member or Staff, contractor or volunteer must not seek or accept personal preferential rates or benefits in kind, for private transactions carried out with companies with which they have had, or may have, official dealings in the course of their work with the CCG. All dealings must go through the approved procurement processes.

Contracts: All staff who are in contact with suppliers and contractors and in particular those who are authorised to sign Purchase Orders or place contracts for goods or services are expected to adhere to professional standards as detailed within the CCGs Procurement Policy and as set out in the Ethical Code of the Institute of Purchasing and Supply http://www.cips.org/aboutcips/whatwedo/codeofprofessionalethics/

Staff involved in procurement processes must not accept any commercial sponsorship during these processes. NO PATHWAY SHOULD BE DESIGNED WITH ASSISTANCE OF ANY PROVIDER WHO COULD POTENTIALLY BID FOR THE WORK. If a provider works to support the development of a pathway then the provider will automatically be barred from any subsequent tender process.

Favouritism in Awarding Contracts: No private, public or voluntary organisation or company should be given any advantage over its competitors in respect of the awarding of contracts. Each new contract must be awarded solely on merit and staff that are known to have “declared interest” should play no part in the selection. Commercial or corporate level agreements must be treated with extreme caution.

Outside Employment: CCG Members on CCG business and Staff are advised not to engage in outside employment which may conflict with their NHS Work, or be detrimental to it. Employees must not at any time allow their employment with NHS Halton to be used by commercial ways in their marketing activities. Staff are advised to inform their line manager if they think they may be risking a conflict of interest. This will allow the line manager to complete a risk assessment of the situation and make an informed decision as to whether or not the outside employment will cause a conflict. Where a line manager considers that a conflict has been identified he/she will speak directly to the employee to advise of this conflict.

. Inspection of Equipment Prior to Purchase: Members on CCG business or Staff who are required to inspect equipment in operation in other parts of the country (or overseas) prior to possible purchase must receive clearance, in advance, from their line manager. Where such visits are authorised the costs will normally be met by the CCG to avoid putting in jeopardy the integrity of subsequent purchasing decisions.

Confidential Information: Members on CCG business, Staff, contractors and volunteers should ensure that they do not disclose information of a confidential nature to any unauthorised persons. Particular attention needs to be paid to matters relating to the contracting of services and, of course, personal information relating to staff and patients.

11. Non-Adherence to this Policy

The CCG is committed to the successful operation of this policy document. Staff are advised that any breaches of this policy will be viewed most seriously and may result in disciplinary action including summary dismissal being taken.

12. Consultation, Approval and Ratification Process

Consultation for this Policy is outlined on the front sheet. Approval of the Policy is via the Integrated Governance Committee with ratification by the CCG Governing Body.

13. Dissemination and Implementation

The policy will be disseminated via Halton Hub, the CCGs Intranet site. Its implementation will be enabled through local induction and awareness raising sessions for Members, staff, contractors and volunteers via CCG Bulletin and via the governance page of the CCG website.

14. Document Control

Document control will be managed via the Governance Team to ensure that the most up to date version of this policy is accessible via the CCGs Intranet site and external site .

15. Monitoring Compliance with and Effectiveness of the Policy

This policy will be monitored via the appropriate committees which are the Audit Committee and Integrated Governance Committee. Failure to comply with the policy will be managed as appropriate through the CCGs Disciplinary Procedure of which all cases are reported to the CCG’s Human Resources Committee.

16. Appendices

1. Appendix A – Short Guide for Managers 2. Appendix B – Short Guide for Staff 3. Appendix C – Declaration of interests for CCG members and employees 4. Appendix D - Declarations of interest checklist 5. Appendix E -Template for recording minutes 6. Appendix F - Procurement checklist 7. Appendix G Procurement Declaration Template 8. Appendix H- Procurement decisions and contracts awarded 9. Appendix I- Register of interests Template for Publication 10. Appendix J -Declarations of gifts and hospitality 11. Appendix K - Register of gifts and hospitality 12. Appendix L - Register of procurement decisions and contracts awarded 13. Appendix M – flow Chart declaration process

Associated Documentation  Code of Conduct for NHS Managers (October 2002)  Ethical Code of the Chartered Institute of Purchasing and Supply  DoH Commercial Sponsorship – Ethical Standards for the NHS (Nov 2000)  Standards for Members of NHS boards and Clinical Commissioning Group Governing bodies in England November 2012

Appendix A

Short guide for Managers

References are to paragraphs in Part B of “Standards of Business Conduct for NHS Staff” (Annex to HSG(93)5)

You must:

Ensure that all Members on CCG business and staff are aware of this guidance (2) and (4);

Develop a local policy and implement it (2 and 14);

Show no favouritism in awarding contracts (e.g. to businesses run by employees, ex- employees or their friends or relatives) (17-18);

Include a warning against corruption in all invitations to tender (19);

Consider requests for staff for permission to undertake additional outside employment (20);

Apply the terms of PM(79)11 concerning doctors’ engagements in private practice (21);

Receive rewards or royalties in respect of work carried out by employees in the course of their NHS work, and ensure that such employees receive due rewards (24);

Similarly ensure receipt of rewards for collaborative work with manufacturers, and pass on to participating employees (25);

Ensure that acceptance of commercial sponsorship will not influence or jeopardise purchasing decisions (26-27);

Refuse “linked deals” whereby sponsorship of staff posts is linked to the purchase of particular products or supply from particular sources (28);

Avoid excessive secrecy and abuse of the term “commercial in confidence” (30)

Appendix B

Short guide for staff

References are to paragraphs in Part B of “Standards of Business Conduct for NHS Staff” (Annex to HSG(93)5).

Do:

 Make sure you understand the guidelines on standards of business conduct, and consult your line manager if you are not sure;

 Make sure you are not in a position where your private interests and NHS duties may conflict (3);

 Declare to your employer any relevant interests (10-14). If in doubt, ask yourself:

 am I, or might I be, in a position where I (or my family/friends) could gain from the connection between my private interests and my employment?

 do I have access to information which could influence purchasing decisions?

 could my outside interest be in any way detrimental to the NHS or to patients’ interests?

 do I have any other reason to think I may be risking a conflict of interest?

 If still unsure – Declare it!

 Adhere to the ethical code of the Institute of Purchasing and Supply if you are involved in any way with the acquisition of goods and services (16);

 Seek your employer’s permission before taking on outside work, if there is any question of it adversely affecting your NHS duties (20). (Special guidance applies to doctors);

 Obtain your employers’ permission before accepting any commercial sponsorship

Do not:

 Accept any gifts, inducements or inappropriate hospitality (see 7-9);

 Abuse your past or present official position to obtain preferential rates for private deals (15);

 Unfairly advantage one competitor over another (17) or show favouritism in awarding contracts (18);

 Misuse or make available official “commercial in confidence” information (29).

Appendix C -Declaration of interests for CCG members and employees

Name: Position within, or relationship with, the CCG (or NHS England in the event of joint committees): Detail of interests held (complete all that are applicable): Type of Description of Interest (including for indirect Date interest Actions to be Interest* Interests, details of the relationship with the relates taken to mitigate person who has the interest) risk *See From & To reverse (to be agreed of form with line for manager or a details senior CCG manager)

I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to the CCG as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, or internal disciplinary action may result.

I do / do not [delete as applicable] give my consent for this information to published on registers that the CCG holds. If consent is NOT given please give reasons:

Signed: Date:

Signed: Position: Date: (Line Manager or Senior CCG Manager)

Please return to Head of Risk /Corporate Services Business Manager who lead on the administrative processes, for advice on conflicts of interest please contact Jan Snoddon Chief Nurse or David Merrill Conflicts of Interest Guardian Types of interest

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

Appendix D -Declarations of interest checklist Under the Health and Social Care Act 2012, there is a legal obligation to manage conflicts of interest appropriately. It is essential that declarations of interest and actions arising from the declarations are recorded formally and consistently across all CCG governing body, committee and sub- committee meetings. This checklist has been developed with the intention of providing support in conflicts of interest management to the Chair of the meeting- prior to, during and following the meeting. It does not cover the requirements for declaring interests outside of the committee process.

Timing Checklist for Chairs Responsibility

In advance 1. The agenda to include a standing item Meeting Chair and of the meeting on declaration of interests to enable secretariat individuals to raise any issues and/or make a declaration at the meeting.

2. A definition of conflicts of interest should also be accompanied with each Meeting Chair and agenda to provide clarity for all secretariat recipients.

3. Agenda to be circulated to enable attendees (including visitors) to Meeting Chair and identify any interests relating secretariat specifically to the agenda items being considered.

4. Members should contact the Chair as soon as an actual or potential conflict Meeting members is identified.

5. Chair to review a summary report from preceding meetings i.e., sub- Meeting Chair committee, working group, etc., detailing any conflicts of interest declared and how this was managed.

A template for a summary report to present discussions at preceding meetings is detailed below.

6. A copy of the members’ declared interests is checked to establish any actual or potential conflicts of interest Meeting Chair that may occur during the meeting.

During the meeting 7. Check and declare the meeting is Meeting Chair quorate and ensure that this is noted in the minutes of the meeting.

Timing Checklist for Chairs Responsibility

8. Chair requests members to declare Meeting Chair any interests in agenda items- which have not already been declared, including the nature of the conflict.

9. Chair makes a decision as to how to manage each interest which has been Meeting Chair and declared, including whether / to what secretariat extent the individual member should continue to participate in the meeting, on a case by case basis, and this decision is recorded.

10. As minimum requirement, the following should be recorded in the minutes of the meeting: Secretariat

 Individual declaring the interest;  At what point the interest was declared;  The nature of the interest;  The Chair’s decision and resulting action taken;  The point during the meeting at which any individuals retired from and returned to the meeting - even if an interest has not been declared;

 Visitors in attendance who participate in the meeting must also follow the meeting protocol and declare any interests in a timely manner.

A template for recording any interests during meetings is detailed below.

Following the meeting 11. All new interests declared at the Individual(s) meeting should be promptly updated declaring interest(s) onto the declaration of interest form;

12. All new completed declarations of interest should be transferred onto Designated person the register of interests. responsible for registers of interest

Template for recording any interests during meetings Report from

Timing Checklist for Chairs Responsibility

Title of paper

Meeting details

Report author and job

Executive summary

Recommendations

Outcome of Impact completed (e.g. Quality IA or Equality IA) Outline engagement – and public/patient:

Management of Conflicts of Interest

Assurance Report previously Risk Assessments

Appendix E -Template for recording minutes

NHS Halton Clinical Commissioning Group Primary Care Commissioning Committee Meeting

Date: 15 February 2016 Time: 2pm to 4pm Location: Room B, XXXX CCG

Attendees:

Name Initials Role Sarah Kent SK XXX CCG Governing Body Lay Member (Chair) Andy Booth AB XXX CCG Audit Chair Lay Member Julie Hollings JH XXX CCG PPI Lay Member Carl Hodd CH Assistant Head of Finance Mina Patel MP Interim Head of Localities Dr Myra Nara MN Secondary Care Doctor Dr Maria Stewart MS Chief Clinical Officer Jon Rhodes JR Chief Executive – Local Healthwatch

In attendance from 2.35pm

Neil Ford NF Primary Care Development Director

Item No Agenda Item Actions

1 Chairs welcome

2 Apologies for absence

3 Declarations of interest

SK reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of XXX clinical commissioning group.

Declarations declared by members of the Primary Care Commissioning Committee are listed in the CCG’s Register of Interests. The Register is available either via the secretary to the governing body or the CCG website at the following link: http://xxxccg.nhs.uk/about-xxx-ccg/who-we-are/our - governing-body/

Declarations of interest from sub committees. None declared

Declarations of interest from today’s meeting

The following update was received at the meeting:  With reference to business to be discussed at this meeting, MS declared that he is a shareholder in XXX Care Ltd.

SK declared that the meeting is quorate and that MS would not be included in any discussions on agenda item X due to a direct conflict of interest which could potentially lead to financial gain for MS.

SK and MS discussed the conflict of interest, which is recorded on the register of interest, before the meeting and MS agreed to remove himself from the table and not be involved in the discussion around agenda item X.

4 Minutes of the last meeting and matters arising

5 Agenda Item

MS left the meeting, excluding himself from the discussion regarding xx.

MS was brought back into the meeting.

6 Any other business

7 Date and time of the next meeting

Appendix F - Procurement checklist

Service:

Question Comment/ Evidence

1. How does the proposal deliver good or improved outcomes and value for money – what are the estimated costs and the estimated benefits? How does it reflect the CCG’s proposed commissioning priorities? How does it comply with the CCG’s commissioning obligations?

2. How have you involved the public in the decision to commission this service?

3. What range of health professionals have been involved in designing the proposed service?

4. What range of potential providers have been involved in considering the proposals?

5. How have you involved your Health and Wellbeing Board(s)? How does the proposal support the priorities in the relevant joint health and wellbeing strategy (or strategies)?

6. What are the proposals for monitoring the quality of the service?

7. What systems will there be to monitor and publish data on referral patterns?

8. Have all conflicts and potential conflicts of interests been appropriately declared and entered in registers?

9. In respect of every conflict or potential conflict, you must record how you have managed that conflict or potential conflict. Has the management of all conflicts been recorded with a brief explanation of how they have been managed?

10. Why have you chosen this procurement route e.g., single action tender?1

1 Taking into account all relevant regulations (e.g. the NHS (Procurement, patient choice and competition) (No 2) Regulations 2013 and guidance (e.g. that of Monitor).

11. What additional external involvement will there be in scrutinising the proposed decisions?

12. How will the CCG make its final commissioning decision in ways that preserve the integrity of the decision-making process and award of any contract?

Additional question when qualifying a provider on a list or framework or pre selection for tender (including but not limited to any qualified provider) or direct award (for services where national tariffs do not apply)

13. How have you determined a fair price for the service?

Additional questions when qualifying a provider on a list or framework or pre selection for tender (including but not limited to any qualified provider) where GP practices are likely to be qualified providers

14. How will you ensure that patients are aware of the full range of qualified providers from whom they can choose?

Additional questions for proposed direct awards to GP providers

15. What steps have been taken to demonstrate that the services to which the contract relates are capable of being provided by only one provider? 16. In what ways does the proposed service go above and beyond what GP practices should be expected to provide under the GP contract? 17. What assurances will there be that a GP practice is providing high-quality services under the GP contract before it has the opportunity to provide any new services?

Appendix G - Procurement Declaration Template

Name of Organisation: Details of interests held:

Type of Interest Details

Provision of services or other work for the CCG

or NHS England

Provision of services or other work for any other potential bidder in respect of this project or procurement process Any other connection with the CCG or NHS England, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG’s or any of its members’ or employees’ judgments, decisions or actions

Appendix H- Procurement decisions and contracts awarded

Ref Contract/ Procurement Existing Procurement CCG CCG Decision Summary Actions Justification Contract Contract Comments to No Service description contract or new type – CCG clinical contract making of conflicts to for actions to awarded value (£) note title procurement (if procurement, lead manger process and of interest mitigate mitigate (supplier (Total)

existing include collaborative (Name) (Name) name of noted conflicts conflicts of name & and details) procurement decision of interest interest registered value to with partners making address) CCG committee

To the best of my knowledge and belief, the above information is complete and correct. I undertake to update as necessary the information.

Signed:

On behalf of:

Date:

Please return to Martin Stanley Head of Contracting lead for procurement management and administrative processes

Appendix I- Register of interests Template for Publication

Date of Action taken Type of Interest to mitigate Current Interest risk position Declared From To (s) held- Interest-

i.e. (Name of Is the Nature Governing the interes of Name Body, organisati t direct Interes Member on and or t

practice, nature of Financial indirec - Employee business) t? Non or other Personal Financial - Financial Interests Financial Professional Interests Professional Non Interests



Appendix E Appendix J -Declarations of gifts and hospitality

Recipient Position Date Date of Details of Estimated Supplier / Details of Details of the Declined Reason for Other Name of Receipt (if Gift / Value Offeror Previous Offers officer reviewing or Accepting Comments Offer applicable) Hospitality Name and or Acceptance and approving Accepted? or Nature of by this Offeror/ the declaration Declining Business Supplier made and date

The information submitted will be held by the CCG for personnel or other reasons specified on this form and to comply with the organisation’s policies. This information may be held in both manual and electronic form in accordance with the Data Protection Act 1998. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and published in registers that the CCG holds. I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to the CCG as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, professional regulatory or internal disciplinary action may result. I do / do not (delete as applicable) give my consent for this information to published on registers that the CCG holds. If consent is NOT given please give reasons:

Signed: Date:

Signed: Position: Date: (Line Manager or a Senior CCG Manager) Please return to Head of Risk/corporate Service business Manager who will ensure appropriate administrate

Appendix K - Register of gifts and hospitality

Name Position Date of offer Declined or Accepted? Date of Receipt (if applicable) Details of Gift /Hospitality Estimated Supplier / Reason for Value Offeror Name Accepting or and Nature of Declining business

Appendix L - Register of procurement decisions and contracts awarded

Ref Contract/ Procurement Existing Procurement CCG CCG Decision Summary of Contract Contract Contract No Service description contract or type – CCG clinical contract making conflicts of Award value (£) value to title new procurement, lead manager process and interest (supplier (Total) CCG procurement collaborative name of declared and name & (if existing procurement decision how these were registered include with partners making managed address) details) committee

$SSHQGL[0&RQIOLFWPDQDJHPHQWIORZFKDUW At every New Member joins meeting the the CCG either as committee employee, new /meeting chair member to a will review and Conflicts are Every quarter practice or as What happens next? request The form is submitted reviewed members and contract/clinical lead Declaration declarations of for Head of risk or and employees/volu they complete a isi recorded Business manager appropriateap interest and declaration of ono register nteer/contract corporate services managemem committee interests for workers will be who will log and refer nt action members will (Advice is available publication asked to review to Chief Nurse for agreed and highlight new from Conflict of and if required shared with declaration interest Guardian or review and response update their the declarer and confirm all Chief Nurse) declaration current. Any which will be Declaration is made conflict in reviewed by using appendix C of relation to Chief Nurse for this policy committee action as business will appropriate be appropriately The CCG will maintain a clear register of hospitality/gifts recorded devised from appropriate declarations (appendix J) which within the it will publish using appendix K minutes and action taken to mitigate All staff and members including contractors/volunteer involved in procurement or contracting will comply with the guidance set out in the policy regarding declarations of conflict to enable publication

Governing Body

st Date: 1 September 2016 Report title: Board Assurance Framework Lead Clinician and/or Jan Snoddon Lead Manager: Chief Nurse Purpose: To present to the Governing Body the latest version of the all risks in the Board Assurance Framework following the development session reviews and outline the process completed to provide some further assurance in relation to one specific risk and agree further similar reviews. The Governing Body is  Which papers on today’s agenda provide assurance to asked to Consider the these risks and at what level?  Do the controls deliver control? following questions:  Does the assurance process deliver assurance?  Is the residual score appropriate?  What gaps do we have in controls & assurance and how do we close them?

This Report supports all of the following CCG Strategic Objectives One: To commission services which continually improve the health and wellbeing of Halton residents.

Two: To continually improve and innovate in our engagement with local people and communities to secure their participation in improving their own health outcomes.

Three: To deliver improvements in the quality of the health and care services accessed by the people of Halton within the resources available to us and our partner organisations.

Four: To deliver all of our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place.

Five: To develop the skills, knowledge and competence of the people who are working with us to create a high performing organisation that will allow us to build effective partnerships with other organisations and develop leadership from within. Commissioning Plan Implications None Financial Implications

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Does this require financial support? Yes/No Board Assurance Framework and Corporate Risk Register This report is the latest full version of the Board Assurance Framework. National Policy, Guidance, Standards, Targets or Legislation N/A Equality and Diversity and Human Rights What are the identified equality implications across protected characteristics?

Are these implications mitigated in your plan? Yes/No – (if Yes please escalate this issue)

Board Assurance Framework

Background

As the Governing Body is aware the CCG has since its inception been working hard to ensure robust risk management across all areas of the organisation. To this end the CCG has a Risk Management Strategy, has invested in DATIX database to improve reporting and management of risks both strategic and operational.

The CCG has well-established processes for highlighting and reporting risks and ensuring these are appropriately identified, level assessed and the risk is then managed or mitigated. All risks on the operational risk register and the Board Assurance Framework have clear links to strategic objectives and have a lead director and responsible manager alongside a link to a committee of the Governing Body which is responsible for monitoring the management of each risk. Every year as part of the preparation for the Annual Governance Statement requirements the internal auditors (MIAA) carry out a review of the effectiveness of the BAF and provide a statement of assurance regarding its effectiveness. The review included assessment of the following sub objectives: 1. The structure of the Assurance Framework meets the requirements 2. There is Governing Body engagement in the review and use of the Assurance Framework 3 The quality of the content of the Assurance Framework demonstrates clear connectivity with the Governing Body agenda and external environment

The review looks at three main areas these are listed below and the outcomes are reflected alongside each area  Structure three domains 1 green 2 ambers  Engagement two domains 2 areas 1 green 1 amber  Quality and Alignment two domains 2 areas both green

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The outcome of the assessment for 15/16 whilst very positive provided some advice and areas for development which are outlined below.

General overview  The organisation’s Assurance Framework meets the NHS requirements.  There could be greater visibility of the use of the Assurance Framework by the Governing Body.  The Assurance Framework reflects the risks discussed by the Governing Body.

Areas for improvement

 The CCG should review the strategic objectives within the AF and ensure they remain consistent with the Strategic Plan.

 The CCG could enhance the AF through clearer action plan, including actions, responsible officers and timeframes (this is covered in part through the quarterly progress updates in the current AF).

 The organisation’s AF does not include consideration of risk appetite/ target risks .  Committee minutes received by the Governing Body do not demonstrate the visibility or use of the AF by the Committees. The AF itself references the Committees to varying extents in terms of sources of assurances for specific risks

 The CCG needs to ensure that the Governing Body minutes more clearly demonstrate collective ownership and discussion of strategic risks, assurances received at Governing Body and actions / mitigations planned and required.

 The Governing Body should consider its assurance expectations in terms of Committees and how it uses the updates provided alongside the AF

 There could be more evidence of the Governing Body connecting risks in papers and discussions to the AF. To support this connection the assurances documented within the AF should be reviewed to ensure they remain focussed at Governing Body level and include reporting route to GB and frequency (e.g. quarterly via Quality Committee).

Outcomes from recent development session Following the outcome of the review by MIAA a workshop Governing Body development session was designed and carried out to highlight some of the key areas of improvement and all to enable some time to be spent on a focused review of all Assurance Framework risks.

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At the session the GB discussed in detail risk appetite and reporting and assurance processes and then working in groups reviewed current AF risks answering a number of key questions:  Is the risk descriptor clear  Is the risk real/appropriate  Is there a linked strategic objective  Are controls clear and real  Are assurances clear and effective?  Are there any risks missing.  Is the risk being managed at the right committee?  Are there action plans for gaps in controls and assurances

The process was very successful with a wide range of amendments identified during the session which have now been made on Datix.

Key outcomes /findings  Redefined risk descriptors.  A number of risks were divided into two risks to enable easier controls and assurances  Controls which are not controls  Lack of action plans for gaps in controls  Assurance which are controls not assurances  Gaps in external assurance which are seen as the most robust  Some risks were highlighted for closure and a number of risk scores where amended.  A number of new risks were identified in relation to sustainability, new assurance processes and financial pressures.

Current status

All reviews of the BAF have now been completed, and responsible managers and directors have been asked to review, develop action plans and provide Q1/Q2 updates. Some risks have been presented at the responsible committee but not all. The Governing body is therefore for this session presented with the risk is there reviewed but not committee approved state.

BAF Assurance Review

One of the key areas in the MIAA review identified a need for assurance and management of risk challenge and to deliver this the audit committee chair and the Chief Nurse have completed one full review of one risk on the BAF. Only one risk has been assured to date as the process is time consuming and it was felt appropriate to feedback to Audit Committee and Governing Body on outcomes before planning further assurance reviews.

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The process for the review was for the risk owner to present evidence of controls and evidence of assurances, the evidence presented was then subject to some challenge and some further questioning in terms of frequency and robustness.

For this review the BAF risk reviewed was provider quality performance and early warning of failure an area included in the improvement and assessment framework for the CCG during 2016/2017

The challenges asked during the review are below

Review each risk Review each risk Review controls, Review assurance is Review action plan for links to descriptor to are these controls the assurance for the risk for strategic ensure clarity of truly controls, and complete, is the effectiveness and objective risk review recorded assurance effective actions being gaps and identify and review gaps delivered any missing and identify any controls/gaps missing assurance/gaps

The outcome of the process for risk 47 was positive with the only key two issues identified  Slight risk of not being able to evidence close performance monitoring for small contracts  Risk need an action plan for a gap on control relating to possible delays in performance data

In general terms the process whilst fairly time consuming did appear to be a useful process a number of idea for improvement to process were agreed:  Lead managers to present  Action plans must be available  Data /evidence in advance is possible  Include MIAA colleague as part of process to increase challenge  To focus on risk with highest scores initially

Improving Governing Body Ownership of BAF and recording of this in minutes.

The GB receives the BAF either in full or a subset at every meeting alongside a number of key questions which are asked regarding links and levels of assurance provided in the papers included in the meeting, the Chief Nurse will ensure these questions are clearly included with answers/comments/issues reported clearly in the minutes of the meetings, chairs of all committees of the GB will also be asked to deliver the same function to enable consistency of approach.

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The Chief Nurse is developing an amended template for key issues to improve the reporting of risk discussion in each committee to the Governing Body as currently the space available to enable this is used to record risk number only and does reflect if the committee felt good level of assurance was received by the committee .

The Governing Body is asked  to review and comment on the new BAF  review the assurance check process for risks and agree continuation of the process  to note the new key issues plan and feedback once presented  to note the need for greater ownership of the BAF and improved reporting within the minutes of the Governing Body of the debate/discussion

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September 2016

Board Assurance Framework Heat Map

Almost 5 10 15 20 25 Certain

8 12 16 20 4 Likely 212,373, 374 12 3 6 9 15 Possible 372, 375, 377,378 LIKELIHOOD 2 4 6 8 10 Unlikely 26 45,57 ,317 1 2 3 4 5 Rare 66 Insignificant Minor Moderate Major Catastrophic

CONSEQUENCE

NHS Halton CCG Risk Summary

This form is to be used to provide a full & detailed update to the Governing Body & or associated Committees Section 1 – Risk Details Risk ID 22 Date Identified 25/04/16 Lead Manager Jan Snoddon Handler Angela Delea Committees Human Resource and Organisational Development Committee

Strategic Five: To develop the skills, knowledge and competence of the people who are working with us Objectives to create a high performing organisation that will allow us to build effective partnerships with other organisations and develop leadership from within. Risk Description Failure of CCG to be able to demonstrate compliance with the Equality Act 2010 in relation to workforce issues could detrimentally affect the reputation of the CCG and have adverse legal impact. Section 2 – Controls Controls in Place E&D Policy developed which highlights the mechanisms and vehicles the CCG employs and approved with compliance reported regularly.

All HR policies take account of the Equality legislations and statutory requirements.

All staff E&D trained in line with mandatory training requirements

The Equality Objective Plan for 16/17 approved by the Governing Body Feb 16.

The Quality Committee receives quarterly updates of progress against Plan for E&D within commissioned providers.

E&D and HR Assurance Report is taken to the HR & OD Committee.

ED Governance Lead and CSU HR Business Partner provide advice & guidance to enhance the HR and ED delivery.

All staff training planned. regular reporting on E&D issues to HR&OD committee. Gaps in Controls Issues that will be difficult to resolve for example, access to staff support groups. Section 3 – Assurance Assurance Full E&D reporting Schedule to appropriate committees, quality committee for commissioned services and HR/OD committee for internal assurance. Training reports to HR/OD Policy compliance reported Full report and approval of EDS submission to the CCG. Gaps in Assurance

Section 4 – Risk Scoring Initial Position Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 20 3 Possible 3 6 9 x 12 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 Current Position

Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 20 3 Possible 3 6 9 12 15 2 Unlikely 2 4 6 x 8 10 1 Rare 1 2 3 4 5 SECTION 5 - Position 2015/2016 Final Position Risk well managed and no perceived impacts in 15/16. Over the last 12 months an equality workforce plan has been approved by the CCG HR Committee - this is to be monitored bi-annually re: progress. Quarter 1 Position Committee briefed on Dying to Work Campaign to ensure CCG following best practice so terminally ill employees are protected with regards to death in service payments/ life assurance policies, that HR procedures are carried out in a positive un-stressful manner, and that reasonable opportunities are provided so that employees can have greater choice of whether they wish to remain in work. E&D questions have been incorporated into the staff engagement survey - launched in April 2016. The Workforce race equality standard and NHSE template was approved. EDS 2 Goal 3 has been completed and approved at the Governing Body along with an equality objective plan and annual report, both of which have actions and activity relating to HR compliance with specific duties and to the public sector equality duty (discrimination, victimisation and harassment). Quarter 2 Position Suggestion to close risk - to be discussed at HR&OD Sept 2016 due to regular monitoring through HR Committee work plan. Sufficient evidence to reduce risk score to target score of 3 to be confirmed. Quarter 3 Position Quarter 4 Position SECTION 6 – Overall Assurance Full High Significant X Adequate Limited Nil Score Movement Quarter 1 Quarter 2 Quarter 3 Quarter 4

NHS Halton CCG Risk Summary

This form is to be used to provide a full & detailed update to the Governing Body & or associated Committees Section 1 – Risk Details Risk ID 45 Date Identified 19/05/14 Lead Manager Mr Simon Banks Handler Jacqui Ireland Committees Performance & Finance Committee

Strategic 4. To deliver all of our statutory duties and commissioning responsibilities effectively, whilst Objectives ensuring there are robust constitutional, governance and financial control arrangements in place. Risk Description Failure to deliver management functions and objectives within the running cost limit set nationally in this year (16/17) and in the future will have a detrimental impact on the CCG reputation and its legal status and the level of assurance from NHSE. Section 2 – Controls Controls in Place The CCG has clearly outlined its budgetary spend in running cost through staffing plans and with SLA for M&LCSU.

RCA Contingency Reserve created.

The CCG has budgetary control processes to closely manage and monitor the performance against the running cost budgets.

CCG staff have PDP and objectives in place.

The CCG has set a clear set of objectives regarding focus on delivery of sustainability in the short, medium and long term.

Regular monitoring of M&LCSU performance in place.

KPIs developed regarding M&LCSU and other contract management functions put in place. Gaps in Controls There remain gaps in relation to future sustainability, planning for further joint working with other commissioning organisations aims to manage this gaps. Section 3 – Assurance Assurance Reporting of delivery against RCA provided to P&F and GB via financial reports.

The contract performance for M&LCSU is now reported via P&F.

Long term sustainability plan developed and for approval at GB.

MIAA will review in year budget management processes and report Gaps in Assurance Section 4 – Risk Scoring Initial Position

Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 20 3 Possible 3 6 9 12 x 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 Current Position Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 20 3 Possible 3 6 9 12 15 2 Unlikely 2 4 6 8 x 10 1 Rare 1 2 3 4 5 SECTION 5 - Position 2015 /2016 Final Position All financial processes delivered in 15/16 Quarter 1 Position Budget set an RCA within budget with contingency reserve available. Quarter 2 Position Quarter 3 Position Quarter 4 Position SECTION 6 – Overall Assurance Full High Significant Adequate X Limited Nil Score Movement Quarter 1 Quarter 2 Quarter 3 Quarter 4

NHS Halton CCG Risk Summary

This form is to be used to provide a full & detailed update to the Governing Body & or associated Committees Section 1 – Risk Details Risk ID 47 Date Identified 25/04/2016 Lead Manager Jan Snoddon Handler Jenny Owen Committees Quality Committee Strategic 1. To commission services which continually improve the health and wellbeing of Halton Objectives residents. 3. To deliver improvements in quality of health and care services accessed by the people of Halton within the resources available to us and our partner organisations. 4. To deliver all our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place. Risk Description The CCG may not recognise early failures of quality in services across all providers this could have a detrimental impact on the health and wellbeing of local people and could also affect the reputation of the CCG. Section 2 – Controls Controls in Place The CCG receives through Contract and Business Intelligence team the early warning dashboard, this provides a monthly status update for all providers across the three domains of quality (safety, effectiveness and patient experience)

Specific areas such as the Quality risk Profile for the providers, any CQC reviews published, performance across quality metrics and CQUINs are included. The Early Warning Dashboard is presented monthly to the Quality Cttee.

The CCG also receives formal reports from complaints received, and soft intelligence from local people via their GPs to [email protected]. Other local clinicians (community staff etc.) also use this email address to raise issues. The process for managing these issues as raised is now established with reports delivered to Quality Cttee.

The CCG has also worked closely with the local practices (PPG) to raise awareness of how they can raise issues is required via TalktoUs (please see gaps).

The CCG encourages the use of Talk2Us an email address via the website as a further way to access the views of local people regarding the quality of care.

The CCG has supported a number of patient and families locally through complaint processes. All of this intelligence is then utilised to identify themes for providers.

The quality Team has developed good relationships with local providers to enable early escalation of potential issues or concerns.

The CCG clinical leads for primary care who lead on primary care quality group to will report quality performance locally and develop approached to improving quality and reduce inappropriate variation. The CCG is working closely on this issue with NHSE Cheshire and Merseyside.

Head of Primary Care Commissioning with Clinical Lead has updated QC and PCCC on Primary Care Quality Issues

Development and implementation of patient experience charter/strategy including wide local consultation. Agreements in development with local providers to implement the experience approach

The CCG has excellent monitoring and implementation of appropriate Quality Schedules and CQUINs across all providers.

The CCG carried out a number of themed reviews during 15/16 ( safety and patient experience) to highlight areas of good practice and areas for development. Gaps in Controls There remain some issues with how local people can raise concerns and whilst acute community and mental health provision has progressed there remain some issues on how issue with primary care quality can be identified.

The PPG processes do not as yet appear to have impacted and reporting is not robust. Reporting of primary care and other issues to Talk2Us in minimal and needs further development.

There remain some issues with real time data, and effectiveness of some reporting systems. Section 3 – Assurance Assurance The CCG reports early warning and other processes via Quality Committee, and via key issues to Governing Body.

The CCG uses us membership and activities of the QSG as high level external assurance. The CCG receives via the QSG national quality performance dashboard, Health Education England reporting on student issues (medical and non medical) regulator updates (CQC, NHS Improvements) and Healthwatch reporting of local issues. This process allow broader triangulation of issues across the health economy

Further assurance is provided through NHSE Cheshire and Merseyside assurance meetings.

The audit Committee also reviews the activity of the quality Committee to ensure it is appropriately mitigating and managing this risk.

The CCG currently receives data on quality performance but we do not know what we do not know so deeper dives into quality performance are required.

16/17 MIAA will provide an assessment of quality reporting Gaps in Assurance The CCG gains reasonable assurance in this regard, but must review process and effectiveness regularly. Does MIAA review pick up themed reviews Outcome of MIAA review Section 4 – Risk Scoring Initial Position Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 20 3 Possible 3 6 9 12 x 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 Current Position

Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 20 3 Possible 3 6 9 12 15 2 Unlikely 2 4 6 8 x 10 1 Rare 1 2 3 4 5 SECTION 5 – Position 2015/2016 Final Position 15/16 whilst some issues with providers no major problems in year, regular review of performance and appropriate challenge being made. Quarter 1 Position Risk review completed by Chief Nurse and Audit Committee Chair on 12/7/16 reasonable assurance on this risk but requires action plans for gaps in controls and assurance. Amendments to assurance explanation added with regard to role of QSG plus risk links to two further strategic objectives. Risk target reviewed and amended to reflect risk appetite in this area. Quarter 2 Position Quarter 3 Position Quarter 4 Position SECTION 6 – Overall Assurance Full High Significant X Adequate Limited Nil Score Movement Quarter 1 X Quarter 2 Quarter 3 Quarter 4

NHS Halton CCG Risk Summary

This form is to be used to provide a full & detailed update to the Governing Body & or associated Committees Section 1 – Risk Details Risk ID 66 Date Identified 28/10/14 Lead Manager Mr Dave Sweeney Handler Jacqui Ireland Committees Performance & Finance Committee Strategic 1. To commission services which continually improve the health and wellbeing of Halton Objectives residents. 3. To deliver improvements in the quality of the health and care services accessed by the people of Halton within the resources available to us and our partner organisations. 4. To deliver all of our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place. Risk Description Without a Strategic oversight and understanding of property and asset the CCG risk financial implications through VOID and ineffective use of buildings. Section 2 – Controls Controls in Place Void costs reviewed Partial review of asset utilisation and a full review will follow. National piece of work currently being undertaken to review charging/rental agreements completed and approved at EMT/Governing Body.

An Estates Strategy approved by Governing Body Action plan in place and being delivered Full estates review completed and approved at EMT/Governing Body.

Action plan in place and being delivered Gaps in Controls Awaiting Data and information from NHSPS to realign costs and contract with Bridgewater FT. Section 3 – Assurance Assurance Strategy and Action Plan in place and being delivered.

Development of local estates working group aligned with a strategic asset management group which oversees the wider system.

Director Transformation is currently the Public Sector Director for CHP which has a regional oversight to Estate Planning. Gaps in Assurance Section 4 – Risk Scoring Initial Position Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 20 3 Possible 3 6 9 12 x 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 Current Position

Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 20 3 Possible 3 6 9 12 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 x 5 SECTION 5 - Position 2015/2016 Final Position Information now received from NHSPS as well as CHP and credit notes received for errors in NHSPS billing for 2015/16. Invoices used to move money between Bridgewater and other providers. Costs to CCG within budget assuming invoices to Bridgewater paid by the Trust. Still to adjust recurrent contract with providers. Quarter 1 Position NHSPS expected to move to market rates which will place an additional pressure onto the CCG. However, likely to be offset by an allocation adjustment but this is yet to be confirmed. Bridgewater has already requested an additional £265k to cover the transition to market rents. CCG not currently in agreement plus adjustments in respect of voids needs to be simultaneously progressed. Quarter 2 Position Quarter 3 Position Quarter 4 Position SECTION 6 – Overall Assurance Full High Significant Adequate X Limited Nil Score Movement Quarter 1 Quarter 2 Quarter 3 Quarter 4

NHS Halton CCG Risk Summary

This form is to be used to provide a full & detailed update to the Governing Body & or associated Committees Section 1 – Risk Details Risk ID 212 Date 25/04/2016 Lead Manager Leigh Thompson Identified Handler Sarah Vickers Committees Primary Care Commissioning Committee Strategic 1. To commission services which continually improve the health and wellbeing of Halton Objectives residents. 3. To deliver improvements in the quality of the health and care services accessed by the people of Halton within the resources available to us and our partner organisations. 4. To deliver all of our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place. Risk Description Due to pressure on capacity in the General Practice the CCG may fail to commission high quality General Medical Services which may lead to reputational and functional impact due the delegated responsibilities. Section 2 – Controls Controls in Place GP Strategy for the future of Primary Care developed and in place.

Training practices and extra training packages for Registrars locally.

PMS review and Federation discussions underway to identify new ways of working and reducing pressures in system.

Pilot programme for Clinical Pharmacists in practices locally now in place and to ensure sustainability CCG supporting risk to practices.

Development of Care Homes model as part of managing work pressures issues and improving quality.

Media messages to local people regarding where to access health advice and support (community pharmacy and self care etc.)

PMCF Awarded and programme of work to explore best models for improving access and developing new ways of workings. Gaps in Controls Insufficient understanding of skill mix in practices Reporting of how we are supporting practice staff in relation to work life balance Numbers of staff planning to retire Section 3 – Assurance Assurance Proposed neighbourhood model presented to member practices and relevant committees. Federation discussions underway and reporting to SDC/PCCC. CCG Triangulation group in place. Practice Nurse forum well established. Revalidation for Nurses PCCC reporting MIAA co-commissioning self assessment review. Gaps in Assurance Formal reporting of patient complaints and issues regarding access Section 4 – Risk Scoring Initial Position Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 x 20 3 Possible 3 6 9 12 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 Current Position

Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 x 20 3 Possible 3 6 9 12 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 SECTION 5 - Position 2015/2016 Final Position Work on new roles developed in year and Joint CCG and Halton Borough Council group to participate in HEE Workforce Development Programme, to commence in May 2016. Quarter 1 Position Quarter 2 Position Quarter 3 Position Quarter 4 Position SECTION 6 – Overall Assurance Full High Significant Adequate Limited X Nil Score Movement Quarter 1 Quarter 2 Quarter 3 Quarter 4

NHS Halton CCG Risk Summary

This form is to be used to provide a full & detailed update to the Governing Body & or associated Committees Section 1 – Risk Details Risk ID 317 Date Identified 25/04/2016 Lead Manager Mr Dave Sweeney Handler Sarah Vickers Committees Primary Care Commissioning Committee Strategic 2. To continually improve and innovate in our engagement with local people and communities Objectives to secure their participation in improving their own health outcomes. 4. To deliver all of our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place. Risk Description The recent delegation agreement for commissioning of general practice moves responsibility for primary care estate to the CCG. The CCG need to ensure a robust estates strategy to deliver current GP practices and new care models failure to do so will lead to issues in implementation of services. There is a potential loss of funding in relation to Appleton & Upton Rocks surgeries for upgrade and rebuild of estates. Both of these practices are currently in buildings not suitable for primary care and therefore are a risk to service delivery. Section 2 – Controls Controls in Place CCG has completed a full estates review. CCG has been working closely with NHSE around plans for specific practice issues. CCG is an active member of the Propco system. Estates working group established and Terms of Reference approved by PCCC in January 2016. Strategic Estates Plan and supporting work plan in place. Gaps in Controls Practices do not understand the risk associated with being in unsuitable accommodation. Detailed project plans, including time lines for specific practice estates issues are under development. Section 3 – Assurance Assurance Estates Working Group reports to Primary Care Commissioning Committee and report will be part of Key Issues to Governing Body Estates Working Group has wide representation from all interested parties, including Local Authority, NHSE, Primary Care and Estate Development organisations. PCCC oversee Strategic Estates Plan and work plan. CQC reviews of practices to date have not identified any major issues in all but one practice. All practices reviewed by Infection Control and Prevention Team to ensure compliance Gaps in Assurance Engagement with the local population is required around further estate developments or changes when known. Section 4 – Risk Scoring Initial Position Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 20 3 Possible 3 6 9 12 x 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 Current Position

Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 20 3 Possible 3 6 9 12 15 2 Unlikely 2 4 6 8 x 10 1 Rare 1 2 3 4 5 SECTION 5 - Position 2015/2016 Final Position Work Plan completed and presented to PCCC in April. Work commenced on estates projects and PCCC have over site of specific issues relating to Appleton Village Surgery and Windmill Hill. Estates Working Group and IM&T Working Group overseeing bids to the Primary Care Transformation Fund (Estates & Technology.) Quarter 1 Position Quarter 2 Position Quarter 3 Position Quarter 4 Position SECTION 6 – Overall Assurance Full High Significant Adequate X Limited Nil Score Movement Quarter 1 Quarter 2 Quarter 3 Quarter 4

NHS Halton CCG Risk Summary

This form is to be used to provide a full & detailed update to the Governing Body & or associated Committees Section 1 – Risk Details Lead Manager Dave Sweeney Risk ID 372 Date Identified 10/06/16 Handler Sheila McHale Committees Service Development Committee Strategic 1. To commission services which continually improve the health and wellbeing of Halton Objectives residents. 3. To deliver improvements in the quality of the health and care services accessed by the people of Halton within the resources available to us and our partner organisations. 4. To deliver all of our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place. Risk Description Failure to deliver the work programme develo0ped in response to the Tony Ryan, Cross Borough Mental Health Review may lead to an inability of the CCG to be assured of the capacity and effectiveness of local mental health services Section 2 – Controls Controls in Place For each work stream within the Tony Ryan Review a Task and Finish Group has been developed

There are clear work programmes for delivery and the deliver is being monitored through mental Health Strategy Group

SDC will receive and approve updates on all pathways and service changes

Quality Committee will receive overview for approval of pathways and any quality marker/metrics Gaps in Controls The risk to delivery Section 3 – Assurance Assurance Reporting to all appropriate committees Governing body will receive assurance and reports as appropriate Assurance through activity and other data on new services as and when implemented Gaps in Assurance Section 4 – Risk Scoring Initial Position Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 x 20 3 Possible 3 6 9 12 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 Current Position

Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 20 3 Possible 3 6 9 12 x 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 SECTION 5 - Position 2016/2017 Final Position Quarter 1 Position Quarter 2 Position Quarter 3 Position Quarter 4 Position SECTION 6 – Overall Assurance Full High Significant Adequate x Limited Nil Score Movement Quarter 1 Quarter 2 Quarter 3 Quarter 4

NHS Halton CCG Risk Summary

This form is to be used to provide a full & detailed update to the Governing Body & or associated Committees Section 1 – Risk Details Risk ID 373 Date Identified Lead Manager Simon Banks, Handler Jacqui Ireland Committees Governing Body Strategic Objectives Risk Description Long term financial sustainability is essential for the CCG, failure to develop and deliver long term sustainability through a robust sustainability plan will lead to severe statutory and reputational issues for the CCG and could lead to NHSE assurance action. Section 2 – Controls Controls in Place Sustainability lead appointed and group now in place meeting biweekly with clear TOR to review delivery

Development and approval of cost improvement Identification and investment, de- commissioning and dis investment policy now completed

The CCG has reviewed and agreed clear areas for cost improvement and possible sustainability action. Plan being reviewed for delivery via the Sustainability Group which reports directly to Executive Team and Governing Body.

Development of LDS for Alliance and STP across C&M will be essential for delivery of long term sustainability

Development of further joint working across commissioners (other CCGs etc.) will support delivery Gaps in Controls There remain some gaps in sustainability plan which needs to be closed. There remains some uncertainty on some areas of cost improvement. Section 3 – Assurance Assurance Clear approval and agreement of plan. Reporting of performance against plan clearly defined through committees and to GB MIAA review for sustainability in audit plan NHSE assurance includes sustainability assurance as part of the Quarterly Reviews Assessment/Assurance of LDS/STP through NHSE Gaps in Assurance Section 4 – Risk Scoring Initial Position Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 x 25 4 Likely 4 8 12 16 20 3 Possible 3 6 9 12 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 Current Position

Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 x 20 3 Possible 3 6 9 12 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 SECTION 5 - Position 2015/2016 Final Position New Risk 2016 Quarter 1 Position Quarter 2 Position Quarter 3 Position Quarter 4 Position SECTION 6 – Overall Assurance Full High Significant Adequate Limited Nil Score Movement Quarter 1 Quarter 2 Quarter 3 Quarter 4

NHS Halton CCG Risk Summary

This form is to be used to provide a full & detailed update to the Governing Body & or associated Committees Section 1 – Risk Details Risk ID 374 Date Identified Lead Manager Leigh Thompson Handler Sarah Vickers Committees Primary Care Commissioning Committee Strategic Objectives Risk Description The lack of a robust workforce plan for General Practice could lead to a failure of the CCG to commission high quality General Practice which will be detrimentally affect the reputation and ability to deliver the statutory functions of the CCG Section 2 – Controls Controls in Place Workforce capacity survey by HEE Successful bid to NHSE for Pharmacists in practice Federation discussions underway PMCF Awarded and programme of work to explore best models for improving access and developing new ways of workings. Joint CCG and Halton Borough Council group to participate in HEE Workforce Development Programme. Programme of meetings of the HEE programme has commenced decision on programme of work now taken this risk will require further assurance All staff now informed of training opportunities from HEE Gaps in Controls Robust Primary Care workforce plan required which includes strategies for mitigating against an ageing workforce, early retirement, poor supply of new GPs, Nurses and PMs, shift in work life balance expectations, impact of clinical commissioning on available time. Insufficient relationships with Deaneries No scheme for GPsSIs Insufficient knowledge of skill mix in practices No clear inter practice working and development opportunities HR support and advice to practices around recruitment requires further work. No National agenda on training places and time lag. Section 3 – Assurance Assurance Reporting to PCCC, SDC and Governing Body. LWEG and HEE reporting Gaps in Assurance Section 4 – Risk Scoring Initial Position Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 x 25 4 Likely 4 8 12 16 20 3 Possible 3 6 9 12 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 Current Position

Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 x 20 3 Possible 3 6 9 12 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 SECTION 5 - Position 2015/2016 Final Position New Risk 2016 Quarter 1 Position Quarter 2 Position Quarter 3 Position Quarter 4 Position SECTION 6 – Overall Assurance Full High Significant Adequate X Limited Nil Score Movement Quarter 1 Quarter 2 Quarter 3 Quarter 4

NHS Halton CCG Risk Summary

This form is to be used to provide a full & detailed update to the Governing Body & or associated Committees Section 1 – Risk Details Risk ID 375 Date Identified Lead Manager Dave Sweeney Handler Sarah Vickers Committees Primary Care Commissioning Committee Strategic 1. Commission health services which continually improve the health and wellbeing of Halton Objectives residents 4. To deliver all our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial controls in place. Risk Description The CCG has identified two practices both of these practices are currently in buildings not suitable for primary care and therefore are a risk to service delivery

The risk is that the premises will affect directly the quality and safety of services being delivered and this will affect the CCGs ability to deliver its statutory function and its reputation. Section 2 – Controls Controls in Place CCG has been working closely with NHSE around plans for specific practice issues. Work commenced on estates projects and PCCC have over site of specific issues relating to the two practices. Detailed project plans, including time lines for specific practice estates issues are under development. All practices reviewed by Infection Control and Prevention Team to ensure compliance Gaps in Controls There is a loss of funding in relation to the two surgeries for upgrade and rebuild of estates. Practices do not understand the risk associated with being in unsuitable accommodation Section 3 – Assurance Assurance CQC reviews of practices to date have not identified any major issues in most practices but one practice has been identified as having specific issues.

All practices reviewed by Infection Control and Prevention Team to ensure compliance with requirements two practices have action plans form these reviews. Gaps in Assurance Section 4 – Risk Scoring Initial Position

NHS Halton CCG Risk Summary

This form is to be used to provide a full & detailed update to the Governing Body & or associated Committees Section 1 – Risk Details Risk ID 377 Date Identified Lead Manager Jan Snoddon Handler Jenny Owen Strategic 3. To deliver improvements in quality of health and care services accessible by the people of Objectives Halton within the resources available to us and our partner organisations Risk Description The CCG is aware and currently managing quality concerns within a local provider, failure to work with other commissioners and the provider to improve quality will detrimentally affect the CCGs ability to deliver key statutory functions and will have a negative effect on the reputation of the CCG locally. Section 2 – Controls Controls in Place Commissioners have identified some quality concerns requiring action is a Local provider. The CCGs concerns relate to maternity issues, spinal surgery, culture, whistleblowing, raising concerns, staff issues.

Some issues identified via external reporting (CQC/Monitor/RCOG) remainder defined by commissioners SIs, complaints, performance etc.

Enhanced surveillance agreed following Single Item QSG and action plan developed (though very delayed)

Review of improvements required via Clinical Quality Performance Group,

Further Single Item QSG following submission of evidence in each area identified some areas and issues closed but a number remain open

June 16 further data submitted and presentation planned for July 6th 16 on remaining key areas: Culture, staff engagement, leadership, maternity doctor training, CQC action plan full delivery.

Commissioners Task and finish Group to review submissions with NHSE. Gaps in Controls Concerns re the speed of action of the provider, lack of understanding of the seriousness of issues raised. Section 3 – Assurance Assurance Reporting and submission of data Reporting via CQPG to CCGs Quality Committee and GB reporting Gaps in Assurance Submissions of evidence not effective at this time and requires further work Section 4 – Risk Scoring Initial Position

Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 x 20 3 Possible 3 6 9 12 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 Current Position Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 20 3 Possible 3 6 9 12 x 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 SECTION 5 - Position 2015/2016 Final Position New Risk 2016 Quarter 1 Position Reporting requirements remain in place, performance dashboard, early warning dashboard, CQPG and SI process. Provider profiles have been developed for Bridgewater. Thematic review underway for BPAS Quality surveillance continues with WHHFT 5BP have reduced their enhanced surveillance status, after submission of provider report to QSG. Quarter 2 Position Quarter 3 Position Quarter 4 Position SECTION 6 – Overall Assurance Full High Significant Adequate X Limited Nil Score Movement Quarter 1 Quarter 2 Quarter 3 Quarter 4

NHS Halton CCG Risk Summary

This form is to be used to provide a full & detailed update to the Governing Body & or associated Committees Section 1 – Risk Details Risk ID 378 Date Identified Lead Manager Dave Sweeney Handler Julie Holmes Committees Primary Care Commissioning Committee Strategic 1. To commission services which continually improve the health and wellbeing of Halton Objectives residents. 4. To deliver all our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place. Risk Description The plan to utilise a local venue as interim accommodation for initial Asylum Seekers, (over and above those being placed under the planned agreement) this may lead to further pressure on primary care practices nearby and may affect the care these vulnerable group receive and also affect the reputation and budget of the CCG Section 2 – Controls Controls in Place LCR group in place planning for planned long term placements but this issue not currently on the radar. Local leadership via planning authority engaged Internal risk identified and escalated. Internal operational group identified LCCG and LA have in place in Brownlow by a out of hours provider a service for initial arrivees which may be utilised initially on arrival but will not be reasonable for use longer term but it may be able to deliver locally. Gaps in Controls Still unclear of planning decision Unclear of timescale, numbers and requirements which us effective out ability to plan. GP practices local to the possible venue are already under pressure and have capacity issues. unclear Section 3 – Assurance Assurance Risk registered on Datix Report for EMT on issues and risks identified. Gaps in Assurance Reporting and assurance yet to be agreed Section 4 – Risk Scoring Initial Position

Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 x 20 3 Possible 3 6 9 12 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 Current Position Consequence Likelihood 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 5 Almost certain 5 10 15 20 25 4 Likely 4 8 12 16 20 3 Possible 3 6 9 12 x 15 2 Unlikely 2 4 6 8 10 1 Rare 1 2 3 4 5 SECTION 5 - Position 2015/2016 Final Position New Risk 2016 Quarter 1 Position Local Authority confirmed that UC24 will provide a service for initial arrives. Planning permission submitted. Quarter 2 Position Quarter 3 Position Quarter 4 Position SECTION 6 – Overall Assurance Full High Significant Adequate X Limited Nil Score Movement Quarter 1 Quarter 2 Quarter 3 Quarter 4

Cover page

The Annual Audit Letter for Halton Clinical Commissioning Group

Year ended 31 March 2016

July 2016

Mark Heap Director T 0161 234 6375 E [email protected]

Liz Temple-Murray Manager T 0161 214 6370 E [email protected]

Contents

Section Page 1. Executive summary 3 2. Audit of the accounts 5 3. Value for Money conclusion 9 4. Working with the CCG 12 5. Grant Thornton in Health 14 Appendices A Reports issued and fees

Purpose of this letter Our work Our Annual Audit Letter (the Letter) summarises the key findings arising from the Financial statements opinion work that we have carried out at Halton Clinical Commissioning Group (the CCG) We gave an unqualified opinion on the CCG's financial statements on 27 May for the year ended 31 March 2016. 2016.

The Letter is intended to provide a commentary on the results of our work to the As well as an opinion on the financial statements, we are required to give a CCG and external stakeholders, and to highlight issues that we wish to draw to the regularity opinion on whether expenditure has been incurred 'as intended by attention of the public. In preparing the Letter, we have followed the National Parliament'. Failure to meet statutory financial targets automatically results in a Audit Office (NAO)'s Code of Audit Practice and Auditor Guidance Note (AGN) qualified regularity opinion. 07 – 'Auditor Reporting'. Based on our review of the CCG's expenditure we gave an unqualified regularity We reported the detailed findings from our audit work to the CCG's Audit opinion. Committee as those charged with governance in our Audit Findings Report on 25 May 2016. Use of statutory powers We did not identify any matters which required us to exercise our additional Our responsibilities statutory powers. We have carried out our audit in accordance with the NAO's Code of Audit Practice, which reflects the requirements of the Local Audit and Accountability Value for money (VfM) conclusion Act 2014 (the Act). Our key responsibilities are to: We were satisfied that the CCG put in place proper arrangements to ensure • give an opinion on the CCG's financial statements (section two) economy, efficiency and effectiveness in its use of resources. We reflected this in • assess the CCG's arrangements for securing economy, efficiency and our report on the financial statements on 27 May 2016 effectiveness in its use of resources (the value for money conclusion) (section three). Certificate We certify that we have completed the audit of the accounts of Halton CCG in In our audit of the CCG's financial statements, we comply with International accordance with the requirements of the Code of Audit Practice Standards on Auditing (UK and Ireland) (ISAs) and other guidance issued by the NAO.

Working with the CCG . During the year we have worked with you to deliver the following outcomes: • An efficient audit – we delivered an efficient audit in line with your timetable to report to the Audit Committee meeting on 25 May 2016, before the statutory deadline. • Understanding your operational health – through the value for money conclusion we provided you with assurance on your operational effectiveness. • We tracked your financial budget position, medium term planning arrangements and strategic partnership working and considered this as part of our value for money assessment. • Improving your annual reporting – we benchmarked your annual report and shared our summary assessment on areas for consideration and improvement . • Sharing our insight – we provided regular Audit Committee updates covering best practice. We also shared our thought leadership reports. • Providing training – we provided your teams with training on financial accounts and annual reporting. • Supporting development – we provided a workshop for GPs on 9 June 2016 and the Governing Body and Audit Committee on 29 June 2016. • Providing information – we shared the information from our data analytics team highlighting health conditions and lifestyle needs in your area.

We would like to record our appreciation for the assistance and co-operation provided to us during our audit by the CCG's staff

Grant Thornton UK LLP July 2016

Our audit approach The scope of our audit Materiality Our audit involves obtaining enough evidence about the amounts and In our audit of the CCG's financial statements, we use the concept of materiality disclosures in the financial statements to give reasonable assurance that they are to determine the nature, timing and extent of our work, and in evaluating the free from material misstatement, whether caused by fraud or error. results of our work. We define materiality as the size of the misstatement in the financial statements that would lead a reasonably knowledgeable person to change This includes assessing whether: or influence their economic decisions. • the accounting policies are appropriate, have been consistently applied and adequately disclosed; We determined materiality for the audit of the CCG's accounts to be £4.143 • the significant accounting estimates made by management are reasonable; million, which is 2% of the CCG's gross revenue expenditure. We used this and benchmark as, in our view, users of the CCG's financial statements are most • the overall presentation of the financial statements gives a true and fair view. interested in where the CCG has spent its allocation in the year. We also read the annual report to check it is consistent with our understanding We also determined a lower level of specific materiality for certain areas such as: of the CCG and with the accounts on which we give our opinion. • Cash and cash equivalents • Disclosures of senior manager salaries and allowances in the remuneration We conducted our audit in accordance with ISAs (UK and Ireland) and the report NAO Code of Audit Practice. We believe that the audit evidence we have • Disclosure of auditor's remuneration obtained is sufficient and appropriate to provide a basis for our opinion. • Provisions • Exit packages Our audit approach was based on a thorough understanding of the CCG's business and is risk based. We identified key risks and set out on the next page We set a lower threshold of £5,000, above which we reported errors to the Audit the work we performed in response to these risks and the results of our work. Committee in our Audit Findings Report.

© 2016 Grant Thornton UK LLP | The Annual Audit Letter for Halton CCG | July 2016 5 Overall review of financial statements Audit of the accounts These are the risks which had the greatest impact on our overall strategy and where we focused more of our work.

Risks identified in our audit plan Work completed

Better Care Fund (BCF) As part of our audit work we: The CCG entered into a £10.5 million S75 pooled budget • obtained the S75 agreement governing the pooled budget and gained an understanding of the CCG's assessment of arrangement as of 1 April 2015 with Halton Borough where control lies and its planned accounting entries in respect of the Fund; Council to procure services from a range of NHS trusts, the Council and private sector bodies. The accounting • documented and reviewed the operating effectiveness of the CCG's controls over the BCF pooled budget; arrangements for this are complex and there is a risk of • tested the accounting entries made in respect of the BCF pooled budget to check they are consistent with our material misstatement in the financial statements and the understanding of the arrangement and the transactions and balances recorded. potential for irregular expenditure. We identified the following issues in relation to this risk: The CCG's 2015/16 spend under the Better Care Fund totalled £9.5 million. Of this, £8.4 million is categorised as payable to Halton Borough Council and the remaining £1.1 million as payable to NHS bodies. Under IFRS 11 the categorisation of cost is determined by the commissioning arrangements. The s75 Agreement and supporting documents, governing Better Care Fund arrangements in 2015/16, does not provide sufficient detail to allow the necessary accounting to be clearly determined. We have, therefore, not been able to gain sufficient assurance that the attribution of cost to providers under the Better Care Fund meets the accounting requirements of IFRS 11. The 2016/17 Better Care Fund budget is more explicit about commissioning arrangements, and may imply that, of the 2015/16 spend, up to £2.1 million should have been categorised in the CCG's 2015/16 accounts as payable to NHS bodies. Whilst we are satisfied that there is no material misstatement in the 2015/16 accounts, going forward we recommended that the CCG takes steps to ensure it can more clearly demonstrate compliance with the accounting principles of IFRS 11, in 2016/17 and beyond.

Primary Care Co-commissioning As part of our audit work we: From April 2015 the CCG assumed full delegated • obtained an understanding of the CCG's arrangements to manage conflicts of interest in relation to GP commissioned responsibility for commissioning general practice (GP) services, including the potential impact for related party transaction disclosures; services and received an allocation for co-commissioning of £17.012 million. For 2015/16 the initial contracts were • gained an understanding of the CCG's controls to ensure that the monthly expenditure is correct; agreed by NHSE and it has continued to make the • tested the accounting entries made in respect of co-commissioning to check they are consistent with our payments to GP providers, resulting in a monthly journal understanding of the arrangement and that transactions and balances recorded are consistent with those recorded by and cash transfer between the CCG and NHSE to reflect counterparty organisations; the transactions. Given the newness of these • verified a sample of payments to GP practices by reference to the National Health Application and Infrastructure arrangements we consider there to be a risk of material Services/Exeter System (NHAIS/EXETER) output; misstatement and the potential for irregular expenditure, given the inherent conflict of interest issues involved. • reviewed service auditor reports on the control environment surrounding the NHAIS/EXETER system and NHS Shared Business Services (NHS SBS) operations We did not identify any issues to report .

© 2016 Grant Thornton UK LLP | The Annual Audit Letter for Halton CCG | July 2016 6 Overall review of financial statements Audit of the accounts These are the risks which had the greatest impact on our overall strategy and where we focused more of our work.

Risks identified in our audit plan Work completed

Valuation of secondary healthcare expenditure As part of our audit work we carried out:

Around 80% of the CCG's expenditure relates to contracts with • documentation of our understanding of processes and key controls over the transaction cycle;

NHS hospital and foundation trusts. • walkthrough of the key controls to confirm our understanding of the system; Trusts invoice the CCG throughout the year for services • substantive testing of secondary healthcare costs including sample testing of contract and non-contract provided, and at the year-end accrue for activity in the final costs, review of intra-NHS agreement of balances exercise, consideration of relevant service auditor reports, quarter. Invoices for the final quarter of the year are not agreed and testing of payments after the year end for significant unrecorded liabilities. until after the accounts are produced for audit. We did not identify any issues to report. There is therefore a risk that expenditure on secondary healthcare income my be understated.

Audit opinion Annual Governance Statement and Annual Report We gave an unqualified opinion on the CCG's financial statements on 27 May We are also required to review the CCG's Annual Governance Statement and 2016, in advance of the national deadline. Annual Report. It provided these on a timely basis with the draft accounts with supporting evidence. We were satisfied that this met the requirements of the As well as an opinion on the financial statements, we are required to give a DH Group Manual for Accounts and entries were consistent with the audited regularity opinion on whether expenditure has been incurred 'as intended by financial statements. Parliament'. Failure to meet statutory financial targets automatically results in a qualified regularity opinion. Consolidation template We also reported on the consistency of the accounts consolidation template Based on our review of the CCG's expenditure we gave an unqualified regularity provided to NHS England with the audited financial statements. We concluded opinion. that these were consistent.

Preparation of the accounts Other statutory powers The CCG presented us with draft accounts in accordance with the national We did not identify any issues that required us to apply our statutory powers deadline, and provided a good set of working papers to support them. The finance and duties under the Act for 2015/16. team responded promptly and efficiently to our queries during the course of the audit.

Issues arising from the audit of the accounts We reported the key issues from our audit to the CCG's Audit Committee on 25 May 2016. We identified no adjustments affecting the CCG's comprehensive net expenditure position and no material or non-trivial misstatement of figures in the statements. We identified 23 disclosure changes during the audit which were made in the final set of financial statements.

As identified in the key audit risks reported above in respect of the Better Care Fund, we recommended that the CCG takes steps to ensure it can more clearly demonstrate compliance with the accounting principles of IFRS 11, in 2016/17 and beyond.

Background Overall VfM conclusion We carried out our review in accordance with the NAO Code of Audit Practice, We are satisfied that in all significant respects the CCG put in place proper following the guidance issued by the NAO in November 2015 which specified the arrangements to secure economy, efficiency and effectiveness in its use of criterion for auditors to evaluate: resources for the year ending 31 March 2016. In all significant respects, the audited body takes properly informed decisions and deploys resources to achieve planned and sustainable outcomes for taxpayers and local people.

Key findings Our first step in carrying out our work was to perform a risk assessment and identify the key risks where we concentrated our work.

The key risks we identified and the work we performed are set out overleaf.

Key findings We set out below our key findings against the significant risks we identified through our initial risk assessment and further risks identified through our ongoing review of documents.

Significant risk Work to address Findings and conclusions

Financial outturn We reviewed the CCG's The CCG achieved the NHSE business rule related to the delivery of a planned 1% surplus and met its statutory The CCG forecast that it would arrangements for: financial targets with a £1.9 million surplus. The most significant areas of overspend in 2015/16 were mainly due to achieve a 1% surplus of £1.9 • putting together and over-performance on mental health and prescribing, offset by an underspend on other commissioning, continuing million for 2015/16 and agreeing its budget, care and overall running costs, including a windfall allocation for the quality premium. identified that this would be a including identification of In 2015/16 the CCG achieved elements of the overall Quality, Innovation, Productivity and Prevention (QIPP) challenge. savings plans; delivered through tariff efficiency and prescribing budget savings but non-tariff savings were not fully achieved. • monitoring and managing delivery of its budget and The CCG's process for compiling its budget was based on a satisfactory analysis of health needs in the locality. savings plans for 2015/16. Savings plans as part of the QIPP process were subject to agreement by budget holders and with providers as part of the contract negotiation process. Performance against budget, including delivery of savings plans against target, was reported monthly to the Performance and Finance Committee where it was subject to challenge, and at a higher level to the Governing Body. The Financial Control Environment Assessment carried out for NHSE scored 4 'Excellent', 11 'Good', 2 'Moderate' with no 'Improvement required.' The MIAA audit of financial systems including budgetary control was completed and received High Assurance. We concluded that the CCG has proper arrangements to plan finances effectively and provide reliable financial reporting to support the delivery of its strategic priorities.

Financial sustainability We reviewed the CCG's In 2016/17, the CCG will receive a core programme budget funding increase of 3.0% (or £5.7 million), giving a total The CCG identified significant arrangements for identifying, programme allocation of £191.3 million though in real terms the growth in 2016/17 is less than 2.5%. The funding challenges in its financial agreeing and monitoring its growth in 2017/18 and 2018/19 drops to 2.0%. Overall although the CCG does have an increase in its allocation it projections for 2016/17 sustainability and operational has many cost pressures to face. The CCG’s Running Cost Allocation (RCA) was reduced by 10% (or £0.221 onwards that it needs to plans, and communicating key million) in 2015/16. NHSE have said that the RCA will be kept at the same level for the next 5 years. address in its medium term findings to the Governing Body Halton CCG is currently forecasting a £8.5m deficit at the end of 2016/17 before QIPP savings, while having a financial plan. and Performance and Finance statutory duty to break even and a business requirement to deliver a 1% surplus, hold a 1% non-recurrent reserve Committee. and a 0.5% contingency. In order to turn around the deficit and bring the budget on to a sustainable surplus position a financial sustainability plan is being developed, led by the Chief Officer and a newly appointed Head of Sustainability. This financial sustainability plan will feed into the Sustainability and Transformation Plan that is being developed across Cheshire and Merseyside covering the period from 2016-2021. It is anticipated that the financial position in Halton will remain static or even deteriorate in the first instance, before a trajectory of improvement is seen and so the CCG may not achieve a breakeven position by the end of the current financial year as it may take two to three years to do so. A series of diagnostic and review processes are being finalised and there will be the creation of a clinical taskforce and a management action team to undertake the key workstreams. We concluded that there remains a significant risk to achieving longer term financial sustainability but the CCG's arrangements for planning finances to support its strategic priorities and in using reliable financial information to support informed decision making are overall adequate. © 2016 Grant Thornton UK LLP | The Annual Audit Letter for Halton CCG | July 2016 10 Value for money

Significant risk Work to address Findings and conclusions

Better Care Fund We reviewed the CCG's arrangements The total £10.5 million 2015/16 BCF Plan for Halton was approved by the CCG and The CCG has committed £9.5 million to the for working with other parties as part of Council as statutory accountable organisations and then endorsed by the Health & Halton Better Care Fund Partnership to the Better Care Partnership, its Wellbeing Board prior to approval by NHS England in early December 2014. The improve the integration of health and social processes for managing risks arising Performance and Finance Committee has oversight of delivery of the Better Care Fund care provision across the area. However, from this, and how it monitors the Plan, supported by the Better Care Partnership Board. governance arrangements and plans effectiveness of the Partnership in The arrangements in place are evolving but we consider that the processes in place at the between the constituent entities are at an delivering improvements to services. CCG are designed effectively and will ensure it can deliver value for money. This is early stage of development. supported by the MIAA review of governance arrangements in place for the Better Care Fund that concluded it could provide significant assurance that robust arrangements were in place to ensure that the BCF objectives could be met. The value of Halton’s BCF for 2016/17 is £10.5 million. We concluded that the CCG has proper arrangements to work with other parties to deliver strategic priorities.

Primary Care Co-commissioning We reviewed the arrangements for how In response to the delegation of powers from NHSE for primary care commissioning, the Arrangements around primary care primary care co-commissioning is CCG established the Primary Care Commissioning Committee to make collective commissioning are new and evolving. The evolving and how they are operating in decisions on the review, planning and procurement of primary care services as part of the CCG has taken on delegated powers to practice. CCG’s statutory commissioning responsibilities in Halton. Following agreement of the commission primary medical service for the terms of reference, the Committee has met regularly and from 1 April 2016 publishes its people of Halton. The delegation took effect agenda and papers publicly. During the year, the Committee has been supported by the on 1 April 2015 and the CCG received an Transition Group including representation from the CCG and NHSE. allocation for co-commissioning of £17.012 As part of the NHSE CCG Assurance Framework 2015-16 the self assessed assurance million. level for delegated commissioning was rated as good. MIAA also carried out a baseline assessment of the Co-Commissioning that was given 'limited' assurance; an action plan has been implemented to address these recommendations. The allocation in 2016/17 for these services is £17.6 million, an increase of 3.6% on 2015/16. We concluded that the CCG is developing proper arrangements to commission services effectively to support the delivery of strategic priorities.

Our work with you in 2015/16 shared our thought leadership briefings in Key Issues Bulletins and national We are really pleased to have worked with you over the past year. We have reports on: established a positive and constructive relationship. Together we have • NHS Governance & Financial Resilience Review 2016: Modelling future delivered some great outcomes. care. The NHS under re-construction. • Mental health collaboration An efficient audit – we delivered the accounts audit to the Audit Committee • Innovation in public financial management. and national deadline. Our audit team are knowledgeable and experienced in • Making devolution work: A practical guide for local leaders. your financial accounts and systems and worked with you closely this year on • Cross-sector review of Audit Committee effectiveness. the new and complex areas of accounting for the Better Care Fund and • Health and Wellbeing Guide (Place Analytics). primary care commissioning. Our relationship with your team provides you with a financial statements audit that continues to finish in line with your Providing training – we provided your teams with training on financial planned schedule and helps you to improve your financial reporting. accounts and annual reporting. Key finance staff attended our local workshops for preparers of accounts at NHS commissioners, run locally in Understanding your operational and financial health - through the value for Liverpool in February 2016. Following the changes outlined in the recent money conclusion we provided you with assurance on your operational and Manual for Accounts, key officers involved in the preparation of the Annual financial effectiveness. We highlighted that there remains a significant risk to Report attended local workshops in Liverpool in January 2015. achieving longer term financial sustainability. Supporting development – we provided workshops on: Improving your annual reporting – we benchmarked your annual report and • 'General Practice - organising to succeed' in Liverpool on 9 June 2016; shared our summary assessment on areas for consideration and improvement. and • 'Assurances in an Integrated World' for Governing Body and Audit Sharing our insight – we provided regular Audit Committee updates covering Committee members on 29 June 2016. best practice including summaries of reports issued by the Department of Health, the National Audit Office, CIPFA and HFMA, Public Sector Audit Providing information – we shared the information from our data analytics Appointments and the Kings Fund covering areas including The Five year team highlighting health conditions and lifestyle needs in your area. Forward View, Better Care Fund, Conflicts of interest, Manual for Accounts, NAO Code of Practice and Lessons learned from Mid Staffordshire. We also

Overall review of financial statements Working with the CCG

Working with you in 2016/17 Locally our focus will be on: We will continue to work with you and support you over the next financial year. • An efficient audit – continuing to deliver an efficient audit, including regular liaison with finance officers on key issues during the year. Nationally we are planning the following events: • Understanding your operational health – we will focus our value for money conclusion work on monitoring your financial position and examining • Health and Social Care Integration – following our recent workshop on progress against your Strategic and Financial Plans. 29 June 2016 where we shared insight into how best to integrate health and social care. we will share the outcome of our work early in 2017. • Thought leadership – we are preparing thought leadership reports on: • Future of Primary Care and on • NHS commercial structures. • Audit updates - we will continue to provide regular Audit Committee updates covering best practice and emerging issues in the sector. • Providing training – we will continue to provide financial accounts and annual reporting training. • Improving your annual reporting – we will benchmark your annual report and highlight potential areas for improvement. • Providing insight – we will update our Health and Well Being analysis and share our information on key health conditions and lifestyle needs in your area.

Grant Thornton in Health

Our client base and delivery Our quality • We are the largest supplier of external audit services to the NHS. • We fully meet the criteria for appointment as external auditors. • We audit over 120 NHS organisations. • Our audit approach complies with the NAO's Code of Audit Practice, and • 99% of 2015/16 audit reports were issued by the national deadline. International Standards on Auditing. • Our clients scored us 8 out of 10 or higher. • We are fully compliant with ethical standards • We have passed all external quality inspections including QAD and AQRT. Our connections • We meet regularly with and second people to the Department of Health, Our technical support CQC, NHS Improvement and NHS England. • We are members of all of the key NAO, ICAEW, and HFMA technical • We work closely with local government and blue light services. forums. • We work with the Think Tanks and legal firms to develop workshops and • We have specialists leads for Public Sector Audit quality and Public Sector good practice. technical. • We provide thought leadership, seminars and training to support our clients • We provide national technical guidance on emerging auditing, financial and to provide solutions. reporting and ethical areas. • In 2016 we issued reports on Mental Health Collaboration, and NHS • Local teams are supported on information technology by specialist IT governance and finance. auditors. • We will publish reviews on the Future of Primary Care and on NHS • We use specialist audit software to identify and assess audit risk. commercial structures later this year. Our people Our support for the sector • We have over 30 engagement leads accredited by ICAEW to issue NHS • We are sponsors for HFMA and work with the provider faculty, mental audit reports health faculty and commissioning faculty. We regularly speak at HFMA • We have over 300 public sector specialists events to share best practice and solutions. • We invest heavily in our people including technical and personal • We provide auditor briefings into what is happening with department development training policy, sector regulation, and at other NHS organisations to help support • We invest in the future of the public sector and employ over 80 Public our clients. Sector trainee accountants • We provide Key Issues Bulletins that summarise what is happening in the sector. • We hold regular 'free to access' financial reporting and other training sessions for finance staff to ensure they have the latest technical guidance.

We confirm below our final fees charged for the audit and confirm there were no fees for the provision of non audit services.

Fees Fees for other services

Planned Actual fees 2014/15 fees Service Fees £ £ £ £ Statutory audit 45,000 45,000 45,000 None Nil

Total fees 45,000 45,000 45,000

Reports issued

Report Date issued

Audit Plan March 2016

Audit Committee progress report and emerging May 2015, September 2015, issues December 2015, March 2016, May 2016

Benchmarking your annual report March 2016

Audit Findings Report May 2016

Annual Audit Letter July 2016

GOVERNING BODY

st Date: 1 September 2016 Report title: One Halton Health and Wellbeing Strategy

Lead Clinician and/or Leigh Thompson, Director of Commissioning Lead Manager: Purpose: The purpose of this report is to provide the Health and Wellbeing Board with an update on the development of the new One Halton Health and Wellbeing Strategy (2017-2022).

The Governing Body is Note progress and provide leadership and oversight for the asked to: development of the new strategy and help inform its chosen priorities This Report supports the following CCG Strategic Objectives Three: To deliver improvements in the quality of the health and care services accessed by the people of Halton within the resources available to us and our partner organisations.

Four: To deliver all of our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place. Commissioning Plan Implications This strategy will inform future commissioning intentions. Financial Implications No additional funding required. However the strategy will inform future activity and spending across the system.

Board Assurance Framework and Corporate Risk Register Does this report link to either the Board Assurance Framework (BAF) or Corporate Risk Register (CRR) or both? NO National Policy, Guidance, Standards, Targets or Legislation The Health and Wellbeing Strategy will inform collaborative action for the Council, NHS, Social Care, Public Health and other key partners as appropriate. Equality and Diversity and Human Rights Throughout the development of this paper and the policies and processes cited NHS Halton CCG has:  Given regard to the need to reduce inequalities between patients in access to, and outcomes from healthcare services and to ensure services are provided in an integrated way where this might reduce health inequalities.

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In Halton we have a good track record of partnership working on health and wellbeing issues. As a result of the Health and Social Care Act 2012, each local area was obliged to set up a new Health and Wellbeing Board. One of the key responsibilities of the Health and Wellbeing Board was to develop a Health and Wellbeing Strategy to meet the needs of the local population. Halton’s first Health and Wellbeing Strategy covered the period 2013-2016 and set out the vision for Health and Wellbeing in Halton. The Strategy was the overarching document for the Health and Wellbeing Board outlining the key priorities the Board has focussed on over the past three years. As the current strategy finishes in 2016 we need to develop a new Health and Wellbeing Strategy to build on successes and make further improvements.

The development of the current strategy was an excellent example of the synthesis of evidence (using the JSNA), stakeholder and public engagement to identify issues of particular significance for the borough. Since its development it has provided a focus for the development and/or strengthening of local action, bringing together partnerships focused on prevention, treatment and care across the lifecourse. The overarching health and wellbeing strategy not only explained why and how priorities were chosen but also laid down a set of principles which each partnership has integrated into priority-focused strategies and action plans. The strategy has been well received locally and nationally – its style told a clear story about why and how we would approach our priorities - and we need to build on this experience for the next one.

It will be vital that the new Strategy is aligned with developing system level plans across Local Authorities and the NHS. Since 2013 when the first strategy was published there have been significant developments within the policy landscape.

Of particular importance is the agreement between the government and the leaders of the Liverpool City Region to devolve a range of powers and responsibilities to the Liverpool City Region Combined Authority and the NHS Five Year Forward View and ask to produce a five year Sustainability and Transformational Plan (STP).

All of the CCGs, Local Authorities and Provider Trusts within Cheshire and Merseyside have agreed to work collaboratively on the STP, to develop a governance structure and to manage any allocations received from the national transformation fund. Although NHS England wants a single STP across an economy footprint, they still require every organisation to provide a local plan. NHS Halton CCG has adopted an integrated Borough wide approach to planning with Halton Borough Council and a series of stakeholders, called “One Halton”.

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The new Health and Wellbeing Strategy needs to reflect current priorities from elsewhere in the system (Devolution and STP) whilst maintaining a local focus that is evidence based and reflects local people’s views.

Priorities identified within the new strategy will be aligned with LCR Devolution, Cheshire and Merseyside STP and the Local Delivery Plans of the Mid Mersey “Alliance” Local Delivery System. The priorities must be backed by a strong evidence base considering the local JSNA, Right Care benchmarks and performance against the range of national and local targets. They are currently being discussed but include:

1. Children & families (Child development 0-5) 2. Generally Well – (Community mobilisation, healthy eating and exercise) including self- care 3. Long term conditions – (CVD, COPD, Respiratory and Cancer) 4. Mental health 5. Older peoples – (Disabilities and aging well) With cross cutting themes such as IM&T, Workforce, OD, Estates and Procurement

The new strategy will include an updated health and wellbeing profile for Halton, outline the progress made since 2013 and the challenges that remain, provide an overview of priorities and how and why these were chosen, outline what we will do as a system at scale to make a difference, and outline how we will measure success.

We believe that success in delivering against the strategy can only be achieved by working in partnership with local people. Therefore, in developing the new Strategy we will consult with a wide range of Halton residents to ensure that the principles and priorities are reflective of the experience and needs of our local communities. Consultation will be undertaken by One Halton portfolio directors using pre-existing networks and forums for engagement e.g. Halton Peoples Health Forum.

After considerable consultation with the public and key stake holders a draft of the new strategy will be presented to the Health and Wellbeing Board for comment in October and the final version presented to the board for approval in January 2017. The final approved version will be made available in hard copy and online.

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GOVERNING BODY

st Date: 1 September 2016 Report title: Building an Accountable Care System: The Next Step for One Halton? Lead Clinician and/or Simon Banks, Chief Officer Lead Manager: Purpose: The One Halton programme has begun to deliver what could be recognised as a place-based approach to health, care and wellbeing for our borough. This paper suggests that we now need to take the next step by actively exploring and committing to establishing a model of accountable care.

The Governing Body is Agree to the development of an accountable care model for NHS asked to: Halton CCG.

This Report supports the following CCG Strategic Objectives One: To commission services which continually improve the health and wellbeing of Halton residents.

Two: To continually improve and innovate in our engagement with local people and communities to secure their participation in improving their own health outcomes.

Three: To deliver improvements in the quality of the health and care services accessed by the people of Halton within the resources available to us and our partner organisations.

Four: To deliver all of our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place.

Commissioning Plan Implications The movement towards an accountable care model would support delivery of our commissioning plans as set out in our One Halton approach. Financial Implications Does this require financial support? No. Board Assurance Framework and Corporate Risk Register Not applicable. National Policy, Guidance, Standards, Targets or Legislation

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Dalton D (2014). Examining new options and opportunities for providers of NHS care: the Dalton review. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/384126/Dalton_Revi ew.pdf (accessed on 3 August 2016)

NHS England (2015). Delivering the Forward View: NHS planning guidance 2016/17-2020/21. London: NHS England. Available at: https://www.england.nhs.uk/wp- content/uploads/2015/12/planning-guid-16-17-20-21.pdf (accessed on 2 August 2016).

Equality and Diversity and Human Rights Throughout the development of this paper and the policies and processes cited NHS Halton CCG has:

 Given due regard to the need to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited under the Equality Act 2010) and those who do not share it; and  Given regard to the need to reduce inequalities between patients in access to, and outcomes from healthcare services and to ensure services are provided in an integrated way where this might reduce health inequalities.

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Building an Accountable Care System: The Next Step for One Halton?

A Discussion Paper

Introduction

Over the last five years health and care organisations working in the borough of Halton have increasingly come together to improve the health, care and wellbeing of the population we serve. This has had most resonance and impact in services for adults in the borough, particularly for older people who are frail and require additional support. The collaborative approach that has emerged, which we refer to as One Halton, has been successful in reducing complexity and fragmentation, making better use of scarce resources and improving health outcomes and the quality of services for our population.

Since the publication of the NHS Five Year Forward View1 there has been considerable interest in “place-based systems of care” in which health and care organisations collaborate and share resources to deliver better outcomes, better care and better value for money. A recent publication by The King’s Fund2 strongly argues that this represents the future direction for health and care in England. There are many examples throughout the country where place-based systems of care are emerging on a more formal basis through a variety of governance frameworks.

The development of place-based systems of care has been actively encouraged by the New Models of Care Programme established by NHS England following the NHS Five Year Forward View and is accelerating through the emerging Sustainability and Transformation Plans (STPs) being developed in response to the shared planning guidance 2016/173. There is considerable interest in the concept of accountable care, where a group of health and care organisations take responsibility for providing all care for a given population for a defined period of time under a contractual arrangement with a commissioner. Providers are then held accountable for achieving a set of pre-agreed quality outcomes within a given budget or expenditure target. There are many international examples of accountable care

1 NHS England, Care Quality Commission, Health Education England, Monitor, NHS Trust Development Authority, Public Health England (2014). NHS five year forward view. London: NHS England. Available at: https://www.england.nhs.uk/ourwork/futurenhs/ (accessed on 2nd August 2016).

2 Ham C and Alderwick H (2015). Place-based systems of care: A way forward for the NHS in England. London: The King’s Fund. Available at: http://www.kingsfund.org.uk/publications/place-based-systems-care (accessed on 2 August 2016).

3 NHS England (2015). Delivering the Forward View: NHS planning guidance 2016/17-2020/21. London: NHS England. Available at: https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf (accessed on 2 August 2016).

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including differing models of accountable care organisations4 and population health models5 in the United States6, including Kaiser Permanente and Nuka, Gesundes Kinzigtal in Germany, Jönköping County Council in Sweden and Counties Manukau and Canterbury in New Zealand.

The One Halton programme has begun to deliver what could be recognised as a place-based approach to health, care and wellbeing for our borough. This discussion paper suggests that we now need to take the next step in our journey together by actively exploring and committing to establishing a model of accountable care that fits with the vision, values and ethos of One Halton.

What are accountable care systems?

The form and governance arrangements for accountable care differ, although all share some common features, these are:

 Integration of all aspects of health, care and wellbeing.  Accountable care is population based, delivered on neighbourhoods or to defined and discrete populations, with further stratification focusing on the small proportion of people who account for a high proportion of use and cost.  Organisations to work together across traditional boundaries to deliver integrated care through networks and alliances.  The people who use the services are engaged as partners in their care and supported to self-manage their health, care and well-being.  Payment systems and incentives are aligned to support integrated care and improvements in quality and outcomes.  Commissioners have a strategic role, defining outcomes and measuring the performance of the system.  Commissioning organisations pool budgets and work together to commission services jointly, moving towards capitated budgets which are developed to cover the whole of a population’s care for providers to collectively manage – this incentivises prevention.

4 Shortell S, Addicott R, Walsh N and Ham C (2014). Accountable care organisations in the United States and England: Testing, evaluating and learning what works. London: The King’s Fund. Available at: http://www.kingsfund.org.uk/publications/accountable-care-organisations-united-states-and-england (accessed on 2 August 2016).

5 Alderwick H, Ham C and Buck D (2015). Population health systems: Going beyond integrated care. London: The King’s Fund. Available at http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/population- health-systems-kingsfund-feb15.pdf (accessed on 2 August 2016).

6 Shortell S, Addicott R, Walsh N and Ham C (2014). Accountable care organisations in the United States and England: Testing, evaluating and learning what works. London: The King’s Fund. Available at: http://www.kingsfund.org.uk/publications/accountable-care-organisations-united-states-and-england (accessed on 2 August 2016).

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 Providers operate under longer-term contracts, reducing transaction costs.  Less detailed contract negotiation and performance management of multiple providers.

Accountable care arrangements take time to build, but it is arguable that our work in developing One Halton gives a good foundation for this to take place with a degree of momentum and urgency. If this aspiration is shared then we need to progress this with a dialogue involving key partners, the people who work in these services and those people who use these services. There should be a timescale within which all parties commit to this change programme and appropriate governance and support put in place.

Question One: Can we agree to this being our ambition for Halton?

Core principles

A change programme to move us towards an accountable care system, using One Halton as a launch pad, requires participants to agree to the core principles set out below for discussion.

Principle One: This is about the people of Halton

An accountable care system must be focused on improving the health and wellbeing of the people of Halton, improving their experience of care and supporting them to be active participants in positively managing their own health and wellbeing. We also want them to be active participants as we design and deliver this change.

Principle Two: We are willing to be accountable together

All organisations are genuinely willing to be accountable for the quality, cost and overall care for the people of Halton. We need to do this to close the health and wellbeing gap, the care and quality gap, and the finance and efficiency gap in the borough.

Principle Three: We will deliver accountable care together

All organisations will commit time and resource to a programme of change that delivers leadership, management and governance to create a model of accountable care that is appropriate for Halton.

Question Two: Can we agree that these are our core principles?

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Building an accountable care system for Halton

If all organisations agree to the ambition and core principles sets out above we need to consider how we build an accountable care system for Halton. The King’s Fund7 suggests that the next steps should be to:

 Define the population group served and the boundaries of the system.

 Identify the right partners and services that need to be involved.

 Develop a shared vision and objectives reflecting the local context and the needs and wants of the public.

 Develop an appropriate governance structure for the system of care, which must meaningfully involve patients and the public in decision-making.

 Identify the right leaders to be involved in managing the system and develop a new form of system leadership.

 Agree how conflicts will be resolved and what will happen when people fail to play by the agreed rules of the system.

 Develop a sustainable financing model for the system across three different levels:

o the combined resources available to achieve the aims of the system

o the way that these resources will flow down to providers

o how these resources are allocated between providers and the way that costs, risks and rewards will be shared.

 Create a dedicated team to manage the work of the system.

 Develop ‘systems within systems’ to focus on different parts of the group’s objectives.

 Develop a single set of measures to understand progress and use for improvement.

Our work to develop the One Halton approach enables us to answer the first of the three next step questions quickly, the population group served is Halton and this is further stratified by the One Halton ‘onion’ (Figure One). Through the One Halton approach and the Halton Health and Wellbeing Board we have engaged the right partners but we would need to

7 Ham C and Alderwick H (2015), op. cit.

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Figure Two: A high-level framework for organisational collaboration

In Halton we should not be tempted to “drag and drop” a particular model or approach, we need to learn from these approaches and adapt and innovate. Our successes through One Halton have been built on the 6Cs of collaboration, cooperation, co-production, communication, common purpose and care. We need to have a similar approach to building an accountable care system for the borough. Nonetheless, it is argued that we should explore the approaches that are going to facilitate rapid change from the foundations we have built, this is likely to be:

 Bringing together a consortium of organisations to provide the range of services we require for the borough;

 Creating a coordinating body that would act as an intermediary covering quality and governance and set strategic direction.

Whatever the shape of the governance arrangements we move towards any accountable care system will need to:

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 Comply with all statutory requirements for safe and effective practice.

 Meet the requirements of commissioners.

 Be able to demonstrate the ability to deliver long term financial and service viability and sustainability.

 Ensure an appropriate balance between effective leadership and management.

 Incorporate all services and all sectors of health, care and wellbeing.

 Increase the satisfaction of the people using the services, improve the quality of service delivered and make increase participation and self-management.

Question Three: Do we agree that we want to build a ‘One Halton’ accountable care system?

Next Steps

If we are agreed that we want to design and implement of an accountable care system for Halton building on the One Halton approach, then the next steps suggested above by The King’s Fund need to be followed and a framework for delivery put in place. This will require further engagement but it is posited that there needs to be three stages to this work, as shown in Figure Three.

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Figure Three: Building accountable care in Halton – Phases of work

Further detail on each of these phases of work is provided in Appendix One.

Question Four: Do we wish to take forward these phases of work?

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Appendix One Building accountable care in Halton – Phases of work

Phase 1: ACS readiness assessment and development of outcomes framework

1. Mobilise ACS programme team, PMO and Programme Board 2. Agree ACS vision statement, objectives for ACS programme and KPIs 3. Agree objectives for individual organisations as members of the ACS programme, including how ACS programme will align with their own organisational statutory / regulatory duties, including NHS contract rounds/planning requirements 4. Agree broader stakeholder engagement plan – stakeholders to include primary care, patients/carers, community stakeholders, the voluntary sector, national NHS bodies/regulators, as well as local commissioners and providers 5. Establish key project working groups and objectives/ways of working for each group 6. Run design workshop to define ACS scope of services including population, geographies and scope of services to be covered 7. Identify key capabilities, competencies and enablers to deliver the ACS and complete “gap” assessment to confirm ACS readiness 8. Develop and agree plan for filling “gaps” agreed through ACS readiness assessment, agreed through stakeholder workshop 9. Gather baseline data (income and cost data, performance, data on key enablers e.g. estates) 10. Run design workshop to establish the core outcomes and benefits the ACS must deliver and document in Outcomes Framework 11. Sign off Outcomes Framework and ACS Readiness Assessment with ACS Programme Board

Phase 2: Rapid design of ACS operating model design

1. Review current organisational forms and appraise options for new organisational relationships/entities 2. Define ACS delivery vehicles, e.g. lead provider models, alliance contracting, and run options appraisal 3. Define commissioning and contracting options and run options appraisal 4. Deliver rapid pathway care design workshops to confirm the service interventions and pathways changes to be deployed in the ACS (if required) 5. Develop principles for ACS governance design (transition and post go-live) 6. Run design workshop to agree preferred ACS delivery model, commissioning/contract arrangements and governance design principles 7. Conduct detailed ACS cost and benefits modelling and document as financial case 8. Run workshop to agree ACS enabler requirements (including estates, workforce and IM&T) 9. Sign-off ACS Rapid Design document with ACS Programme Board

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Phase 3: Transition and implementation planning

The precise scope of services to be performed in Phase 3 would be agreed following the completion of Phases 1 and 2, but will include agreement of detailed work to be undertaken to support providers and commissioners respectively.

This is likely to include:

1. Detailed contract design and payment model including legal input (commissioner led) 2. Set-up of commercial delivery vehicles and due diligence (provider led) 3. Agreement of individual V member organisation transitioning arrangements 4. Alignment to statutory / regulatory responsibilities of each individual organisation, including NHS planning guidance and contracting rounds 5. Agreement of individual organisation capacity development plans and resourcing requirements 6. Agreement on support requirements including priorities for transformation fund 7. Development of 5 Year Roadmap and phasing, with relative organisational responsibilities and commitments to these defined.

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Governing Body

st Date: 1 September 2016 Report title: NHS Halton CCG 2016/17 Corporate Performance Report Lead Clinician and/or Dr Cliff Richards, Chair Lead Manager: Mike Shaw, Performance and Planning Manager

Purpose: The performance report provides the Governing Body with position statements regarding performance for 2016/17 The Governing Body is Note performance and any associated improvement plans. Note asked to: and review the Performance Report considering additional action NHS Halton CCG can make to support recovery plans

This Report supports the following CCG Strategic Objectives One: To commission services which continually improve the health and wellbeing of Halton residents.

Three: To deliver improvements in the quality of the health and care services accessed by the people of Halton within the resources available to us and our partner organisations.

Four: To deliver all of our statutory duties and commissioning responsibilities effectively, whilst ensuring there are robust constitutional, governance and financial control arrangements in place. Commissioning Plan Implications Clear and credible plans which continue to deliver the QIPP (Quality, Innovation, Productivity and Prevention) challenge within financial resources, in line with national outcome standards and local joint health and wellbeing strategies. Proper constitutional and governance arrangements, with the capacity and capability to deliver all their duties and responsibilities including financial control as well as effectively commission all the services for which they are responsible. Financial Implications Does this require financial support? No If Yes - Is there currently a budget for this? Board Assurance Framework and Corporate Risk Register Does this report link to either the Board Assurance Framework (BAF) or Corporate Risk Register (CRR) or both? Does this report link to either the BAF or RR or both? YES.

National Policy, Guidance, Standards, Targets or Legislation

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The purpose of this report is to provide NHS Halton CCG with an update on performance against national and local quality and performance targets for 2015/16. It provides information at a CCG and provider level, for onward reporting in relation to:

 The NHS Outcomes Indicator Set of the NHS Outcomes Framework for 2015/16  The NHS Constitution operational standards  Quality Premium Indicators (both local and national) Equality and Diversity and Human Rights None identified

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Halton CCG - Performance Report 2016-17

2015-16 2016-17 2016-17 Reporting Metric Information Level Q1 Q2 Q3 Q4 Q1 YTD Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Preventing People from Dying Prematurely Ambulance Handover delays - NOTE: following mid mersey SRG meeting. from 12/08/2016 funding for NWAS ambulance liasion officer at Whiston has been halted due to lack of funds and limited evidence of effectiveness. At Cheshire and Merseyside hospitals, there was a small fall in the number of extended handovers, however, the average turnaround time continues to be over 5 minutes longer than what was being achieved at this time last year.Total PES activity was 8.1% up on plan for the month and cumulatively 8.5% over plan.Activity levels continue to be significantly higher than was planned for and this (together with the ongoing issues regarding turnaround times) continues to be reflected in the performance against the response time targets.At both a regional and county level, NWAS failed to achieve any of the response time targets. Cumulatively, only the county level Red 1, 8 minute target was achieved.The significant increase in Red activity in month (12.1% above plan in Merseyside) partly manifested itself in higher than planned conveyance, with a 4.5% adverse variance across the county.The bulk of the increased activity, however, was managed through “Hear and Treat” and “See and Treat”, resulting in patients receiving appropriate treatment without an avoidable A&E attendance.Turnaround times, which at an average of over 32 minutes, are 5 minutes longer than in June last year. This represents a significant loss of resource for NWAS (with an average of 6 vehicles unavailable at any one time) and has a consequent adverse effect on their ability to meet the national response time targets.

191: % Patients seen within two weeks for an urgent GP referral for Latest Date: 29/02/2016 RAG R G R R G G R G G G G G G G suspected cancer (MONTHLY) Halton CCG Actual The percentage of patients first seen by a specialist within two weeks Target = 93% 91.3% 93.3% 92.8% 92.8% 95.6% 96.2% 92.7% 96.2% 94.4% 93.6% 95.0% 94.7% 93.5% 94.4% when urgently referred by their GP or dentist with suspected cancer

17: % of patients seen within 2 weeks for an urgent referral for Latest Date: 29/02/2016 RAG R R G G G G G G G G G R G G breast symptoms (MONTHLY) Halton CCG Actual Two week wait standard for patients referred with 'breast symptoms' Target = 93% 84.8% 89.7% 93.3% 96.4% 95.4% 96.1% 93.3% 100.0% 93.3% 97.2% 97.8% 88.1% 93.5% 93.2% not currently covered by two week waits for suspected breast cancer

535: % of patients receiving definitive treatment within 1 month of a Latest Date: 29/02/2016 RAG G R G R G G G R G G G R G G cancer diagnosis (MONTHLY) Halton CCG Actual The percentage of patients receiving their first definitive treatment Target = 96% 97.6% 91.7% 97.9% 94.9% 100.0% 100.0% 96.4% 95.9% 100.0% 97.3% 97.9% 95.7% 96.5% 96.6% within one month (31 days) of a decision to treat (as a proxy for diagnosis) for cancer 26: % of patients receiving subsequent treatment for cancer within Latest Date: 29/02/2016 RAG R R G G G G G G G G G G R R 31 days (Surgery) (MONTHLY) Halton CCG Actual 31-Day Standard for Subsequent Cancer Treatments where the Target = 94% 87.5% 87.5% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 71.4% 89.5% treatment function is (Surgery)

1170: % of patients receiving subsequent treatment for cancer within Latest Date: 29/02/2016 RAG G G G G G G G R G R G G G G 31 days (Drug Treatments) (MONTHLY) Halton CCG Actual 31-Day Standard for Subsequent Cancer Treatments (Drug Target = 98% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 88.2% 100.0% 95.7% 100.0% 100.0% 100.0% 100.0% Treatments)

25: % of patients receiving subsequent treatment for cancer within Latest Date: 29/02/2016 RAG G G G G G G G G G G R G R R 31 days (Radiotherapy Treatments) (MONTHLY) Halton CCG Actual 31-Day Standard for Subsequent Cancer Treatments where the Target = 94% 95.0% 100.0% 100.0% 100.0% 94.4% 100.0% 100.0% 100.0% 100.0% 100.0% 84.6% 100.0% 83.3% 91.4% treatment function is (Radiotherapy)

539: % of patients receiving 1st definitive treatment for cancer Latest Date: 29/02/2016 RAG R G G R R R G R G R R G G G within 2 months (62 days) (MONTHLY) Halton CCG Actual The % of patients receiving their first definitive treatment for cancer Target = 85% 73.7% 92.6% 95.7% 63.6% 71.4% 79.2% 85.7% 75.0% 87.5% 84.2% 75.9% 88.4% 92.0% 85.6% within two months (62 days) of GP or dentist urgent referral for suspected cancer

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2015-16 2016-17 2016-17 Reporting Metric Information Level Q1 Q2 Q3 Q4 Q1 YTD Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 540: % of patients receiving treatment for cancer within 62 days from Latest Date: 29/02/2016 RAG G G G G G G G G G an NHS Cancer Screening Service (MONTHLY) Halton CCG Actual Percentage of patients receiving first definitive treatment following Target = 90% - - - 100.0% 100.0% - 100.0% - 100% 100% 100% 100% 100% 100% referral from an NHS Cancer Screening Service within 62 days.

541: % of patients receiving treatment for cancer within 62 days Latest Date: 29/02/2016 RAG upgrade their priority (MONTHLY) Halton CCG Actual % of patients treated for cancer who were not originally referred via No national target set 100.0% 100.0% 100.0% - 100.0% - 66.7% 100.0% 50.0% 100.0% 100.0% 100.0% 66.7% 87.5% an urgent GP/GDP referral for suspected cancer, but have been seen by a clinician who suspects cancer, who has upgraded their Ambulance

546: Category A calls responded to within 19 minutes Latest Date: 29/02/2016 RAG G G G R G R R R R R R R R R Category A calls responded to within 19 minutes Halton CCG Target = 95% Actual 96.3% 95.4% 97.0% 94.3% 95.0% 93.5% 94.8% 91.4% 88.9% 88.1% 93.1% 92.4% 91.6% 92.4%

NORTH WEST Latest Date: 29/02/2016 RAG G R G R R R R R R R R R R R AMBULANCE Target = 95% Actual 95.9% 94.6% 95.1% 94.6% 94.1% 92.0% 92.7% 89.9% 88.1% 86.7% 92.0% 91.5% 91.5% 91.7% SERVICE NHS TRUST 1889: Category A (Red 2) 8 Minute Response Time Latest Date: 29/02/2016 RAG G R G G G G G R R R R R R R Number of Category A (Red 2) calls resulting in an emergency Halton CCG Actual response arriving at the scene of the incident within 8 minutes Target = 75% 78.4% 74.8% 75.8% 75.9% 78.2% 75.2% 77.7% 67.4% 67.4% 68.9% 70.6% 71.2% 64.8% 68.9%

NORTH WEST Latest Date: 29/02/2016 RAG G G G R R R R R R R R R R R AMBULANCE Actual 78.2% 76.0% 75.4% 74.9% 72.5% 68.4% 69.5% 63.5% 61.1% 58.9% 67.5% 66.3% 66.2% 66.6% SERVICE NHS Target = 75% TRUST 1887: Category A Calls Response Time (Red1) Latest Date: 29/02/2016 RAG R G G G R G G R R R R R R R Number of Category A (Red 1) calls resulting in an emergency Halton CCG Actual response arriving at the scene of the incident within 8 minutes Target = 75% 65.7% 83.8% 75.7% 80.6% 67.4% 75.5% 76.2% 69.2% 70.0% 60.0% 65.7% 74.2% 71.8% 70.5%

NORTH WEST Latest Date: 29/02/2016 RAG G G G G G R R R R R G R R R AMBULANCE Actual 79.8% 79.3% 77.7% 78.4% 75.9% 73.4% 75.0% 69.3% 70.5% 67.3% 76.5% 74.3% 73.1% 74.6% SERVICE NHS Target = 75% TRUST

1932: Ambulance: 30 minute handover delays Latest Date: 29/02/2016 RAG Number of ambulance handover delays over 30 minutes WARRINGTON Actual 48 13 29 50 79 87 148 242 376 347 263 149 68 480 HOSPITAL

Latest Date: 29/02/2016 RAG WHISTON Actual 111 151 113 203 271 366 404 736 544 681 265 307 423 995 HOSPITAL

THE ROYAL Latest Date: 29/02/2016 RAG LIVERPOOL Actual 139 100 61 203 188 249 369 529 647 857 606 448 322 1,376 UNIVERSITY HOSPITAL http://bi.xfyldecoast.nhs.uk/_vti_bin/ReportServer/http://bi.xfyldecoast.nhs.uk/All_Reports/Performance Monitoring Report.rdl 1932: Ambulance: 30 minute handover delays Number of ambulance handover delays over 30 minutes

Halton CCG - Performance Report 2016-17

2015-16 2016-17 2016-17 Reporting Latest Date: 29/02/2016 Metric THE ROYAL Information LIVERPOOLLevel Q1 Q2 Q3 Q4 Q1 YTD UNIVERSITY Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun HOSPITAL

1933: Ambulance: 60 minute handover delays THE ROYAL Latest Date: 29/02/2016 RAG Number of ambulance handover delays over 60 minutes LIVERPOOL Actual 17 12 1 44 48 63 143 244 266 447 274 117 66 457 UNIVERSITY HOSPITAL

Latest Date: 29/02/2016 RAG WARRINGTON Actual 5 1 1 11 28 12 47 108 160 144 105 42 9 156 HOSPITAL

Latest Date: 29/02/2016 RAG WHISTON Actual 7 25 5 55 41 107 143 303 177 286 51 65 118 234 HOSPITAL

Enhancing Quality of Life for People with Long Term Conditions

Mental Health

Estimated diagnosis rate for people with dementia (PHOF 4.16 / NHS Latest Date: 29/02/2016 RAG G R G G R R R R R R R R R R OF 2.6i) Halton CCG Halton CCG YTD 70.9% 71.6% 71.8% 72.2% 71.2% 71.5% 71.1% 70.6% 72.0% 72.0% 69.5% 68.8% 70.3% 70.3% (LOCAL DATA USED) Target 70.5% 71.0% 71.5% 72.0% 71.5% 72.5% 73.0% 74.0% 74.5% 75.0% 71.2% 71.2% 71.2% 71.2%

Improving access to psychological therapies (QP2) Halton CCG - Latest Date: 29/02/2016 RAG R R R G G G R R R G G G G G Halton CCG Access Quarterly position (sum of current and previous 2 month's %, (LOCAL DATA YTD where available) Target = 3.75% 3.4% 3.3% 3.5% 3.9% 4.1% 4.0% 3.5% 3.5% 3.4% 3.8% 3.9% 3.9% 3.9% 3.9% USED) - Monthly http://bi.xfyldecoast.nhs.uk/_vti_bin/ReportServer/http://bi.xfyldecoast.nhs.uk/All_Reports/Performance Monitoring Report.rdl Halton CCG - Performance Report 2016-17

2015-16 2016-17 2016-17 Improving access to psychological therapies (QP2) Halton CCG - Reporting Latest Date: 29/02/2016 Metric Halton CCG Information Access Quarterly position (sum of current and previous 2 month's %, Level Q1 Q2 Q3 Q4 Q1 YTD (LOCAL DATA where available) Target = 3.75% Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun USED) - Monthly

Improving access to psychological therapies (QP2) Halton CCG - Latest Date: 29/02/2016 RAG R R R R R R R R R R R R R R Halton CCG Recovery Month Actual (LOCAL DATA Target = 50% YTD 49.0% 45.8% 36.1% 39.3% 42.7% 37.3% 27.4% 40.5% 36.4% 41.0% 39.1% 44.4% 41.6% 42.5% USED) - Monthly

The proportion of people that wait 6 weeks or less from referral to Latest Date: 29/02/2016 RAG R G R G G G G G Halton CCG entering a course of IAPT treatment against the number of people (LOCAL DATA who finish a course of treatment in the reporting period (EH1 - A1) Target = 75% YTD 50.0% 75.0% 66.7% 80.9% 86.9% 87.3% 91.8% 89.6% USED) - Monthly

The proportion of people that wait 18 weeks or less from referral to Latest Date: 29/02/2016 RAG R R R R G G G G Halton CCG entering a course of IAPT treatment against the number of people (LOCAL DATA who finish a course of treatment in the reporting period (EH2 - A2) Target = 95% YTD 68.8% 93.8% 83.3% 90.5% 92.6% 92.7% 95.6% 90.9% USED) - Monthly

138: Proportion of patients on (CPA) discharged from inpatient care Latest Date: 31/12/2015 RAG G G G G G G who are followed up within 7 days 97.2% Halton CCG Target = 95% Actual 96.2% 97.0% 98.9% 95.5% 97.2%

Helping People to Recover from Episodes of Ill Health or Following Injury

Emergency Re-admissions

1425: Emergency Re-admissions within 30 days of discharge Latest Date: 31/01/2016 RAG G G R R R R G G G R R Halton CCG % of Admissions which are Emergency Re-Admissions (LOCAL DATA Target = 15.5% Actual 14.6% 15.0% 16.6% 16.4% 17.4% 16.4% 15.2% 15.4% 15.2% 19.0% 19.0% USED)

Ensuring that People Have a Positive Experience of Care

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2015-16 2016-17 2016-17 Reporting Metric Information Level Q1 Q2 Q3 Q4 Q1 YTD Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Friends and Family

WARRINGTON Addressing issues identified in 2013/14 Friends & Family Test - Latest Date: 29/02/2016 RAG G G G R R R R R R R G G G G AND HALTON Warrington A&E (provider catchment) (NHS OF 4c / Local QP4) - in HOSPITALS NHS Actual month figure Target = 86% 88.2% 86.8% 89.7% 84.8% 85.7% 85.3% 82.3% 76.1% 80.6% 78.0% 90.0% 90.0% 92.0% 92.0% FOUNDATION TRUST Friends & Family test Whiston A&E (provider catchment) (NHS OF ST HELENS AND Latest Date: 29/02/2016 RAG G G G G G G G R R R G G R G 4c)in month figure KNOWSLEY Actual 92.9% 92.2% 92.8% 92.2% 92.8% 90.0% 93.5% 85.0% 84.6% 85.0% 88.0% 87.0% 85.0% 85.0% HOSPITALS NHS Target = 86% TRUST WARRINGTON Friends & Family test Warrington site inpatient (provider catchment) Latest Date: 29/02/2016 RAG G G G G G G G G G G G R G G AND HALTON (NHS OF 4c)in month figure HOSPITALS NHS Target = 94% Actual 97.7% 96.9% 95.0% 95.5% 95.4% 94.5% 94.2% 94.3% 95.1% 95.0% 96.0% 93.0% 95.0% 95.0% FOUNDATION WARRINGTONTRUST Friends & Family test Halton Hospital site inpatient (provider Latest Date: 29/02/2016 RAG G G G G G G G G G G G G G G AND HALTON catchment)(NHS OF 4c)in month figure HOSPITALS NHS Target = 94% Actual 99.5% 98.8% 100.0% 99.2% 98.5% 98.9% 98.2% 100.0% 97.0% 98.0% 98.0% 99.0% 99.0% 99.0% FOUNDATION TRUST Friends & Family test St Helens Inpatient (provider catchment) (NHS ST HELENS AND Latest Date: 29/02/2016 RAG G G G G G G G G G G G G G G OF 4c)in month figure KNOWSLEY Actual 98.2% 97.3% 97.8% 96.8% 95.4% 97.6% 96.5% 96.4% 96.1% 98.0% 95.0% 95.0% 96.0% 95.0% HOSPITALS NHS Target = 94% TRUST EMSA

1067: Mixed sex accommodation breaches - All Providers Latest Date: 29/02/2016 RAG G G G R G G G R R G R R R R No. of MSA breaches for the reporting month in question for all Halton CCG providers Target = 0 Actual 0 0 0 1 0 0 0 1 1 0 1 1 1 3

1812: Mixed Sex Accommodation - MSA Breach Rate Latest Date: 29/022016 RAG G G G R G G G R R G R R G R MSA Breach Rate (MSA Breaches per 1,000 FCE's) Halton CCG Target = 0 Actual - - - 0.287 - - - 0.291 0.291 - 0.291 0.28 0 3.00

Referral to Treatment (RTT) & Diagnostics

1291: Referral to Treatment RTT (Incomplete) Latest Date: 29/02/2016 RAG G G G G G G G G G G G G G G Percentage of patients waiting at period end (RTT) for incomplete Halton CCG Actual pathways (Commissioner) Target = 92% 95.5% 95.4% 95.1% 94.9% 94.6% 94.5% 94.3% 94.3% 93.8% 93.5% 93.9% 94.2% 93.8% 94.0%

1839: Referral to Treatment RTT - No of Incomplete Pathways Latest Date: 29/02/2016 RAG G G G G G R G G G G R R R R Waiting >52 weeks Target = 0 Halton CCG Actual The number of patients waiting at period end for incomplete 0 0 0 0 0 1 0 0 0 0 1 1 1 3 pathways >52 weeks

1828: % of patients waiting 6 weeks or more for a diagnosic test Latest Date: 29/02/2016 RAG G G G G G G R G G G G G G G The % of patients waiting 6 weeks or more for a diagnosic test Halton CCG Target = 1%

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2015-16 2016-17 2016-17 Reporting Metric Information Level Q1 Q2 Q3 Q4 Q1 YTD 1828: % of patients waiting 6 weeks or more for a diagnosic test Latest Date: 29/02/2016 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun The % of patients waiting 6 weeks or more for a diagnosic test Halton CCG Target = 1% Actual 0.1% 0.0% 0.0% 0.0% 0.0% 0.1% 2.3% 0.2% 0.1% 0.1% 0.3% 0.2% 0.1% 0.2%

Cancelled Operations

1983: Urgent Operations cancelled for a 2nd time ST HELENS AND Latest Date: 31/01/2016 RAG G G G G G G G G G G G G G G Number of urgent operations that are cancelled by the trust for non- KNOWSLEY Actual 0 0 0 0 0 0 0 0 0 0 0 0 0 0 clinical reasons, which have already been previously cancelled once HOSPITALS NHS Target = 0 for non-clinical reasons. TRUST WARRINGTON Latest Date: 31/01/2016 RAG AND HALTON G G G G G G G G G G G G G G HOSPITALS NHS Target = 0 Actual 0 0 0 0 0 0 0 0 0 0 0 0 0 0 FOUNDATION TRUST LIVERPOOL Latest Date: 31/01/2016 RAG G G G G G G G G G G G G G G WOMEN'S NHS Actual 0 0 0 0 0 0 0 0 0 0 0 0 0 0 FOUNDATION Target = 0 TRUST ROYAL Latest Date: 31/01/2016 RAG LIVERPOOL AND G G G G G G G G G G G G G G BROADGREEN Target = 0 Actual 0 0 0 0 0 0 0 0 0 0 0 0 0 0 UNIVERSITY HOSPITALS NHS 1982: % of Cancellations for non clinical reasons who are treated LIVERPOOL Latest Date: 31/12/2015 RAG within 28 days WOMEN'S NHS Actual 8% 0% 0% 0% All patients who have operations cancelled, on or after the day of FOUNDATION No national target set admission (including the day of surgery), for non-clinical reasons to be TRUST offered another binding date within 28 days, or the patient's ST HELENS AND Latest Date: 31/12/2015 RAG treatment to be funded at the time and hospital of the patient's KNOWSLEY Actual 0% 0% 0% 2% choice. HOSPITALS NHS No national target set TRUST ROYAL Latest Date: 31/12/2015 RAG LIVERPOOL AND BROADGREEN No national target set Actual 1% 0% 0% 4% UNIVERSITY WARRINGTONHOSPITALS NHS Latest Date: 31/12/2015 RAG AND HALTON HOSPITALS NHS No national target set Actual 10% 4% 17% FOUNDATION TRUST Treating and Caring for People in a Safe Environment and Protect them from Avoidable Harm

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2015-16 2016-17 2016-17 Reporting Metric Information Level Q1 Q2 Q3 Q4 Q1 YTD Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

HCAI

497: Number of MRSA Bacteraemias Latest Date: 29/02/2016 RAG G G G G G G G R R R R R R R Incidence of MRSA bacteraemia (Commissioner) (cumulative) Target = 0 Halton CCG YTD 0 0 0 0 0 0 0 1 1 1 1 1 1 1

24: Number of C.Difficile infections Latest Date: 29/02/2016 RAG R R R R R R R G G G G G G G Incidence of Clostridium Difficile (Commissioner) (cumulative) YTD 10 13 15 20 26 26 27 28 32 33 1 4 8 8 Halton CCG Target 9 11 14 16 19 21 24 28 32 36 3 6 9 9

Accident & Emergency

431: 4-Hour A&E Waiting Time Target (Monthly Aggregate for Total ST HELENS AND Latest Date: 31/01/2016 RAG R R R R R R R R R R R R R R Provider) KNOWSLEY Actual 93.0% 92.8% 94.7% 91.4% 88.0% 86.4% 87.9% 85.5% 84.7% 83.2% 88.4% 87.2% 83.2% 86.7% % of patients who spent less than four hours in A&E (Total Acute HOSPITALS NHS Target 95% position from Unify Weekly SitReps) TRUST BRIDGEWATER Latest Date: 31/01/2016 RAG COMMUNITY G G G G G G G G G G G G G G HEALTHCARE Target 95% Actual 100.0% 99.7% 99.6% 99.4% 99.9% 100.0% 99.9% 99.2% 99.3% 99.0% 99.6% 99.5% 99.8% 99.6% NHS WARRINGTONFOUNDATION Latest Date: 31/01/2016 RAG AND HALTON R R R R R R R R R R R R R R HOSPITALS NHS Target 95% Actual 92.5% 94.0% 93.2% 91.7% 90.7% 86.5% 85.2% 81.3% 79.9% 83.7% 90.4% 92.2% 93.5% 92.1% FOUNDATION TRUST http://bi.xfyldecoast.nhs.uk/_vti_bin/ReportServer/http://bi.xfyldecoast.nhs.uk/All_Reports/Performance Monitoring Report.rdl 431: 4-Hour A&E Waiting Time Target (Monthly Aggregate for Total Provider) % of patients who spent less than four hours in A&E (Total Acute position from Unify Weekly SitReps) Halton CCG - Performance Report 2016-17

WARRINGTON 2015-16 2016-17 2016-17 Reporting Latest Date: 31/01/2016 Metric Information AND HALTONLevel Q1 Q2 Q3 Q4 Q1 YTD HOSPITALS NHS Target 95% Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun FOUNDATION TRUST Halton CCG at ST A&E Attendances: Type 1 Latest Date: 29/02/2016 RAG R G R R G R R R G R R Line 1: Number of attendances Type 1 A&E depts HELENS AND KNOWSLEY Actual 1,314 1,415 1,298 1,307 1,284 1,345 1,354 1286 1246 1363 1235 1387 1263 3885 HOSPITALS NHS Target 1190 1469 1078 1250 1502 1198 1194 1274 1274 1275 TRUST (LOCAL DATA) Halton CCG at Latest Date: 29/02/2016 RAG R G R G G R R G G R G WARRINGTON AND HALTON Actual 1,016 946 967 951 1,031 1,048 995 1014 985 1053 1005 1002 917 2924 HOSPITALS NHS Target 975 1204 884 1024 1231 982 979 1045 1045 1045 FOUNDATION TRUST (local A&E Attendances: Type 3/4 Latest Date: 29/02/2016 RAG R R R R R R R R R R R Line 1: Number of attendances Type 3/4 Urgent Care Centres (LOCAL Halton CCG at Actual DATA) Runcorn Urgent 1497 1557 1400 1477 1596 1589 1427 1648 1752 2067 1734 2029 1893 5656 care Centre Target 1024 1265 928 1076 1293 1032 1028 1097 1097 1098 (LOCAL DATA)

Latest Date: 29/02/2016 RAG G G G G G G R R R R R Halton CCG at Widnes Urgent Actual 2459 2742 2648 2811 2888 2897 3067 3284 3153 3487 2878 3189 2927 8994 Care Centre Target 2562 3163 2321 2691 3234 2580 2571 2744 2744 2745 (LOCAL DATA)

A&E Attendances: All Types Latest Date: 29/02/2016 RAG R R R R R R R R R R R R R R Line 2: Number of attendances at all A&E depts Halton CCG Actual 6,728 7,113 6,793 6,950 7,207 7,298 7,284 7647 7537 8425 7152 7940 7215 22307 (LOCAL DATA) Target 6121 7558 5545 6429 7726 6165 6144 6557 6557 6558 7135 7298 7161 21594

WARRINGTON 1928: 12 Hour Trolley waits in A&E Latest Date: 31/01/2016 RAG G G G G G G G G G G AND HALTON G G G G Total number of patients who have waited over 12 hours in A&E from (Target 0) HOSPITALS NHS Actual decision to admit to admission 0 0 0 0 0 0 0 0 0 0 0 0 0 0 FOUNDATION TRUST ST HELENS AND Latest Date: 31/01/2016 RAG G G G G G G G G R R G G G G KNOWSLEY (Target 0) Actual 0 0 0 0 0 0 0 0 1 1 0 0 0 0 HOSPITALS NHS TRUST

Activity

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2015-16 2016-17 2016-17 Reporting Metric Information Level Q1 Q2 Q3 Q4 Q1 YTD Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Activity

1934: GP Written Referrals (MAR) Latest Date: 29/02/2016 RAG R R R G G R R R R R R R R R GP written referrals for a first outpatient appointment in G&A YTD 2,534 2,763 2,340 2,575 2,535 2,387 2,863 2,880 3,076 3,021 2,657 2,880 2,760 8,297 specialties Halton CCG Target 2491 2744 2168 2751 2566 2377 2273 2410 2471 2571 2600 2372 2626 7,598

69: Other Referrals for First Outpatient Appointments (MAR) Latest Date: 29/02/2016 RAG G R R R G R R R R R R R R R Number of other referrals for a first outpatient appointment in G&A YTD 1,518 1,591 1,368 1,485 1,381 1,372 1,812 1,964 2052 2,145 2,027 1,932 1,932 5,891 specialties Halton CCG Target 1532 1586 1297 1407 1446 1241 1314 1393 1470 1738 1444 1352 1573 4,369

1936: Total Referrals (MAR) Latest Date: 29/02/2016 RAG R R R G G R R R R R R R R R Total number of referrals (GP written referrals made & other referrals - YTD 4,052 4,354 3,708 4,060 3,916 3,759 4,675 4,844 5,128 5166 4,684 4,812 4,692 14188 MAR) Halton CCG Target 4023 4330 3465 4158 4012 3618 3587 3803 3941 4309 4044 3724 4199 11,967

Elective - ordinary admissions (NHS AM1) Halton CCG (EC1) (MAR) Latest Date: 29/02/2016 RAG G R R G G G G R R G G R R R

YTD 254 284 258 253 274 247 210 265 262 244 226 263 275 764 Halton CCG Target 266 276 255 259 296 273 210 212 200 261 249 258 250 757

Halton CCG at Elective - ordinary admissions (NHS AM1a) HCCG at WHHFT (MAR) Latest Date: 29/02/2016 RAG G R G G G G R G R G G R R R WARRINGTON AND HALTON YTD 106 144 107 109 113 105 116 97 113 104 100 122 117 339 HOSPITALS NHS Target 126 131 121 123 140 129 100 101 95 123 109 113 109 331 FOUNDATION TRUST Elective - ordinary admissions (NHS AM1b) HCCG at StH&K (MAR) Halton CCG at ST Latest Date: 29/02/2016 RAG G G R G G G G R R G G G R G HELENS AND YTD 81 69 82 74 88 78 54 77 73 68 55 75 79 209 KNOWSLEY HOSPITALS NHS Target 82 85 79 80 92 85 65 66 62 81 73 75 73 221 TRUST http://bi.xfyldecoast.nhs.uk/_vti_bin/ReportServer/http://bi.xfyldecoast.nhs.uk/All_Reports/Performance Monitoring Report.rdl Halton CCG - Performance Report 2016-17

Elective - ordinary admissions (NHS AM1b) HCCG at StH&K (MAR) Halton CCG at ST Latest Date: 29/02/2016 2015-16 2016-17 2016-17 HELENSReporting AND Metric Information KNOWSLEYLevel Q1 Q2 Q3 Q4 Q1 YTD HOSPITALS NHS Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun TRUST

Elective - day cases (NHS AM2) Halton CCG (EC2) Latest Date: 29/02/2016 RAG R G G G G R G G G G R R R R

YTD 1,504 1,495 1,246 1,395 1,405 1,530 1,199 1,326 1356 1415 1431 1317 1556 4304 Halton CCG Target 1441 1572 1290 1520 1546 1422 1256 1561 1431 1513 1242 1226 1370 3,838

Halton CCG at Elective - day cases (NHS AM2a) HCCG at WHHFT Latest Date: 29/02/2016 RAG R R R R R R R R R R R G R R WARRINGTON AND HALTON YTD 836 839 669 751 770 876 648 734 701 744 755 653 840 2248 HOSPITALS NHS Target 665 726 596 702 714 657 580 721 661 697 678 669 747 2,094 FOUNDATION TRUST Elective - day cases (NHS AM2) HCCG at StH&K Halton CCG at ST Latest Date: 29/02/2016 RAG R R R R R R R G R R R R R R HELENS AND YTD 446 472 389 452 461 470 378 383 471 447 464 448 487 1399 KNOWSLEY HOSPITALS NHS Target 373 407 334 393 400 368 325 404 370 392 391 386 432 1,209 TRUST

Non-elective admissions (NHS AM 3) Halton CCG (EC4) Latest Date: 29/02/2016 RAG G G G G G G G G G G G R R R

YTD 1,362 1,384 1,330 1,426 1,429 1,442 1,387 1,368 1332 1468 1427 1548 1455 4430 Halton CCG Target 1432 1649 1406 1429 1599 1494 1572 1613 1423 1557 1484 1458 1417 4,359

Halton CCG at Non-elective admissions (NHS AM 3a) HCCG at WHHFT Latest Date: 29/02/2016 RAG G G G R G R G G G R G R G R WARRINGTON AND HALTON YTD 601 590 560 630 647 689 618 567 537 657 632 686 620 1938 HOSPITALS NHS Target 603 694 592 601 673 629 661 679 599 653 650 638 620 1,908 FOUNDATION TRUST Non-elective admissions (NHS AM 3b) HCCG at StH&K Halton CCG at ST Latest Date: 29/02/2016 RAG R G R R G G G G R R G R R R HELENS AND YTD 647 705 667 691 688 652 699 698 696 712 692 753 718 2163 KNOWSLEY HOSPITALS NHS Target 641 738 629 640 716 669 704 722 637 695 730 718 697 2,145 TRUST

All first outpatient attendances (NHS AM 4) Halton CCG (EC5) G&A) Latest Date: 29/02/2016 RAG G G G G G R G G G G G R G G MAR) YTD 3,592 3,692 3,213 3,767 3,563 3,576 3,178 3,279 3479 3530 3991 3868 4026 11885 Halton CCG Target 3658 3858 3292 3911 3813 3506 3250 3519 3561 3561 4010 3784 4229 12,023

Halton CCG at All first outpatient attendances (NHS AM 4a) HCCG at WHHFT G&A Latest Date: 29/02/2016 RAG G G G G G G G G G G (MAR) WARRINGTON AND HALTON YTD 1,568 1,721 1,477 1,655 1,518 1,580 1,316 1,221 1340 1428 1407 1382 1414 4203 HOSPITALS NHS Target 1665 1756 1498 1780 1735 1596 1479 1601 1621 1619 FOUNDATION TRUST All first outpatient attendances (NHS AM 4b) HCCG at StH&K (G&A Halton CCG at ST Latest Date: 29/02/2016 RAG R G G G G R R R R R (MAR) HELENS AND KNOWSLEY http://bi.xfyldecoast.nhs.uk/_vti_bin/ReportServer/http://bi.xfyldecoast.nhs.uk/All_Reports/Performance Monitoring Report.rdl HOSPITALS NHS TRUST Halton CCG - Performance Report 2016-17

2015-16 2016-17 2016-17 Reporting Metric Information Level Q1 Q2 Q3 Q4 Q1 YTD All first outpatient attendances (NHS AM 4b) HCCG at StH&K (G&A Latest Date: 29/02/2016 Halton CCG at ST Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun (MAR) HELENS AND YTD 1,513 1,505 1,314 1,563 1,541 1,540 1,435 1,557 1600 1591 1582 1569 1687 4838 KNOWSLEY HOSPITALS NHS Target 1482 1563 1333 1584 1544 1420 1316 1425 1442 1443 TRUST

Others

Delayed Transfers of care - days (BCF 11.3) in month figure (Halton Latest Date: 31/01/2016 RAG G G G G R G R R G G G R R G UA) Halton LA YTD 164 204 216 215 296 235 347 247 100 191 181 238 242 220 (LOCAL DATA) Target 236

Antibiotic prescribing in primary care (Quality Premium) (12 month Latest Date: 31/01/2016 RAG R R R R R G G G G G rolling figure) Halton CCG YTD 1.461 1.451 1.437 1.418 1.392 1.383 1.351 1.324 1.318 1.313 (LOCAL DATA) Target 1.439 1.418 1.397 1.376 1.380 1.384 1.388 1.392 1.396 1.401

Broad Spectrum antibiotic prescribing in primary care (Quality Latest Date: 31/01/2016 RAG G G G G G G G G G G Premium) (12 month rolling figure) Halton CCG YTD 10.1% 10.0% 9.9% 9.7% 9.6% 9.5% 9.3% 9.2% 9.0% 8.7% (LOCAL DATA) Target 11.2% 11.8% 11.8% 11.8% 10.9% 10.9% 10.9% 10.6% 10.6% 10.6%

Financial Gateway

Adverse Variance to planned surplus (Quality Premium) Latest Date: 29/02/2016 RAG G G G G G G G G G G G G G G Halton CCG YTD No No No No No No No No No No No No No No (LOCAL DATA) Target "No"

Qualified Audit Report - Halton CCG Latest Date: 29/02/2016 RAG G G G G G G G G G G G G G G Halton CCG YTD No No No No No No No No No No No No No No (LOCAL DATA) Target "No"

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