Governing Body Meeting in Public Thursday 24 May 2018

Governing Body Meeting in Public

Thursday 24th May 2018 [Intentionally left blank] Governing Body Public Meeting Thursday 24th May 2018, 9:00am-11:00am Focolare Centre (Meeting Room 1) – Welwyn Garden City

AGENDA

Item Time Subject Report Action

1. 09:00 WELCOME AND APOLOGIES FOR ABSENCE Chair Note Verbal

2. DECLARATIONS OF INTERESTS . To receive any new declarations of interest or Chair Note declarations relating to matters on the Agenda. Enclosed . To reconfirm current declarations on the Register of Interests are accurate and up-to- date.

3. MINUTES OF THE LAST MEETING HELD ON 22 MARCH 2018 AND MATTERS ARISING Chair Approve Enclosed

4. ACTION TRACKER Chair Discuss Enclosed

GOVERNANCE, FINANCE AND PERFORMANCE 5. 09:15 INTEGRATED PERFORMANCE AND QUALITY REPORT Director of Note Enclosed Operations

6. 09:35 WORKFORCE REPORT Director of Note Enclosed Workforce

7. 09:45 EEAST – INDEPENDENT SERVICE REVIEW (FINAL) Chief Finance Note Enclosed Officer (Appendix 1 Available Upon Request)

8. 09:55 DRAFT ANNUAL REPORT AND ACCOUNTS 2017/18 Chief Finance Approve Enclosed Officer

Page 1 of 3 Item Time Subject Report Action

9. 10:10 GOVERNANCE AND AUDIT COMMITTEE ANNUAL REPORT Lay Member – Note Enclosed Governance and Audit

10. 10:20 LOCALITY COMMITTEE ANNUAL REPORT 2017-18 Director of Approve Enclosed Commissioning

11. 10:30 PUBLIC ENGAGEMENT AND INVOLVEMENT STRATEGY AND ACTION PLAN Chief Executive Approve Enclosed

FOR INFORMATION 12. 10:40 THE PRIMARY CARE COMMISSIONING COMMITTEE (PCCC): PURPOSE AND FUNCTION Director for Note Enclosed Primary Care Development

13. 10:50 GOVERNANCE AND AUDIT COMMITTEE MINUTES Lay Member – Note Enclosed To note the Minutes of the meeting held on: Governance electronically . 14th March 2018 and Audit

14. JOINT COMMISSIONING PARTNERSHIP BOARD Director of Note Electronically MINUTES Commissioning Enclosed To note the Minutes of the meeting held on: . 26th October 2017 . 30th November 2017 . 11th January 2018 . 15th February 2018 . 15th March 2018

15. LOCALITY COMMISSIONING COMMITTEE MINUTES Director of Note Enclosed To note the Minutes of the locality meetings held on: Commissioning electronically . Lower Lea Valley – 7th March 2018 . Stevenage – 13th March 2018, . Stort Valley and Villages 7th December 2017 . Upper Lea Valley – 17th January 2018

16. 10:55 QUESTIONS FROM MEMBERS OF THE PUBLIC To receive any questions from members of the Chair Discuss Verbal public.

Page 2 of 3 Item Time Subject Report Action

17. ANY OTHER URGENT BUSINESS To consider any other matters which, in the opinion All Discuss Verbal of the Chair, should be considered as a matter of urgency.

18. 11:00 DATE OF NEXT MEETING Chair Note Verbal Thursday 26th July 2018 09:00am – 11:00am - Public Session

Focolare Centre, Meeting Room 1

Resolution to exclude members of the press and public The Governing Body of the Clinical Commissioning Group resolves that representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest, in accordance with the Public Bodies (Admissions to Meetings) Act 1960.

Page 3 of 3 Agenda Item No: 2

Date of Meeting: 24th May 2018

Governing Body Meeting in Public

Paper Title: Declarations of Interest

Decision or Approval Discussion Information

Report author: Maryla Hart, Governing Body Administrator

Report signed off by:

Executive Summary: The purpose of this paper is to receive any new declarations of interest or declarations relating to matters on the Agenda, and to reconfirm current declarations on the Register of Interests are accurate and up-to-date.

The following should be recorded in the minutes of the meeting:

 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.

Recommendations . To review the Register of Interests of the Governing Body or to the members: relevant committee membership, and highlight any potential conflicts, which the Chair needs to manage: http://www.enhertsccg.nhs.uk/declarations-interest

. To declare those interests at the start of the meeting. . To complete a declaration form available from the Company Secretary. This will be recorded in the Minutes of the meeting.

Conflicts of Interest . There are none identified. involved:

Page | 1 Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional benefit Professional Interests from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are not Personal Interests directly linked to their professional career and do not give rise to a direct financial benefit. 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.

Page | 2 Declarations of Interest Register 2018-19

Locality GP Surgery (If appropriate) First Name Last Name Current position(s) held in Declared Interest Type of interest: Is the Nature of Interest Date of Interest: Action taken to mitigate risk the CCG (Name of the organisation and nature Financial Non- Non- Indirect interest From: To: Date received i.e. Governing Body member; of business) financial financial interest direct or Committee member; Member professio personal indirect? practice; CCG employee or nal other

ULV THE LIMES SURGERY Mark Andrews GP Governing Body Hertfordshire Community NHS y Indirect Wife is employee of HCT (Hertfordshire 01/04/2017 Ongoing Declare interests as required 02/05/2018 Member, Representing Trust Community NHS Trust) as a Perinatal Upper Lea Valley Locality / Mental Health Lead. Chair of Upper Lea Valley Commissioning Board / Clinical Cancer and End of Life Lead

ULV THE LIMES SURGERY Mark Andrews GP Governing Body The Limes Surgery y Direct Salaried General Practitioner at the Limes 01/04/2018 31/03/2019 Declare interests as required 02/05/2018 Member, Representing Surgery. I no longer represent the Limes at Upper Lea Valley Locality / Locality Meetings. I am chair of Upper Lea Chair of Upper Lea Valley Valley Commissioning Board. Commissioning Board / Clinical Cancer and End of Life Lead

NH PORTMILL SURGERY Tara Belcher GP Governing Body The Portmill Surgery y Direct GP Partner providing commissioned 01/04/2007 Ongoing CCG delegated and I will not vote 17/01/2018 Member representing North 114 Queen Street, Hitchin, Herts services on commissioning matters – Herts Locality SG4 9TH mitigation embedded in CCG processes for all GP GB members

NH PORTMILL SURGERY Tara Belcher GP Governing Body 12 Point Care Ltd (company y Direct The Portmill Surgery has a share in the 25/09/2014 Ongoing I shall declare this verbally in any 17/01/2018 Member representing North number 09214266) local GP Federation, 12 Point Care Ltd. relevant discussion Herts Locality Kingston Smith LLP Shareholder is Dr M Cheung. The Orbital House, 20 Eastern Road, Federation may provide bid for services Romford, Essex RM1 3PJ commissioned by the CCG

NH PORTMILL SURGERY Tara Belcher GP Governing Body Health Education England y Direct GP Trainer (Health Education England) 03/10/2012 Ongoing Declaration 17/01/2018 Member representing North Herts Locality

NH PORTMILL SURGERY Tara Belcher GP Governing Body Central Midlands Area Team (NHS y Direct GP Appraiser 07/10/2016 Ongoing Declaration 17/01/2018 Member representing North England) Herts Locality

NH PORTMILL SURGERY Tara Belcher GP Governing Body Mills and Reeve LLP (company y Indirect Spouse Christopher Belcher is a Partner at 01/10/2009 Ongoing If there is a vote in which Mills & 17/01/2018 Member representing North number OC326165) Mills & Reeve LLP who have a contract Reeve have a financial interest I Herts Locality 4th Floor, Monument Place, 24 with ENHerts CCG and may bid for other shall abstain and declare verbally Monument Street, London EC3R legal work from this and other CCGs and to the Chair 8AJ Hospital Trusts.

LLV Director for Primary Care Denise Boardman Director for Primary Care Occupational Therapist y Direct As a registered Occupational Therapist and Sep-17 Ongoing Any requests received are 16/04/2018 Development, ENHCCG Development Royal College of Occupational former member of the Royal College of discussed in 1:1 meetings with my Therapy Occupational Therapy Professional line manager prior acceptance. Practice Board, I receive “ad hoc” requests to deliver presentations to specialist sections of the Royal College of Occupational Therapy.

LLV STANHOPE SURGERY Haydar Bolat GP Governing Body Stanhope Surgery. y Direct Governing Body Member / Locality Co- 01/05/2017 Ongoing Declare any relevant interests at 29/01/2018 Member representing Lower Chair: Lower Lea Valley / Practice meetings. Not to be present in Lea Valley Locality Representative at Locality deciding / voting meetings.

Page 1 of 10 Declarations of Interest Register 2018-19

LLV STANHOPE SURGERY Haydar Bolat GP Governing Body Lower Lea Valley Locality y Direct GP Partner, Stanhope Surgery. Both 23/08/2016 Ongoing Declare any relevant interests at 29/01/2018 Member representing Lower provider and commissioner. meetings. Not to be present in Lea Valley Locality deciding / voting meetings.

LLV STANHOPE SURGERY Haydar Bolat GP Governing Body LEA VALLEY HEALTH LTD y Direct Stanhope Surgery is a member of The 23/08/2016 Ongoing Declare any relevant interests at 29/01/2018 Member representing Lower (Locality Federation) Practice is a member of LEA VALLEY meetings. Not to be present in Lea Valley Locality Orbital House, 20 Eastern Road, HEALTH LTD deciding / voting meetings. Romford, Essex, RM1 3PJ Company number 09114753

LLV STANHOPE SURGERY Haydar Bolat GP Governing Body Dr Bolat Ltd, 3C Government Row, y Direct Director, Dr Bolat Ltd. (A company through Oct-13 Ongoing Declare any relevant interests at 29/01/2018 Member representing Lower Enfield, EN3 6JN Company which I perform locum work). meetings. Not to be present in Lea Valley Locality number 08683924 deciding / voting meetings.

LLV STANHOPE SURGERY Haydar Bolat GP Governing Body North MIDDLESEX University y Direct Employee at North MIDDLESEX University Aug-16 Ongoing Declare any relevant interests at 29/01/2018 Member representing Lower Hospital, Hospital. Urgent Care GP Sessions in A&E meetings. Not to be present in Lea Valley Locality N18 department. deciding / voting meetings.

WH Director of Commissioning - Harper Brown Director of Commissioning Harper Brown Consulting Ltd y Direct Director: Harper Brown Consulting Ltd 07/04/2014 Ongoing Declare conflict when it occurs 12/02/2018 ENHCCG Farm Cottages, Cardinals Green, Househeath, Cambridge, CB21 4QX. Company No: 08982673

WH Director of Commissioning - Harper Brown Director of Commissioning University of East Anglia, School y Direct Honorary Senior Lecturer 10/04/2012 Ongoing Declare conflict when it occurs 12/02/2018 ENHCCG of Health Economics, Norwich

Dianne Desmulie Lay Member - Co- Pieve Solutions Ltd Company No, y Direct & Director of my own company: Pieve Nov-14 Ongoing Provide new declaration of 21/02/2018 Commissioning 5600186. Registered Indirect Solutions Ltd. I have worked through this interest in event of either myself address: Orchard House, Park company as a freelance Management or my husband entering into a Lane, REIGATE, Surrey, RH2 8JX. Consultant. consultancy contract with a Nature of business: I have worked My husband, Robert Pinkham, is a supplier to the CCG through this company as a freelance management consultant and also freelance Management Consultant. a director of this company

Dianne Desmulie Lay Member - Co- Hoddesdon Carers' Support Hub y Direct I am the Volunteer Hub Lead for the Feb-16 Ongoing Declare non financial personal 21/02/2018 Commissioning Hoddesdon Carers' Support Hub. This is interest at any meeting where part of Carers in Hertfordshire, a charity contract or performance of CinH which contracts with Herts County Council (Carers in Hertfordshire) is to be and the CCG and NHS locally. This discussed particular project is funded by the Big Lottery.

Dianne Desmulie Lay Member - Co- Hanscombe House Patient y Direct I am a practice patient and a Member of Nov-14 Ongoing Declare non financial personal 21/02/2018 Commissioning Participation Core Group Hanscombe House Patient Participation interest where funding or Core Group. I am acting secretary for the performance of Hanscombe group. House practice is to be discussed

Page 2 of 10 Declarations of Interest Register 2018-19

SVV SOUTH STREET SURGERY Sarah Dixon GP Governing Body Member South Street Surgery y Direct GP Partner, South Street Surgery. Apr-18 Ongoing Declare conflict at meetings when 15/02/2018 representiong Stort Vally necessary and Villages

SVV SOUTH STREET SURGERY Sarah Dixon GP Governing Body Member Stort Valley and Villages (SVV) y Direct GP WorkForce and Education Lead for Apr-18 Ongoing Declare conflict at meetings when representiong Stort Vally Locality Stort Valley and Villages (SVV) necessary and Villages

SVV SOUTH STREET SURGERY Sarah Dixon GP Governing Body Member STORT VALLEY HEALTHCARE y Direct South Street Surgery Practice is a member Apr-18 Ongoing Declare conflict at meetings when 15/02/2018 representiong Stort Vally LIMITED of Locality Federation. necessary and Villages Registered office address - C/O GP Partner Dr Kwasi Appiah is a Federation Parsonage Surgery Hertfordshire Director & Essex Community Hospital, Cavell Drive, Bishops Stortford, Hertfordshire, United Kingdom, CM23 5JH Company number 09489615 (Locality Federation)

SVV SOUTH STREET SURGERY Sarah Dixon GP Governing Body Member West Essex Vocational Training y Direct GP Trainer West Essex Vocational Training Apr-18 Ongoing Declare conflict at meetings when representiong Stort Vally Scheme Scheme and Princess Alexandra Hospital necessary and Villages and Foundation Programme Princess Alexandra Hospital Foundation Programme

SVV SOUTH STREET SURGERY Sarah Dixon GP Governing Body Member NHS England – Midlands and East y Direct GP Appraiser Apr-18 Ongoing Declare conflict at meetings when representiong Stort Vally necessary and Villages

SVV SOUTH STREET SURGERY Sarah Dixon GP Governing Body Member GP Locality Lead for Medicines y Direct GP Locality Lead for Medicines Apr-18 28/05/2018 Declare conflict at meetings when representiong Stort Vally Management and GP Patient Management and GP Patient necessary. Stepping down from and Villages commissioning group commissioning group roles 28/05/2018

Page 3 of 10 Declarations of Interest Register 2018-19

SVV Director of Operations, Sharn Elton Director of Operations Nil 20/12/2017 ENHCCG

Linda Farrant Lay Member, Governance Ofsted y Direct Non Executive Board Member of Ofsted. Aug-11 Jan-18 As appropriate to situation 09/03/2018 and Audit

Linda Farrant Lay Member, Governance Audit Committee of Care Quality y Direct Independent Member of Audit Committee of Jul-15 Ongoing As appropriate to situation 09/03/2018 and Audit Commission (CQC) Care Quality Commission (CQC)

Linda Farrant Lay Member, Governance South Street Surgery, Bishop y Direct Patient of South Street Surgery 2001 Ongoing As appropriate to situation 09/03/2018 and Audit Stortford

Beverley Flowers Chief Executive Hertfordshire Criminal Justice y Direct Member of the Hertfordshire Criminal Jan-17 Ongoing None 20/12/2017 Board Justice Board representing the NHS.

Sachin Gupta GP Governing Body Member Garden City Practice, 11 Guessens y Direct Partner -Garden City Practice, 11 Guessens 01/11/2015 Ongoing Declare interests at meetings 11/02/2018 Representing WelHat Road, Welwyn Garden City, AL8 Road, Welwyn Garden City, AL8 6QW. GP where relevant. Locality. Locality Co-Chair 6QW. Partner since 01/08/2010. at WelHat Locality Meetings. Governing Body Member since 1st Nov 15. Nature of conflict: Member Practice of East and North Herts CCG.

WH GARDEN CITY PRACTICE Sachin Gupta GP Governing Body Member Ephedra Healthcare Ltd, Suite 3, y Direct Garden City Practice is a shareholder in 01/08/2010 Ongoing Declare interests at meetings 11/02/2018 Representing WelHat Middlesex House, Rutherfield Welwyn Hatfield GP Federation - Ephedra where relevant. Locality. Locality Co-Chair Close, Stevenage, SG1 2EF. Healthcare Ltd at WelHat Locality Meetings. Company No: 06560722 (Welwyn Hatfield GP Federation)

WH GARDEN CITY PRACTICE Sachin Gupta GP Governing Body Member SG Healthcare Limited. y Direct Director and shareholder in SG Healthcare 03/12/2012 Ongoing Declare interests at meetings 11/02/2018 Representing WelHat Registration No: 08316300 Limited. I do locum GP sessions, OOH and where relevant. Locality. Locality Co-Chair Address: Bracey's Accountants, Urgent Care sessions and GP appraisal at WelHat Locality Meetings. Wilbury Way, Hitchin, SG4 0TW. work through this company. No conflict I do locum GP sessions, OOH and perceived. Urgent Care sessions and GP appraisal work through this company.

WH GARDEN CITY PRACTICE Sachin Gupta GP Governing Body Member SG Healthcare Limited. Details y Indirect Wife is a Director of SG Healthcare Ltd 03/12/2012 Ongoing Declare interests at meetings 11/02/2018 Representing WelHat given above where relevant. Locality. Locality Co-Chair at WelHat Locality Meetings.

WH GARDEN CITY PRACTICE Sachin Gupta GP Governing Body Member Face and Skin Ltd. Company No: y Direct Director and shareholder. Face and Skin 22/01/2016 Ongoing No conflict perceived 11/02/2018 Representing WelHat 09964525. Address: Bracey's Ltd. No conflict perceived Locality. Locality Co-Chair Accountants, Wilbury Way, at WelHat Locality Meetings. Hitchin, SG4 0TW I provide non surgical aesthetic procedures through this company.

Page 4 of 10 Declarations of Interest Register 2018-19

WH GARDEN CITY PRACTICE Sachin Gupta GP Governing Body Member Pearl Blossom Ltd, Co. No. y Direct Director: Pearl Blossom Limited. SG 05/05/2016 Ongoing No conflict perceived as trading 11/02/2018 Representing WelHat 10163796. Incorporated Healthcare is a Shareholder in Pearl outside of Hertfordshire. Locality. Locality Co-Chair 05/05/2016. Address: Bracey's Blossom Ltd. No Conflict Perceived at WelHat Locality Meetings. Accountants, Wilbury Way, Hitchin, SG4 0TW. Provider of a residential nursing care home in Lincolnshire

WH GARDEN CITY PRACTICE Sachin Gupta GP Governing Body Member Amber Blossom Ltd, Co No y Direct Director: Amber Blossom Ltd. SG 16/03/2017 Ongoing No conflict perceived as trading 11/02/2018 Representing WelHat 10673689 Incorporated 16/03/2017. Healthcare is a Shareholder in Amber outside of Hertfordshire. Locality. Locality Co-Chair Address: Bracey's Accountants, Blossom Ltd. No conflict perceived. at WelHat Locality Meetings. Wilbury Way, Hitchin, SG4 0TW. Provider of a residential care home in Lincolnshire.

WH GARDEN CITY PRACTICE Sachin Gupta GP Governing Body Member Pearl Blossom Group Holding Ltd y Direct Director, Pearl Blossom Group Holding Ltd. 01/03/2017 Ongoing No conflict perceived as trading 11/02/2018 Representing WelHat Co no 10645623 No conflict perceived. outside of Hertfordshire. Locality. Locality Co-Chair Incorporated 01/03/2017 at WelHat Locality Meetings. Address Bracey's Accountants, Wilbury Way, Hitchin, SG4 0TW. Manages holdings of Amber Blossom Ltd and Pearl Blossom Ltd

WH GARDEN CITY PRACTICE Sachin Gupta GP Governing Body Member Jade Blossom Ltd, Co. No. y Direct Director: Jade Blossom Limited. Pearl 08/01/2018 Ongoing No conflict perceived as trading 11/02/2018 Representing WelHat 11137242. Incorporated 08/01/18. Blossom Group Holding Ltd has outside of Hertfordshire. Locality. Locality Co-Chair Address: Bracey's Accountants, shareholding in Jade Blossom Ltd. at WelHat Locality Meetings. Wilbury Way, Hitchin, SG4 0TW. No Conflict Perceived Company is not yet in business.

WH GARDEN CITY PRACTICE Sachin Gupta GP Governing Body Member NHS England y Direct I am a Disciplinary Specific Practitioner 01/01/2017 Ongoing No conflict perceived 11/02/2018 Representing WelHat (DSP) for NHS England – PAG Locality. Locality Co-Chair (Performance Advisory Group) meetings at WelHat Locality Meetings. and PLDP (Performers List Decision Making) Panel. No conflict perceived

WH GARDEN CITY PRACTICE Sachin Gupta GP Governing Body Member Beds and & Herts Local Medical y Direct I am working with Beds and & Herts Local 12/05/2017 Ongoing No conflict perceived 11/02/2018 Representing WelHat Committee (LMC) Medical Committee (LMC) on GPRP Locality. Locality Co-Chair (General Data Protection Regulation)- GP at WelHat Locality Meetings. Resilience Programme. I am undertaking practice visits under this programme. I am visiting practices outside ENHCCG. No conflict perceived Stevenag CHELLS SURGERY Russell Hall GP Board Member / Locality GP Practice, Chells Way, y Direct GP Partner, Chells Way Surgery. GP May-00 Ongoing Declare at meetings 01/02/2018 e Co-Chair Stevenage Stevenage, SG2 0NH Partner and Provider - GMS Services.

Stevenag CHELLS SURGERY Russell Hall GP Board Member / Locality Stevenage Health Ltd (Stevenage y Direct Chells Practice is a member of Stevenage Jul-15 Ongoing Declare at meetings 01/02/2018 e Co-Chair Stevenage Federation) Federation, a private company.

Page 5 of 10 Declarations of Interest Register 2018-19

LLV THE MAPLES Alison Jackson GP Governing Body Member The Maples Health Centre, y Direct Principle GP Partner at The Maples Health 01/04/2013 Ongoing Follow CCG conflict of interest 23/02/2018 / Locality Co-Chair: Lower Vancouver Road, Turnford, EN10 Centre. policy. Lea Valley 6FD Provider of GMS and Enhanced Services Declaring all interests at committees, meetings.

LLV THE MAPLES Alison Jackson GP Governing Body Member Lea Valley Health LTD, Orbital Financial Direct Both commissioner (locality representative) 01/07/2014 Ongoing I shall disclose this verbally, in 23/02/2018 / GP Governing Body House, 20 Eastern Road, Romford, and provider. any relevant discussions and Member/Locality Co-Chair: Essex, RM1 3PJ. Company meetings in accordance with CCG Lower Lea Valley number 09114753 The practice is a member of Lea Valley conflict of interest policy. Health Ltd.

ULV Medical Director, ENHCCG Rachel Joyce Medical Director Spire, Ramsay (Private Hospital) y y Direct Married to Ear, Nose and Throat Surgeon 2000 Ongoing Will declare any 14/02/2018 Indirect who works at Spire, Ramsay, Locally. potential interest at Income from Private Practice is shared. the start of any relevant meeting, to allow the Chair to manage the conflict. Will not be on any procurement panels for this specialty.

Stevenag STANMORE MEDICAL Pragasen Moodley GP Governing Body Member Stanmore Medical Group y Direct Principal GP Partner, 08/02/2004 Ongoing I declare this at meetings where 26/02/2018 e GROUP Representing Stevenage 5 Stanmore Road, Stevenage, SG1 Stanmore Medical Group relevant according to the statutory Locality 3QA [Canterbury Way Surgery & St Nicholas guidelines. / Locality Co-Chair Health Centre have both fully merged with Stevenage Locality the Stanmore Medical Group] Both provider and commissioner

Stevenag STANMORE MEDICAL Pragasen Moodley GP Governing Body Member Clinical Lead for Mental Health y Direct Clinical Lead for Mental Health (employed 01/04/2010 Ongoing I don't perceive any conflict of 26/02/2018 e GROUP Representing Stevenage (employed by ENHCCG) by ENHCCG) interest Locality / Locality Co-Chair Stevenage Locality

Stevenag STANMORE MEDICAL Pragasen Moodley GP Governing Body Member Nursing Homes y Direct I work as one of doctors from my practice 01/11/2014 Ongoing I declare this at meetings where 26/02/2018 e GROUP Representing Stevenage who provide extra cover for nursing relevant Locality homes. We provide additional ward rounds / Locality Co-Chair during the year and I usually assist with Stevenage Locality this. Service Commissioned by Locality and I am Locality Co-Lead.

Stevenag STANMORE MEDICAL Pragasen Moodley GP Governing Body Member Stevenage Health Limited, Dr. Raj y Direct My Practice is part of the Federation. 02/02/2012 Ongoing I declare this at meetings where 26/02/2018 e GROUP Representing Stevenage Kaja, The Health Centre, Stanmore Stevenage Health Limited. relevant Locality Road, Stevenage, Hertfordshire, I am not directly involved. / Locality Co-Chair England, SG1 3QA. Company Service Commissioned by Locality and I am Stevenage Locality number 08877494 (Federation) Locality Co-Lead.

Dermot O'Riordan Secondary Care West Suffolk NHS Foundation y Direct Consultant Surgeon & Chief Clinical Sep-01 Ongoing Declare in line with conflict of 22/03/2018 Representative Trust Information Officer, West Suffolk NHS FT interest policy.

Dermot O'Riordan Secondary Care Ipswich Hospital y Indirect My wife is a consultant surgeon at Ipswich 2015 Ongoing Declare in line with conflict of 22/03/2018 Representative Hospital interest policy.

Page 6 of 10 Declarations of Interest Register 2018-19

WH BRIDGE COTTAGE Hariharan Pathmanathan Chair Ephedra Healthcare Ltd, Suite 3, y Direct Ownership or part ownership of private 01/09/2014 Ongoing If discussions relating to Ephedra 31/01/2018 SURGERY Middlesex House, Rutherford companies, businesses or consultancies Healthcare Ltd were being Close, SG1 2EF. Co No: 06560722. likely or possibly seeking to do business discussed in a meeting I was with the CCG: attending I would declare this Practice is shareholder in Ephedra interest Healthcare Ltd,

WH BRIDGE COTTAGE Hariharan Pathmanathan Chair Bridge Cottage Surgery y Direct Practice receives ad hoc sponsorship of 01/09/2014 Ongoing None 31/01/2018 SURGERY clinical meetings by pharmaceutical companies.

WH BRIDGE COTTAGE Hariharan Pathmanathan Chair Sue Ryder Home y Direct Practice receives retainer from Sue Ryder 01/09/2014 Ongoing None 31/01/2018 SURGERY Home Role or relationship which the public could perceive would impair or otherwise influence the individual's judgement or actions in their role within the CCG.

WH BRIDGE COTTAGE Hariharan Pathmanathan Chair ENHCCG y Indirect Wife is a GP Principal in East and North 01/09/2014 Ongoing None 31/01/2018 SURGERY Herts CCG

WH BRIDGE COTTAGE Hariharan Pathmanathan Chair Bridge Cottage Surgery, 41 High y Direct GP Partner in Bridge Cottage Surgery 01/09/2014 Ongoing None 31/01/2018 SURGERY Street, Welwyn, AL6 9EF

NH Chief Finance Officer, Alan Pond Chief Finance Officer GP Partner in Herts Valleys CCG y y Indirect Partner (Corina Ciobanu) 01/08/2010 Ongoing If ENHCCG ever seeks to procure 11/12/2017 ENHCCG (Haverfield Surgery, Kings services from GPs and/or GP Langley) and Chair of Dacorum Surgeries outside the CCG, I will Locality keep confidential any information I receive that could be of benefit to Haverfield Surgery and/or Corina Ciobanu. Should Haverfield Surgery and/or Corina Ciobanu submit a proposal to undertake any work for ENHCCG I will declare this interest and will not take part in any discussions and/or decisions on any appointment.

Page 7 of 10 Declarations of Interest Register 2018-19

NH Chief Finance Officer, Alan Pond Chief Finance Officer Director of Assemble Community y Direct These companies form the LIFT (Local Jul-08 Ongoing My role on the Board of the LIFT 11/12/2017 ENHCCG Partnership Ltd (Company Improvement Finance Trust) for South East Company Group is to represent Number 06471276) and associated Midlands which was created to develop the interests of the local public companies community premises for the NHS. The sector, provide insight, but also to Assemble Fundco 2 Ltd (Company shares in the companies are held by oversee the financial and Number 08309498) Guildhouse Ltd and Community Health governance arrangements of the Assemble Holdco 2 Ltd (Company Partnership, the latter being a company companies. Number 08309495) wholly owned by the Department of Health. The Group of Companies was Wolverton Holdings (Company The directorship is unpaid, nominated by created to provide benefits to the Number 08307564) Community Health Partnerships and NHS locally and a conflict is Wolverton Fundco 1 Ltd represents the interests of the CCGs in the highly unlikely to occur. Should (Company Number 08306830 LIFT area, including East and North any conflict of interest arise, I Assemble Fundco 1 Ltd (Company Hertfordshire CCG. would excuse myself from both Number 06471659) parties for the relevant matter and Assemble Holdco 1 Ltd (Company should an Ongoing conflict arise Number 06471233) would resign my director position All of 128 Buckingham Palace with the Group of Companies Road, London, SW1W 9SA.

Stevenm Director of Nursing & Sheilagh Reavey Director of Nursing & Nil 19/12/2017 age Quality, ENHCCG Quality

WH WRAFTON HOUSE Ashish Shah GP Governing Body Member Wrafton House Surgery y Direct Principal GP and GP Trainer 01/11/2014 Ongoing Any conflict arising out of 08/02/2018 SURGERY representing WelHat 9-11 Wellfield Road Wrafton House Surgery. Both provider and discussions regarding same at Locality. Locality Chair – Hatfield commissioner. meetings will be raised at the WelHat Locality AL1 OBS meeting.

WH WRAFTON HOUSE Ashish Shah GP Governing Body Member Abhirush Limited. y Direct Director (Joined) of Abhirush Limited. I 01/11/2014 Ongoing Any conflict arising out of 08/02/2018 SURGERY representing WelHat Company registered address work through the Limited Company as an discussions regarding same at Locality. Locality Chair – 5 Chedburgh Out of Hours GP at Herts Urgent Care. meetings will be raised at the WelHat Locality Welwyn Garden City meeting. AL7 2PU. Company No: 07998120 Nature of Business: I work through the Limited Company as an Out of Hours GP at Herts Urgent Care.

WH WRAFTON HOUSE Ashish Shah GP Governing Body Member Ephedra Healthcare Ltd, Suite 3, y Direct Principal GP at Wrafton House Surgery. 01/11/2014 Ongoing Any conflict arising out of 08/02/2018 SURGERY representing WelHat Middlesex House, Rutherford Practice is a Shareholder of Ephedra discussions regarding same at Locality. Locality Chair – Close, Stevenage, Herts, SG1 2EF. Healthcare Limited, which is a local meetings will be raised at the WelHat Locality Company no: 06560722 federation for WelHat Locality. meeting. Ephedra Healthcare Ltd.

Page 8 of 10 Declarations of Interest Register 2018-19

WH WRAFTON HOUSE Ashish Shah GP Governing Body Member Locality Lead for Workforce y Direct I Work as a Locality Lead for Workforce 01/01/2016 Ongoing Any conflict arising out of 08/02/2018 SURGERY representing WelHat Planning and Educational Network Planning and Educational Network for discussions regarding same at Locality. Locality Chair – for ENHCCG. ENHCCG. meetings will be raised at the WelHat Locality meeting.

WH WRAFTON HOUSE Ashish Shah GP Governing Body Member GP Partner, locum and Out of y Indirect Wife works as a GP Partner, locum and Out 01/11/2014 Ongoing Any conflict arising out of 08/02/2018 SURGERY representing WelHat Hours GP in Hertfordshire of Hours GP in Hertfordshire. discussions regarding same at Locality. Locality Chair – meetings will be raised at the WelHat Locality meeting.

SVV SOUTH STREET SURGERY Nabeil Shukur GP Board Member South Street Surgery y Direct GP Partner, South Street Surgery 2001 Ongoing I need to declare when any 24/02/2018 83 South Street Nature of conflict: Primary Care Provider discussion about the benefit to Bishops Stortford practices and CCG investment in Herts Bishops Stortford primary care CM23 3AP

SVV SOUTH STREET SURGERY Nabeil Shukur GP Board Member NHA Medical Ltd y Direct & Director and 20% shareholder. NHA Medical 2012 Ongoing I need declare when any 24/02/2018 4 Beech Drive Indirect Ltd discussion is related to the above Sawbridgeworth two specialities and if for any CM21 0AA Provides Musculoskeletal Services and reason there is a discussion about Co No: 08386895. Dermatology services. I am MSK provide.r NHA medical Provides Musculoskeletal My wife a is a dermatology provider. Services (MSK) and Dermatology services.

SVV SOUTH STREET SURGERY Nabeil Shukur GP Board Member NHA Medical Ltd y Indirect Wife and son are both directors and 2012 Ongoing I will declare if there is any thing 24/02/2018 4 Beech Drive shareholders. related to NHA medical or the Sawbridgeworth above two specialities mentioned CM21 0AA Co No: 08386895. Provides Musculoskeletal Services and Dermatology services.

SVV SOUTH STREET SURGERY Nabeil Shukur GP Board Member GP with Special Interest in y Direct GP with Special Interest in orthopaedics. 2006 Ongoing Need to be declare if there is any 24/02/2018 orthopaedics. service redesign or procurement for MSK service

SVV SOUTH STREET SURGERY Nabeil Shukur GP Board Member Clinical Referral Service. Provided y Indirect GPSI (GP with Special Interest) contracted 2013 Ongoing As above with contracts related to 24/02/2018 by Stellar Health Care Ltd, by the Stellar Health Care MSK 4 Spencer Close, Epping, Essex, I am not employed by Stellar CM16 6TN. Health Care

SVV SOUTH STREET SURGERY Nabeil Shukur GP Board Member STORT VALLEY HEALTHCARE y Indirect My practice is part of federation: 2014 Ongoing I will need to declare if there is 24/02/2018 LIMITED STORT VALLEY HEALTHCARE LIMITED discussion bout awarding Orbital House, 20 Eastern Road, contract to Stort Valley Health or Romford, Essex, RM1 3PJ any discussion about making Company number 09114753 changes which makes them favourable

Page 9 of 10 Declarations of Interest Register 2018-19

ULV CHURCH STREET SURGERY Nicky Williams Deputy Clinical Chair CCG / Church Street Surgery, Ware y y Direct GP Partner: Church Street Surgery, Ware. 1997 Ongoing As appropriate to situation 04/01/2018 GP Governing Body Member Lower Lea Valley

ULV CHURCH STREET SURGERY Nicky Williams Deputy Clinical Chair CCG / GENERATING HEALTHCARE y y Direct GP Practice is member of Local GP 2013 Ongoing As appropriate to situation 04/01/2018 GP Governing Body Member LIMITED Company number Federation, GENERATING HEALTHCARE Lower Lea Valley 08830754 (GP Federation) LIMITED

Page 10 of 10 Agenda Item No: 3

Date of Meeting: 24th May 2018

Governing Body Meeting in Public

Paper Title: Draft – Governing Body Minutes

Decision or Approval Discussion Information

Report author: Tracey Middleton, Governing Body Clerk Maryla Hart, Governing Body Administrator Report signed off by: Jas Dosanjh, Corporate Governance Manager

Executive Summary: To approve the draft Minutes of the meeting held on 22nd March 2018.

Recommendations . To approve the Minutes. to the members:

Conflicts of Interest . There are none identified. involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Page | 1 Governing Body Public Meeting Thursday 22nd March 2018 Focolare Centre (Meeting Room 1) – Welwyn Garden City

MINUTES Present: Mark Andrews [MA] GP Lead, Upper Lea Valley Tara Belcher [TB] GP Lead, North Herts. Haydar Bolat [HBo] GP Lead, Lower Lea Valley Harper Brown [HB] Director of Commissioning Dianne Desmulie [DD] Lay Member, Patient and Public Engagement Sharn Elton [SE] Director of Operations Linda Farrant [LF] Lay Member, Governance and Audit Beverley Flowers [BF] Chief Executive (Accountable Officer) Sachin Gupta [SG] GP Lead, Welwyn and Hatfield Russell Hall [RH] GP Lead, Stevenage Rachel Joyce [RJ] Medical Director Prag Moodley [PM] GP Lead, Stevenage Dermot O’Riordan [DO] Secondary Care Specialist Hari Pathmanathan [HP] Chair Sheilagh Reavey [SR] Director of Nursing and Quality Alan Pond [AP] Chief Finance Officer Nabeil Shukur [NS] GP Lead, Stort Valley and Villages Yvette Twumasi-Ankrah [YT] Lay Member, Co-Commissioning Nicky Williams [NW] Deputy Chair

In Attendance:

Denise Boardman [DB] Programme Director Peter Chapman [PC] Patient Representative Paul Curry [PC] Equality and Diversity Lead Sarah Feal [SF] Company Secretary James Gleed [JG] Associate Director Primary Care

Page 1 of 11 Tracey Middleton [TM] Governing Body Administrator Gerry Moir [GM] Associate Director Performance Sue Russell [SR] Lead Pharmacist Hein Scheffer [HS] Director of Workforce Michael Taylor [MT] Patient Representative

Page 2 of 11 Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE The meeting opened at: 09.06 The Chair welcomed all to the meeting

1. It was noted that this was YT’s final meeting and thanks were extended to YT for her contribution to the Governing Body 2. It was agreed that the agenda will be organised according to presenter availability

Apologies were received from

• Ashish Shah [AS] GP Lead, Welwyn and Hatfield

The Chair declared that the meeting was quorate

2. DECLARATIONS OF INTERESTS

The Chair invited members to declare any declarations relating to matters on the Agenda.

1. Item 9 – Prescribing Report • Non-financial interest - Dr Ashish Shah is a partner in Wrafton House Surgery, Welwyn & Hatfield Locality whose data is included in the Locality totals. • Financial interest - All GP Board members who have prescribed in the period of the report will have contributed to the data included. • Financial interest - GP Board representatives’ practices are members of Locality federations which are private companies which may provide CCG - commissioned services 2. The Chair agreed that colleagues could remain in the meeting during this agenda item as the item was for information, and not for decision. 3. All other members confirmed they have no declarations in relation to matters on the Agenda.

The Chair invited the members to reconfirm their current declarations on the Register of Interests and advise of any new declarations.

4. All members confirmed their declarations were accurate and up- to-date.

Page 3 of 11 Item Subject Action by 3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING

The Minutes of the Governing Body in Public meeting held on 18th January 2018 were approved as an accurate record subject to the following amendment being made

1. Item 19 - Any Other Business, to read The Governing Body was advised that there will be minimal impact from Carillion’s current difficulties however, it is noted that the Mount Prison relies on Carillion Services

ACTION: The final minutes of the previous meeting held to be MH updated to reflect amendments

4. ACTION TRACKER

The contents of the Action Tracker were discussed.

The following actions were agreed to be closed:

1. Actions 18, 20 and 23: Integrated Performance and Quality Report 2. Action 21: Locality Committee Annual Report

ACTION: The Action Tracker to be updated to reflect the updates MH

GOVERNANCE, FINANCE AND PERFORMANCE 5. INTEGRATED PERFORMANCE AND QUALITY REPORT

The Integrated Performance and Quality Report was presented and it was noted that the information is predominantly for the December position. Areas highlighted included:

NHS Constitution 1. Referral to Treatment (RTT) – 18 weeks referral to treatment - 92% of patients to have been waiting under 18 weeks for treatment 2. East and North Herts NHS Trust (ENHT) is expected to be off national reporting until November for RTT and diagnostic waits. This was further discussed. At CCG level the number of 52 week wait breaches has reduced from 11 in December to 1 in January 3. Cancer – At CCG level, 2 week wait standards and 31 day and 62 day standard to first definitive treatment were all achieved for December for the first time in 2017/18. Although performance dropped in January, ENHT is still confident of meeting 85%

Page 4 of 11 Item Subject Action by against the 62 day standard for March. All cancer standards continue to be met at Princess Alexandra Hospital NHS Trust (PAH) 4. Sustainability and Transformation Partnership (STP) Funding – funding has been announced from the Cancer Alliance and bids have been submitted by the STP covering ENHT, PAH and West Herts HHS Trusts. Work is ongoing in relation to the timed pathways work for lung and prostate cancer.

Accident & Emergency (A&E) 5. Nationally A&E performance remains challenging and this is also the case at both ENHT and PAH. 6. Nationally the requirement for all trusts to be delivering the 95% standard has been pushed back with trusts now expected to meet 90% by September 2018 and 95% by March 2019.

Ambulance 7. Performance has fallen in January against the new ambulance metrics as a consequence of a very challenging winter for East of England Ambulance Service NHS Trust (EEAST). Discussions are being held nationally and locally to work collaboratively with NHS 111 providers to reduce the number of C3 and C4 ambulance dispositions.

Mental Health 8. Improving Access to Psychological Therapies (IAPT). All access and recovery and waiting times targets continue to be met.

Dementia 9. Recorded as 64.1% for January - still not meeting target of 67.7% Actions to improve performance were outlined

Positive Behaviour, Autism, Learning Disability and Mental Health Service (PALMS) Herts Community NHS Trust (HCT)

10. Demand for PALMS is outside the capacity for the service which has increased waiting times. Additional money has been allocated but HCT has struggled to recruit and retain staff although are looking at recruitment strategies. A wider issue is the number of children and young people with challenging behaviour which is being looked at from a system wide perspective.

Further discussion 11. The purpose of the Locality Scorecard was debated and it was noted that it would be helpful to provide national averages where available 12. ACTION: Content of the locality packs to be reviewed at a Governing Body Workshop to determine what should be DB included in the Public meeting including Practice

Page 5 of 11 Item Subject Action by Performance. 13. ACTION: Now that the CCG is in Delegated Commissioning, DB the executive to review what primary care data/information can be shared in public. 14. Discussion noted that there is no correlation between high prescribing practices and Clostridium Difficile. Each case is reviewed by the Trust. A different approach has been discussed with Acute Directors of Nursing. Root cause analysis submission is being interrogated. The Appeals Process and fines were explained 15. ACTION: Governing Body Workshop discussion on Clostridium Difficile to be arranged SR 16. A&E performance has been escalated and the Trust was praised for the work it is undertaking in increasing performance 17. Following the publication of the Care Quality Commission (CQC) report, PAH is now out of special measures. 18. ENHT is currently being inspected by the CQC

The Governing Body noted the report

6. CHIEF EXECUTIVE’S REPORT

The report provided information on activities undertaken by the Clinical Commissioning Group and further discussion included:

1. A letter has been received from the Human Rights Commission regarding the Continuing Health Care Policy. Due diligence is being undertaken and the Policy is being reviewed. Interim minor amendments are being made to the Policy 2. The Nascot Lawn Judicial Review was outlined in detail and the Governing Body noted that there has been engagement 3. The Vanguard celebration was well attended and thanks were extended to the team for its contribution. The feedback and video will be shared at a future public meeting. It was noted that future event details will be made available to the Governing Body 4. The Future Heroes school event was successful and photographs will be added to the CCG website

The Governing Body noted the report

7. GOVERNANCE REPORT

The Governance Report was presented as detailed:

1. It was noted that the register of risks is well managed 2. Non-compliance with the Declaration of Interest Process by GPs will be escalated by the Chair for resolution

Page 6 of 11 Item Subject Action by 3. The Data Protection Officer line management arrangements were outlined 4. The on-line training date has been published

The Governing Body noted and ratified the decisions made at the Governing Body Workshops.

The Governing Body noted the report from the Governance and Audit Committee.

The Governing Body noted the updated Strategic Risk Register and Risk Controls Assurance Dashboard, including actions agreed by the Executive Team.

The Governing Body received the Register of Interests and Register of Gifts and Hospitality reported in 2017-18.

The Governing Body agreed to complete the new piece of conflicts of interest mandatory training by 30 April 2018.

The Governing Body designated the Company Secretary, as the Data Protection Officer.

8. FINANCE REPORT

The Finance Report Month 10 2017/18, which provided an update of the finance position as at the end of January 2018, was reviewed

The Finance Plan 2018/19 was reviewed

1. Assurance was provided that the position will be reached 2. The recent release of funding and clawback was outlined 3. The control total was referred to and the requirement should funding not be forthcoming challenged. The cumulative position was clarified SG arrived at 10.04 4. The response to the late release of funding will be further discussed 5. The Finance Plan was outlined as detailed in the paper 6. The planning assumptions were questioned and it was noted that the NHS expectations were negotiated in line with previous imbalance 7. The national and local expectations were referred to in terms of assessment capacity 8. The indemnity regarding non weighted allocation was outlined 9. ACTION: Quality, Innovation, Productivity and Prevention (QIPP) programme discussion to be undertaken in a AP Workshop 10. The criteria for patient transport was explained

Page 7 of 11 Item Subject Action by The Governing Body noted the Finance Report

FINANCIAL PLAN

The Governing Body approved the draft budgets for 2018/19 as proposed in the Financial Plan

9. PRESCRIBING REPORT BF left the meeting at 10.09 – 10.13 The Prescribing Report was presented to the Governing Body

1. Antibacterial prescribing is being addressed well and colleagues were acknowledged for their contribution 2. An increase in numbers of patients diagnosed with Type 2 diabetes is, and will continue to impact on resources and individual care planning is a focus. This, combined with new treatments will introduce a significant cost pressure. JG arrived at 10.15 3. Reference was made to the key performance indicators in the CCG prescribing QIPP plan and how growth in patient numbers affected cost reductions. The savings on respiratory drugs are on target. The Governing Body debated the impact of user feedback including prescribing products used within homes 4. RJ mentioned that there was a need to prioritise a piece of work that supports the administration of non-prescribed medicines by care workers 5. Bariatric surgery was discussed in relation to increasing numbers of patients with Type 2 Diabetes. 6. The issue of the wide range of acceptance rates of ScriptSwitch messages by practices was raised. SR explained that this can be due to technology issues in a practice but is also prescriber- dependent. TB explained that there is an element of ’learned behaviours’ by clinicians which affects the number of times the software is triggered. SR left the meeting at 10.20 The Governing Body noted the financial position as at December 31st 2017 and noted the work undertaken by practices and the Pharmacy Medicines Optimisation Team (PMOT) to provide quality services to our population, within available resources

11. NATIONAL STAFF SURVEY 2018 - BRIEFING

The National Staff Survey 2018 Briefing was presented to the Governing Body. The briefing summarised the top and bottom findings of the NHS National Staff Survey in comparison to other CCGs who partook in the survey.

Page 8 of 11 Item Subject Action by RH left the meeting 10.22 - 10.25 1. The details of the survey have been interrogated and facilitated sessions with staff undertaken 2. The Governing Body agreed this is a helpful survey and discussed how individual markers and overall scores can be addressed 3. It was noted that individual reports have not been formally received, yet incidents have been recorded. This indicates that staff feel that they can report incidents but have not done so. 4. The subjective nature of terminology was referred to 5. ACTION: It was requested that trends of the first indicator are reported in more detail and actions taken identified HS

The Governing Body approved the briefing and agreed to monitor the next steps as detailed in the report

12. EAST AND NOTH HERTS CCG GENDER PAY GAP REPORT

The Governing Body was provided with an update on the strategy:

1. Comparisons with neighbouring authorities were shared and it was noted that there are no discrepancies to report 2. ACTION: The data to be added to the Government Website PC today

The Governing Body noted the findings of the Gender Pay Gap analysis, produced as required by the Equality Act 2010 (Specific Duties and Public Authorities) Regulations 2017 HS, PC left the meeting at 10.38

10. SEASONAL FLU REPORT 2017/8 The Seasonal Flu Report was presented to the Governing Body:

1. The communication from Pharmacies was referred to and it was noted that software has been purchased to liaise with the Practices 2. The locality allocation funding was referred to and impact questioned and it was noted that recommendations have been made for next year regarding incentives and collaborative working 3. ACTION: Paper to be returned for discussion in June JG

The Governing Body noted the report JG left the meeting at 10.46

Page 9 of 11 Item Subject Action by 13. GOVERNANCE AND AUDIT COMMITTEE MINUTES

The minutes of the meeting dated 10th January 2018 were introduced to the Governing Body

The Governing Body noted the minutes

14. HBL ICT STAKEHOLDER BOARD MINUTES

The minutes of the meetings dated 18th December 2017 and 15th January 2018 were introduced to the Governing Body

1. The patient WIFI funding was questioned and it was noted that it should be available to patients in GP practices

The Governing Body noted the minutes

15. JOINT CO-COMMISSIONING COMMITTEE MINUTES

The minutes of the meetings dated 12th October 2017 and 25th January 2018 were introduced to the Governing Body

The Governing Body noted the minutes

16. LOCALITY COMMITTEE MINUTES

The minutes of the following meetings were introduced to the Governing Body

1. Lower Lea Valley – 11 January 2018 2. North Hertfordshire – 8 November 2017, 17 January 2018 3. Stevenage – 12 December 2017, 16 January 2018, 6 February 2019 4. Upper Lea Valley – 15 November 2017 5. Welwyn and Hatfield – 12 October 2017

The Governing Body noted the minutes

17. QUESTIONS FROM THE PUBLIC

No members of the public in attendance

Page 10 of 11 Item Subject Action by 18. ANY OTHER BUSINESS 1. A Quality Assurance Team visited the Lister Hospital and an overview was provided. The thoroughness and effectiveness of colleagues was complimented 2. The Governing Body agreed that this work contributes to quality improvement and the impact of a limited resource is noted

19. DATE OF NEXT MEETING:

Thursday 24th May 2018 09:00am – 11:00am

Focolare Centre, Meeting Room 1 The meeting closed at 11.07

Page 11 of 11 Agenda Item No: 4

Date of Meeting: 24th May 2018

Governing Body Meeting in Public

Paper Title: Action Tracker

Decision or Approval Discussion Information

Report author: Maryla Hart, Governing Body Administrator Tracey Middleton, Governing Body Clerk Report signed off by: Nakiya Jafferji, Corporate Governance Manager

Executive Summary: The purpose of this paper is to discuss the Action Tracker.

Recommendations . To discuss the Action Tracker. to the members:

Conflicts of Interest . There are none identified. involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Page | 1 Governing Body in Public Action Tracker

No. Meeting Date Item No. and Title Action Responsible Manager Past deadlines Deadline Current Position Status (Since Revised)

22 18/01/2018 10. Equality and Qualitative Data was identified regarding British Minority Director of Workforce 31/08/2018 13/03/2018: Work has started on the findings around BME recruitment. A Close on Diversity Annual Report Ethnic (BME) and Reasons for Leaving Correlations. This meeting has been arranged with Louise Dent, Recruitment and HR 2018-05-24 data is to be further explored Operations Manager, for 21 March to look at the recruitment process and where there may be scope for differing outcomes. This will guide further work. Work on the reasons for BME staff leaving and retention or younger employees is linked to on going work on appraisals and talent development. We will continue to monitor these areas to identify where, and how, we may be able to improve retention, where appropriate. When looking at work/life balance we saw a reduction in the number of female employees working part time but an increase in the number of male employees working part time. This indicates an awareness of the part time working offer, and we will continue to monitor this. This action can be closed. 22/04/2018: Ongoing 15/05/2018: HR has looked into the recruitment side and will be proposing actions to go into the new Equality and Diversity Action Plan when that’s written. The other areas are about monitoring and picking up on what comes out of the monitoring. There will be nothing new to report until the Equality Action Plan is presented. The latest the Equality Action Plan will be written and published; following agreement of the GB will be March 2019. That means that HR can link monitoring data and workforce equality data that we bring to GB in 01/2019 into the report. There are plans to have an action plan in place by the end of August 2018. The action can be closed.

27 22/03/2018 12. Gender pay gap The data to be added to the government website today Director of Workforce / 22/03/2018 22/03/2018: Information has been added to the government Close on 2018-05- Equality and Diversity website. 24 Lead

28 22/03/2018 10. Seasonal Flu Paper to be returned for discussion in June Director of 31/06/2018 22/03/2018: Flu paper scheduled for 21st June GB Workshop. Close on 2018-05- Commissioning / AD This will be a new paper and set out proposals for the flu action 24 Commissioning Primary plan for 2018-19. Care

25b 22/03/2018 5. Integrated Now that the CCG is in Delegated Commissioning, the Director for Primary Care 07/06/2018 11/05/2018: This is still work in progress. A Paper regarding Open Performance And executive to review what primary care data/information can be Development this issue to be presented at the next PCCC meeting on Quality Report shared in public. 07/06/2018.

24 22/03/2018 5. Integrated Workshop discussion on Clostridium Difficile to be arranged Director of Nursing 21/06/2018 28/03/2018: This is on the GB Workshop agenda for 10/05/2018. Open Performance And 08/05/2018: This discussion will now take place at the Quality Report Governing Body Workshop on 21/06/2018.

Page 1 of 2 Governing Body in Public Action Tracker

29 22/03/2018 8. Financial Plan QIPP discussion to be undertaken in a Workshop CFO 30/06/2018 08/05/2018: This discussion will now take place at the Open Governing Body Workshop on 21/06/2018.

25a 22/03/2018 5. Integrated Content of the Locality pack to be reviewed at a Governing Director for Primary Care 31/08/2018 23/04/2018: The Locality Packs to be reviewed at Governing Body Open Performance And Body Workshop to determine what should be included in the Development / Medical Workshop on 10/05/2018. Quality Report Public meeting including Practice Performance Director 11/05/2018: Locality Packs to now come under the Medical Director's Team. Dr Linda Mercy will be reviewing locality packs. Director for Primary Care Development to stay involved.

26 22/03/2018 11. National Staff Survey It was requested that trends of the first indicator are reported Director of Workforce TBA by the 18/05/2018: Update to be given at GB meeting on 24/05/2018. Open in more detail and actions taken identified Director of Workforce

Page 2 of 2 Agenda Item No: 5

Date of Meeting: 24th May 2018

Governing Body Meeting in Public

Paper Title: Integrated Performance and Quality Report

Decision or Approval Discussion Information

Report author: Rosie Connolly – Quality Manager Claire Jackson – Clinical Quality Manager Jo O’Connor – Head of Performance Report signed off by: Sharn Elton – Director of Operations

Executive Summary: This Integrated Performance and Quality report provides an update on the performance and quality of local NHS Trusts in relation to key national performance standards. It includes quality and performance information at CCG level and also at provider level (ENHT, PAH, BCF, HCT, EEAST, HPFT, HUC, TPP and Private Providers).

The performance and quality metrics included within the report are published information predominantly for the February position. All metrics have been included with commentary for exceptions where performance standards have not been met.

Recommendations . To note to the members:

Conflicts of Interest None to declare. involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Page | 1 Non-Financial This is where an individual may benefit personally in ways which are not Personal Interests directly linked to their professional career and do not give rise to a direct financial benefit. 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.

1. Executive summary (half page maximum)

This Integrated Performance and Quality report provides an update on the performance and quality of local NHS Trusts in relation to key national performance standards. It includes quality and performance information at CCG level and also at provider level (ENHT, PAH, BCF, HCT, EEAST, HPFT, HUC, TPP and Private Providers).

2. Background N/A

3. Issues N/A

4. Options N/A

5. Resources implications N/A

6. Risks/Mitigation Measures N/A

7. Recommendations

. To note

8. Next Steps (including when the decision will be reviewed) N/A

Page | 2 Integrated Performance and Quality Report

May 2018 Contents |

Description Page Number Introduction 3 NHS Constitution - CCG Level 6 Provider Profiles 22 ENHT 23 PAH 40 RFH 55 HCT 59 EEAST 70 HPFT 79 HUC 91 TPP 104 Private Providers 105 Glossary 108

2 Introduction| This Integrated Performance and Quality report provides an update on the performance and quality of local NHS Trusts in relation to key national performance standards. It includes quality and performance information at CCG level and also at provider level.

A glossary of terms used in this report is provided in the back of this document.

In this report the published metrics being reported are for February 2018 unless stated otherwise.

Data Sources • Cancer Open Exeter data • Stroke SSNAP • RTT, A&E, Diagnostics, MSA, FFT, DToC and Cancelled Operations UNIFY2 data • Ambulance, DToC , Stroke, HPFT, HUC Trust Reports • HCAI, Safer Staffing, SI’s, Safeguarding, LAC ENHCCG Quality Dashboard

Please note: all Trust data is looking at the Trust wide position unless stated as ENHCCG only data.

Key: ‘Increase/ decrease in performance from last period’ denotes the change in performance from the previous period:  Improvement/Increased performance/activity compared to prior period;  Deterioration/reduced performance/activity compared to prior period;

 No Change

‘Movement’ denotes increase/decrease in figures from previous period: + Increase in numbers from the previous period - Decrease in numbers from the previous period 3 Headline Summary Outlined below is a summary of the key areas of concern and underperformance that the CCG Governing Body need to be aware of. Detailed commentary is provided for each of the areas listed within the report. CCG

1. Referral to Treatment Slide 10 5. Mental Health Slide 15 2. Cancer Waits Slide 11 6. Dementia Slide 17 3. Accident & Emergency Slide 13 6. HCAI Slide 18 4. Ambulance Performance Slide 14 7. Safeguarding Adults Slide 20 8. Safeguarding Children Slide 21

Acute Trusts ENHT PAH RFH 1. Stroke Slide 25 1. Referral to Treatment Slide 42 1. Summary Slide 57 2. Cancer Waits Slide 26 2. Cancer Waits Slide 44 Cancer waits 3. Accident & Emergency Slide 28 3. Accident & Emergency Slide 45 Diagnostics 4. Ambulance Handovers Slide 29 4. Ambulance Handovers Slide 46 A&E 5. Cancelled Ops & Outpatients Slide 30 5. Serious Incidents Slide 47 RTT 6. Serious Incidents Slide 31 6. HCAI Slide 48 C-Diff &MRSA 7. HCAI Slide 32 7. Maternity Slide 49 Never events 8. Friends and Family Slide 33 8. MSA Slide 50 Pressure Ulcers 9. Pressure Ulcers Slide 34 9. Friends and Family Slide 51 Workforce 10. Maternity Slide 35 10. Workforce Slide 52 11. Workforce Slide 36 11. Safer Staffing Slide 53 12. Safer Staffing Slide 38 12. Other Slide 54 13. Other Slide 39 Other Providers HCT EEAST HPFT HUC 1. ALOS Slide 60 1. AQIs Slide 71 1. Monitor Slide 81 1. Integrated Urgent Care Slide 93 2. DToCs Slide 61 2. Response Times Slide 73 2. Access Slide 82 2. Serious Incidents Slide 101 3. EDD Slide 62 3. Turnaround Times Slide 75 3. Safe & Effective Slide 83 3. Workforce Slide 102 4. Serious Incidents Slide 63 4. Work Force Slide 77 4. CAMHS Slide 85 4. Rota Fill Slide 103 5. Workforce Slide 64 5. Other Slide 78 5. Serious Incidents Slide 87 6. Safer Staffing Slide 66 6. Workforce Slide 88 7. PALMS Slide 67 7. Other Slide 90

TPP Slide 104 Private Providers Slide 105 4 Key Headlines ׀ Comments

A&E There is a national requirement that 95% of patients attending A&E are treated, admitted or transferred within 4 hours of arrival. Nationally there is an expectation that all Trusts will meet 90% by September 2018 and 95% by March 2019. Performance in January was much improved at over 80% at both ENHT and at CCG level and although February performance dipped, March performance was back above 80% at ENHT.

Stroke For ENHT, the 90% of time on a stroke unit target continues to be met although we saw performance dip under 70% from January – March 18 in the 4 hours direct to stroke unit target.

RTT Under the NHS constitution there is a performance target related to patients still waiting for treatment; the target being that 92% are to have been waiting for less than 18 weeks. Given the large number of ENHCCG patients being referred to ENHT, performance at CCG level is largely influenced by performance at the Trust. In agreement with NHS Improvement, ENHT is currently off national reporting until November 2018 for RTT, 52 weeks and diagnostic waits. Without ENHT figures, the CCG figures are incomplete and have therefore been removed from the IPQR until ENHT resume reporting. RTT performance was not met at PAH for January or February for the first time in 2017/18.

Cancer Under the NHS constitution, there is a performance target related to cancer waiting times; the target being that 85% are to have had their first definitive treatment within 62 days of being referred on a cancer pathway. Performance continues to improve against the 62 day standard; ENHT recorded the highest performance since April 2015 in Feb at 84.4% post adjustment for late referrals. In March performance dipped again slightly at 80.90% post adjustment but remained higher from all months previous in year.

5 NHS Constitution Scorecard

Increase/ decrease in YTD Description Target Month performance Current Prior Actual Month Month from last Month

Consultant Led Referral to Treatment Times (RTT) Admitted patients None Feb 80.1% 79.6% 80.1%  Non-admitted patients None Feb 92.1% 93.5% 92.1%  Incomplete pathways 92% Feb 90.2% 90.2% 90.2%  Patients waiting at the end of the month None Feb 16,905 16,902 16,905  Number of 52 week breaches 0 Feb 4 1 4 

Diagnostic waiting times

Total number on waiting list None Feb 2,808 2,825 2,808  No patient should wait > 6 weeks 99% Feb 99.11% 98.48% 99.11% 

Cancer waits 2 weeks for urgent cancer GP referrals 93% Mar 96.91% 97.73% 97.43%  2 weeks for urgent breast symptom referrals 93% Mar 93.78% 100.00% 94.69%  31 days to first definitive treatment for all cancers 96% Mar 98.36% 95.58% 96.33%  31 days for subsequent surgery 94% Mar 97.50% 100.00% 93.00%  31 days for subsequent drug 98% Mar 98.63% 100.00% 96.79%  31 days for subsequent radiotherapy 94% Mar 95.12% 95.71% 94.01%  62 days to first definitive treatment for all cancers 85% Mar 82.35% 83.33% 80.25%  62 days following screening referral 90% Mar 96.00% 100.00% 80.71%  62 days following consultant upgrade 85% Mar 88.00% 95.45% 90.12% 

6 NHS Constitution Scorecard Increase/ decrease in YTD Description Target Month Current Prior performance Actual Month Month from last Month A&E Total A&E attendances None Mar 16,756 16,350 217,218 - Percentage seen within 4 hours 95% Mar 77.64% 78.33% 81.88%  Total Emergency Admissions None Mar 3,900 4,107 52,078 -

Ambulances Mean C1 calls response time (<7 minutes) 7:00 Feb 8:34 8:31 8:34  Mean C2 calls response time (<18 minutes) 18:00 Feb 30:05 29:57 30:22  90th Centile C3 calls response time (<120 minutes) 120:00 Feb 187:06 188:10 196:13  90th Centile C4 calls response time (<180 minutes) 180:00 Feb 209:29 210:24 214:23 

Mental Health Number of people entering IAPT treatment 761 Feb 744 815 8,822  IAPT % clients moving towards recovery 50% Feb 53.7% 48.5% 53.5%  IAPT 18 week RTT 95% Feb 100.0% 100.0% 100.0%  IAPT 6 week RTT 75% Feb 87.0% 83.7% 87.0%  EIP 14 day wait 50% Feb 66.7% 50.0% 70.9% 

Dementia Early Memory Diagnosis Service <6 week wait 90% Feb 81.7% 82.5% 89.4%  65+ estimated diagnosis rate 66.7% Feb 63.8% 64.1% 64.4%  Time from referral to EMDASS diagnosis (Hertfordshire) (weeks) None Feb 14.80 11.40 13.21 

Mixed Sex Accommodation Number of clinically unjustified MSA breaches 0 Feb 0 4 55 

HCAI 112 No. Clostridium - Acute and Non-Acute (annual) Feb 8 15 122  No. MRSA - Hospital Acquired 0 Feb 0 1 6 

7 ENHCCG Localities Scorecard Stort North Lower Lea Upper Lea CCG Description Valley & Stevenage Wel/Hat Herts Valley Valley Average Villages Urgent Care Total A&E Attendances Rate per 1000 328.4 257.4 440.8 321.8 402.9 338.7 344.8 A&E Attendances: In Hours Rate per 1000 188.0 107.5 222.7 134.0 172.2 161.9 159.0 6 Day A&E Attendances Rate per Total A&E Att's 11% 10% 18% 11% 18% 14% 14% A&E Conversion Rate NEL Spells / A&E Att's 23% 35% 18% 29% 23% 25% 25% Total Emergency Admissions Rate per 1000 74.6 90.3 78.5 94.7 94.2 84.1 87.4 Emergency Re-Admissions within 30 days % NEL Spells 17% 18% 17% 19% 19% 19% 18% Emergency Admissions LoS 5.25 4.83 5.45 4.14 4.44 5.51 4.86

Demand Management GP Initiated 1st OP Attendances Rate per 1000 186.3 185.9 217.6 179.5 189.0 206.5 193.9 Elective Admissions Rate per 1000 138.2 118.8 133.7 117.1 112.2 129.2 123.2

Cancer % New Cancer cases referred on 2ww pathway % 54.01% 47.52% 37.86% 48.37% 47.99% 42.52% 45.66%

AIHVS AIHVS Usage Across ENHCCG Visits per 1000 22.4 21.4 18.8 20.6 26.5 17.0 21.2 Home First: Rapid Response Rate per 1000 6.7 3.3 5.7 5.4 3.5 3.7 4.4

GP Survey Ease of getting through on the phone % 49.74% 59.35% 51.47% 58.64% 56.35% 69.06% 58.70% Overall experience of making an appointment % 59.43% 67.36% 62.53% 65.43% 64.03% 71.96% 65.91%

Overall experience of GP surgery % 74.49% 85.20% 73.12% 81.99% 80.35% 85.53% 81.02%

Total Weighted List Size 57,243 121,176 81,027 99,064 116,168 118,141 592,819 Total List Size >65 9,990 21,536 12,627 13,495 18,073 22,821 98,542

8 ENHCCG | Localities

׀ Comments

Activity Shifts since December report:

- Although there are minor variations, the A&E Attendance and Emergency Admission rates are consistent with the previous report; Average Length of Stay for Emergency Admissions is increased slightly across all Localities. - GP Initiated 1st Outpatient Attendances are up across all Localities; but the Elective Admissions rate is consistent with the previous report.

- AIHVS utilisation (updated to March) shows a slight overall increase. - Home First (Rapid Response) utilisation is unchanged overall, although Stort Valley shows an increase (from 5.8 to 6.7) and WelHat shows a decrease (from 4.0 to 3.5).

- Cancer and GP Survey figures are unchanged from the previous report.

9 ENHCCG | RTT 52 week waits

׀ Comments Trust Specialty Number >52 weeks Performance Although ENHT are currently off national reporting for RTT and 52 PAH Urology 2 week waits, the CCG is still receiving details of where ENHCCG patients have breached 52 week waits at other hospitals. There are 4 ENHCCG patients breaching 52 week waits for February as detailed in the table Royal Free Dermatology 1 on the left. March 52 week waiters at PAH increased however CCG split is still awaited.

Imperial T&O 1 Actions College The CCG has contacted the lead CCGs for the respective Trusts for an updated position for each patient to confirm that the patient has either now been treated or has a To Come In (TCI) date. Clinical harm reviews are undertaken for all patients breaching 52 weeks.

10 ENHCCG | Cancer Waits| page 1 of 2

׀ days to first definitive treatment for all cancers Comments 62

100% Performance Performance against the 62 day standard remains just below the 80% required 85% in March.

60% Actions The CCG continues to support ENHT in the delivery and sustainment of 40% the 62 day standards and improvements in clinical outcomes and 20% patient experience through: • Support to the implementation of timed pathways for lung, prostate 0% and colorectal, ensuring there is clear clinical engagement and Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar accountability for this work with transformational funding made available through the STP. % Achieved Target 85% • Supported rollout of faecal immunochemical testing (FIT) with a workshop planned for April 2018. • Review and development of straight to test and one stop shop capacity in order to streamline the diagnostic phase of key pathways e.g. urology, lower GI. • Work with ENHT and Cancer Research UK to develop patient information leaflets to encourage patients to make themselves available for any appointments offered in support of their cancer pathway and to advise them of escalation routes.

11 ENHCCG | Cancer Waits| page 2 of 2

׀ Day Cancer Waits ENHCCG Patients Comments 100+ 18 16 Performance The number of ENHCCG patients waiting over 100 days was 5 in March 14 with 4 at ENHT and 1 patient at PAH. Breach reasons were identified as 12 follows: 10 8 • Complexity. 6 • Diagnostics delays. 4 • Patient choice. 2 0 Actions Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar The CCG and ENHT jointly undertake a clinical harm review of all patients breaching 100 days. ENHT Other Provider Joint work continues with the CCG and ENHT on the implementation of timed pathways for lung, prostate and colorectal cancer and the development of straight to test and one stop shops to reduce delays in the pathway.

Recovery Further detail is provided in the Provider Section.

12 ENHCCG | Accident and Emergency

׀ Comments ENHCCG seen within 4 hours Performance There is a national constitutional requirement that 95% of patients 100% attending A&E are treated, admitted or transferred within 4 hours of 80% arrival. Performance at CCG level largely reflects performance at ENHT but will also include ENHCCG patients attending other A&E 60% departments such as PAH and the RFH. Performance went up in January but fell to 77% in March at CCG level as a consequence of 40% ongoing pressures within the system. 20% Actions 0% ENHCCG has a Systems Resilience Group (SRG) that meets monthly Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar and is responsible for the day-to-day delivery of the actions outlined in the Urgent and Emergency (UEC) Delivery Plan 2017/18. It is % Achieved Target accountable to the East & North Hertfordshire A&E Delivery Board. Local system actions have been agreed in line with the national urgent and emergency care delivery plan and covers the following areas: • NHS 111 online • NHS 111 calls • Ambulance Response Programme • Urgent Treatment Centre designation • Hospital Improvement Programme • Hospital to Home The progress against these actions is reviewed monthly. The CCG is monitoring the Emergency Pathway and Patient Flow Improvement Programme at ENHT as part of the Redial Action Plan to improve A&E performance.

Recovery Nationally the requirement for all Trusts to be delivering the 95% standard has been pushed back with Trusts now expected to meet 90% by September 2018 and 95% by March 2019. 13

ENHCCG | Ambulance Performance

׀ Ambulance Responses C1 calls ENHCCG (<7 minutes) Comments

10:00 Performance 08:00 New ambulance performance standards to measure ambulance 06:00 response times have been in operation from October 2017. There are 04:00 4 new categories of call with associated required average response 02:00 times: 00:00 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb C1 People with life threatening injuries and illness (<7 minutes) Av Response Time Av Target < 7 mins C2 Emergency calls (<18 minutes) C3 Urgent calls (<120 minutes) C4 Less urgent calls (<180 minutes) Ambulance Responses C2 calls ENHCCG (<18 minutes) 30:00 There has been a continued improvement against all call categories at 25:00 CCG level. Early indications for March and April suggest this is being 20:00 maintained. 15:00 10:00 Actions 05:00 Specific actions are detailed in the provider section under EEAST. 00:00 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Official reporting commenced on the 1st April 2018. Av Response Time Av Target < 18 mins

Ambulance Responses C3 (<120 mins) and C4 calls (<180 mins) ENHCCG 03:45:00 03:00:00 02:15:00 01:30:00 00:45:00 00:00:00 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb C3 90th Centile Response Time C4 90th Centile Response Time C3 Target < 120 mins C4 Target < 180 mins 14 ENHCCG | Mental Health | page 1 of 2

׀ Comments People entering IAPT treatment 1,200 Performance: 1,000 Access target - the number of people entering treatment in February for HPFT was below target by 17 and 65 for the AQP providers. 800 However the CCG’s year to date target has been exceeded by 1,160 600 people.

400 Recovery target - the CCG is currently achieving a recovery rate of 200 53.7% which is above the set target of 50%.

0 Actions: Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb No actions needed as we are exceeding the set KPI’s for IAPT Access and Recovery. Number entering through AQP Number entering through HPFT Combined Target 16.8%

IAPT % clients moving towards recovery

100%

80%

60%

40%

20%

0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

% Achieved Target 50% 15 ENHCCG | Mental Health | page 2 of 2

׀ IAPT 18 week RTT Comments

100% Performance The CCG is exceeding both the 6 week and 18 week wait times target for IAPT access. 50%

Actions No action needed for IAPT as all KPIs are being meet. 0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

% Achieved Target 95%

IAPT 6 week RTT 100%

50%

0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar % Achieved Target 75% Performance EIP 14 day wait EIP 14 day wait continues to meet the 50% target. 100% Actions Additional funding agreed for 2018/19 to fully roll out the new 50% staffing model with standalone EIP teams. We are continuing to monitor demand levels as there has been an increase in the number of referrals. 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar % Achieved Target 50% 16 ENHCCG | Dementia

׀ Early Memory Diagnosis Service <6 week wait Comments

100% Performance EMDASS 6 Week Assessment waiting target at 90% measures the time 50% to an initial appointment with the nurse, rather than the time to diagnosis. For 2018/19 this will be replaced by a new target measuring the time to diagnosis. This reflects the development of the One Stop 0% Pathway where patients will receive an assessment and diagnosis Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb together. The new performance target is set at 80% of referrals to be % Achieved Target 90% seen diagnostics had received within 12 weeks.

Actions 65+ estimated diagnosis rate . Revised One Stop Pathway being implemented which gives more 70% focus on speedier diagnosis.

60% One Stop Pathway Implementation

East quadrant 50% Currently 86.21% of referrals are waiting less than 6 weeks for a One Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Stop appointment . Diagnosis rate Trajectory Target The pathway has been fully operational for 3 months and is Time from referral to EMDASS diagnosis (Hertfordshire) performing well.

20 North quadrant 15 1 newly recruited nurse taking up post week commencing 23rd April 10 with second appointment taking up post at the end of May. Planning to initiate the One Stop pathway will take place in May with a view to 5 commence in June. 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Time in weeks 17 ENHCCG | HCAI ENHCCG C-Diff Cases 2017/18 • Review of recent primary care antibiotic history requested by a clinical member of practice staff 140 • The Antimicrobial Pharmacy Advisor, Head of IPC and local Microbiologist are being booked to present regarding C-Diff, antibiotic 120 2016-17 cumulative cases prescribing and antimicrobial resistance at each of the next Target 100 events. Dates are currently being co-ordinated • Advice regarding C-Diff (including re-sampling of positive cases) has 80 2017-18 been included in GP newsletter cumulative cases 60 • CCG C-Diff Appeals Panel terms of reference have been reviewed and updated to ensure greater involvement with clinical teams 2017-18 40 • Trust proton pump inhibitor policies have been reviewed cumulative limit 20 • CCG primary care proton pump inhibitor guidance has been reviewed – no changes. It will be re-distributed to GPs

0 • Monitoring of progress against Trust C-Diff action plans is now a

Jul

Jan

Jun

Oct

Apr Feb

Sep regular agenda item at Trust QRMs (quarterly)

Dec

Aug

Nov Mar May • Re-introduction of broad spectrum antibiotic prescribing measure into Clostridium difficile 2018/19 CFF i.e. number of co-amoxiclav, cephalosporins and During 2017-18 the number of C-Diff cases reported within the ENHCCG quinolones as a percentage of the total number of selected antibiotics population has been at its highest point for the last 5 years. During the prescribed in primary care to be 10% or below months of June to October 2017, there was a notable sharp increase in cases, however, this then slowed. By the end of March, the 2017/18 MRSA Blood Stream Infection (BSI) cumulative rate of infection per 100,000 population was 22.548, which One further case of MRSA BSI was reported during Q4, bring the CCG was below the national and regional rates. Across 2017-18, total for 2017-18 to seven. Although this is above the ceiling of zero, the approximately 71% of all cases reported were apportioned to the CCG rate of MRSA BSI for the year was 1.24 per 100,000 population community. This is a significant increase from last year, when 57% of which was below both regional and national rates. A post infection cases were assigned to the community. review was undertaken for each case and where necessary learning identified. Progress against action plans is being monitored by the Trust A monthly IPC Focus Group, chaired by the Director of Nursing & Quality QRMs and via the Herts IPC Group. has been established to monitor progress against IPC action plans and address any challenges or difficulties encountered in achieving these. The post infection review for the Q4 case identified no known history of MRSA in this gentleman, and a primary source of the BSI as endocarditis. Targeted actions to address local C-Diff rates: No learning or lapses in care were identified. • Review of risk factors for each case by Head of IPC. Response rate to requests for surveillance data from primary care has increased to 88% since Dec 17 18

ENHCCG | HCAI

ENHCCG E coli BSI Cases 2017/18 • Production of a primary care catheter formulary

• Review of trial without catheter services 400 • Development of catheter registers in primary care 350 • Review of use of bladder scanners across the community 300 • Review of results for UTI and catheter audits at ENHT being 2016/17 250 Cumulative Cases undertaken by the CCG

200 • Audit of discharge processes for catheterised patients • Replication of Stevenage UTI Pathway Project across other 150 2017/18 localities 100 Cumulative Cases • Education for UTI prevention across the community 50 • Review of trends in numbers of patients discharged with catheters 0 2017/18

Jul

Jan

Jun

Oct

Apr

Sep Feb

Dec

Aug

Nov Mar May Cumulative Limit • Dates for the CCG “To dip or not to dip” (TDONTD) programme for care homes and home care providers are currently being arranged. The programme will include a series of educational events covering the appropriate diagnosis of UTI in over 65’s, and the reduction in reliance on urinalysis as an indicator of UTI, as well as wider issues that will help to E coli Blood Stream Infection (BSI) reduce UTI and E coli BSI locally e.g. recognising the deteriorating During 2017-18, there had been a total of 375 cases of E coli BSI reported in resident, improving hydration, and urinary catheter care. the ENHCCG population. Although this was a similar number to that reported • TDONTD has already been launched across ENH within primary care during 2016/17, it was approximately 10% above the CCG ceiling. The during 2017/18. reported cases represent a rate of 66.29 per 100,000 population which was • Antibiotic guidance for the treatment of UTIs & the Hertfordshire below both regional and national rates. Antibiotic App has been updated and re-launched.

• Acute providers are recording surveillance data on acute and community Local surveillance data collected by reporting Trusts reflects national data, acquired cases of E coli BSI. with approximately one half of cases having a primary source of the urinary • The production of CCG UTI prophylaxis guidance is currently underway tract and approximately two thirds being assigned to the community setting. for primary care. Targeted actions to address local rates of E coli BSI: • The Hertfordshire wide UTI Best Practice Forum which is chaired by the CCG and held monthly. Its membership includes representatives from all main providers in Hertfordshire. The work plan for this group continues to progress and includes:

• Increase in the utilisation of urinary catheter passports and review of current passport 19 ENHCCG | Safeguarding Adults ׀ Comments Following the Domestic Abuse Topic Group session in December the following recommendations were made:

• To introduce Domestic Abuse (DA) Champions county wide including GPs. • That DA training and awareness raising is adopted by the HSAB as part of mandatory safeguarding training for operational front line staff and managers across Adult Care Services (ACS); and, that all relevant ACS contracts build in DA training as a mandatory requirement. • That the Hertfordshire DA Partnership actively creates support services for medium and standard risk victims. • That work should be undertaken with Princess Alexandra Hospital, Luton and Dunstable Hospital and Barnet General Hospital to identify and develop improved communications with the service that performs a similar function to that of the Independent Domestic Violence Advisors (IDVAs) at the Lister and Watford hospitals. • That the partnership develops a countywide non-mandatory perpetrator programme.

The Head of Adult Safeguarding has developed a safeguarding adult strategy setting out expectations for the next 3 years in line with the CCG objectives.

Following the letter from NHSE wanting to understand the progress that NHS organisations have made in reaching compliance with the Prevent Duty, the Head of Adult Safeguarding received the following assurance from all four Trusts; All organisations uploaded prevent data to Unify2 within the timescales set by NHSE. All organisations continue to work towards the 85% compliance target for prevent training. The Head of Adult Safeguarding organised Prevent Wrap training for key staff from provider organisations to improve the delivery of Prevent Wrap training.

The Named Nurse for Adult Safeguarding is working with colleagues to provide adult safeguarding training at primary care Target days. This includes having stalls at Locality events. The Named Nurse is also supporting several GP practices to produce reports for Domestic Homicide Reviews and ensures that learning is shared.

The Safeguarding Adult Team continue to support the HSAB at a number of sub groups which include reviewing policies, developing learning events, raising awareness and reviewing Safeguarding Adult Reviews.

The annual assurance process of safeguarding adult assurance visit to providers began in March for the year 2017/18.

All providers continue to work towards their compliance targets for adult safeguarding and Prevent Training which are monitored by the Head of Adult Safeguarding through the quarterly dashboards. The main area of concern is regarding Prevent training and ENHT and HPFT have provided action plans outlining how they will meet the NHSE targets for Prevent Training.

20 ENHCCG | Safeguarding Children

׀ Comments • The Designated Office is involved in a number of work streams, in collaboration with partner agencies and the Hertfordshire Safeguarding Children Board (HSCB). Examples include Safeguarding Supervision and Management Oversight; Scoping of self harm; Domestic Homicide Review; Private Fostering; Preparation for the Joint Targeted Area Inspection (JTAI); Harmful Sexualised Behaviour; revision of Children Services’ referral forms and development of an enhanced information sharing solution between Hertfordshire Urgent Care (HUC) and Hertfordshire Community NHS Trust (for children attending HUC). • Two Serious Case Reviews (SCRs) are currently in progress. A third SCR has been declared and is awaiting identification of a reviewer. Two further individual cases are advancing as multi-agency investigations (as opposed to SCRs). • Section 11 visits to HCT, HUC and ENHT have been completed ahead of schedule. A Section 11 visit to Hertfordshire Partnership NHS Trust is planned for July 2018. Action plans to improve quality of Safeguarding practice have been formulated and will be monitored by the Designated Office. Recent actioned concerns in relation to training compliance have demonstrated significant improvement. Compliance rates, in relation to safeguarding supervision, is under current scrutiny. • Audit scheduling, for 2018/2019, for Provider services, based on recommendations from Section 11 visits, will continue. Planned audits include completion of Graded Care Profile Neglect Assessment Tool by frontline staff (HCT); Think Family initiative (ENHT); Quality of safeguarding supervision (HPFT); Spotting the Sick Child training programme (HUC) and quality of referrals to Children’s Services from Primary Care. • Safeguarding Assurance Tool (SAT) – all key standards in relation to CCG Safeguarding practices reportable to NHS England, are currently rated as Green. Two areas remain Amber for Looked After Children (LAC) whilst a health needs analysis is awaited. • A fundamental review of the role and functions of Local Safeguarding Children Boards (LSCBs) and an exploration of the child death review process (Wood Report 2016) has made recommendations for centralisation of SCR information to support a national learning framework and a move of ownership of the arrangements for supporting Child Death Overview Panels (CDOP) from the Department of Education to the Department of Health. A full consultation, regarding progression of future arrangements for CDOP panels, is being led by NHS England and is expected to complete in 2018 (actual date not specified). The consultation process has highlighted a number of professional concerns including lack of statutory guidance for implementation, lack of governance arrangements, change in roles and responsibilities of Designated Doctors for Child Death and a shift in how review meetings (first meeting following a child death) are managed. Further information is awaited following conclusion of Consultation process. • A review of the functions of the Hertfordshire Safeguarding Children Board (HSCB), and it’s relationship with the Adult Board is currently being undertaken by the HSCB chair. A preliminary report is expected in Spring 2018. • Ongoing support is being offered to GP practices to ensure completion of the registration process for identified Female Genital Mutilation. Bespoke training is offered to GP practices as required. • A proposed Primary Care Dashboard has been formulated which will enable capture of key indicators and selected key areas of performance relating to safeguarding children arrangements within General Practice. The tool will support Primary Care in achieving and maintaining required standards. It is envisaged that the information captured will additionally identify areas of good practice and highlight areas where further support or guidance may be required and provide valuable benchmarking and evidence for Care Quality Commission (CQC) inspections. • A number of Primary Care specialist conferences have taken place, with others planned for 2018, in collaboration with the LMC. Key topics include Harmful Sexualised Behaviour in Children and Prevent Awareness. • Looked After Children (LAC) – Completion rates for Initial and Review LAC health assessments are in excess of 80%. Delay in completion of Out of County health assessments continues to be of concern. A clear escalation process involving NHS England and host CCGs is in place to improve the current situation. Quarter 4 figures currently stand at 14% completion within timescale.

PROVIDER PROFILES

22 ENHT |

Increase/ decrease in YTD Description Target Month Current Prior performance Actual Month Month from last Mar Feb Month Stroke 4 hours direct to stroke unit (ASI 2) 90% Mar 60.0% 56.9% 72.1%  90% of time on the stroke unit (IPMR) 80% Mar 85.1% 84.8% 86.1%  Thrombolysed within 3 hours 12% Mar 7.2% 8.6% 7.2%  TIA high risk, not admitted, treated <24 hours (IPMR) 60% Mar No data No data 64.9%  TIA - low risk, treated within 7 days from onset 65% Mar No data No data 53.4% 

Consultant Led Referral to Treatment Times (RTT) Completed - Admitted patients None Mar No data No data No data  Completed - Non-admitted patients None Mar No data No data No data  Incomplete pathways 92% Mar No data No data No data  Patients waiting at the end of the month None Mar No data No data No data  Number of 52 week breaches 0 Mar No data No data 6 

Diagnostic waiting times Total number on waiting list None Mar No data No data No data  Patients waiting less than 6 weeks from referral 99% Mar No data No data No data 

Cancer waits 2 weeks for urgent cancer GP referrals 93% Mar 97.39% 97.55% 97.69%  2 weeks for urgent breast symptom referrals 93% Mar 93.58% 100.00% 93.98%  31 days to first definitive treatment for all cancers 96% Mar 96.62% 92.39% 92.96%  31 days for subsequent surgery 94% Mar 91.30% 92.31% 86.66%  31 days for subsequent drug 98% Mar 97.16% 96.99% 95.76%  31 days for subsequent radiotherapy 94% Mar 92.45% 93.58% 90.07%  62 days to first definitive treatment for all cancers 85% Mar 79.06% 80.30% 73.88%  62 days following screening referral 90% Mar 89.29% 100.00% 71.48%  62 days following consultant upgrade 85% Mar 65.00% 80.95% 69.48% 

23 ENHT |

Increase/ decrease in Current Prior YTD Description Target Month performance Month Month Actual from last Mar Feb Month Maternity Caesarean Section rate (total) 27% Mar 33% 27% 28%  Planned Caesarean Section 11% Mar 16% 14% 14%  Unplanned Caesarean Section 15% Mar 17% 13% 15% 

Friends and Family Inpatient Percentage Recommended None Mar 96.7% 96.9% 97.1%  Inpatient Response Rate None Mar 41.5% 44.1% 45.4%  A&E Percentage Recommended None Mar 88.8% 91.6% 92.4%  A&E (Type 1 & 2) Response Rate None Mar 4.7% 3.6% 3.0% 

A&E Total A&E attendances None Mar 13,426 12,042 138,787 - Percentage seen within 4 hours 95% Mar 80.21% 79.57% 83.10%  Total Emergency Admissions None Mar 3,730 3,488 38,431 -

Ambulances Handovers from ambulance to A&E <15mins 100% Mar 44.00% 40.00% 57.10%  Number of patients waiting >30 - <60mins None Mar 276 366 1,806  Number of patients waiting >60mins None Mar 101 117 435 

Mixed Sex Accommodation Number of clinically unjustified MSA breaches 0 Mar 0 0 0 

VTE VTE Risk Assessments 95% Mar No data No data 97.33% 

HCAI 11 No. Clostridium - Hospital Acquired (annually) Mar 2 4 26  No. MRSA - Hospital Acquired 0 Mar 0 0 1 

24 ENHT | Stroke

׀ hours direct to stroke unit (ASI 2) Comments 4

100% Performance

80% ENHT has seen a reduction in performance against the 4 hour direct to stroke unit standard in February and March 2018, achieving 56.9% and 60% 60.0% respectively. Scanning within 24 hours has also seen a reduction in performance, with achievement of 94.8% in March 2018. 40%

20% Actions

0% Performance in February and March was affected by bed availability, Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar and a high number of strokes (96 in March 2018, which is the highest volume seen in an individual month). ENHT are currently working with % Achieved Target 90% A&E to ensure processes are in place to support the timely transfer of clinically stable stroke patients to the stroke unit.

Scanned within 24 hours It should be noted that ENHT has changed the method through which it 100% captures stroke information. The new system include inpatient strokes and is contributing to the reduction in the 4 hour direct to stroke unit 98% standard. Work is underway to try and capture inpatient stroke 96% performance appropriately.

94% A revised scanning protocol has been implemented, which allows 92% stroke nurses to directly requests CT scans. It is envisaged that this will support improvements in both scanning standards and thrombolysis 90% rates.

88% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Recovery

ENHT continues to work towards achievement and sustainment of 80- % Achieved Target 100% 85% against the 4 hour target. 25

ENHT | Cancer Waits | Page 1 of 2

׀ days for subsequent radiotherapy Comments 31 100% 80% Performance 60% 31 day standard for subsequent radiotherapy, surgery and drugs is 40% below target for March, although 31 days to definitive treatment for all cancers met at 96.62%. 20%

0% Actions Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar % Achieved Target 94% Specific actions to improve the 31 day standard include the commissioning of additional brachytherapy capacity. Additional actions to improve overall performance in cancer standards are 31 days for subsequent surgery detailed on the following slide. 100% 80% 60% 40%

20%

0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar % Achieved Target 94%

31 days for subsequent drug 100% 80% 60% 40% 20% 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar % Achieved Target 98% 26 ENHT | Cancer Waits | Page 2 of 2

׀ days to first definitive treatment for all cancers Comments 62 100% 80% Performance 60% ENHT recorded its best performance against the 62 day standard in February since April 2015, achieving 84.4% following adjustment for 40% late referrals against the 85% target. Performance dipped again 20% slightly in March at 80.90% following adjustment for late referrals. 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actions % Achieved Target 85% There has been considerable joint working between ENHT and the CCG in order to identify clear and specific actions required to 62 day for first definitive treatment improve 62 day standard performance. Key actions undertaken are: 100% 80% • Patient breach analysis and reporting to identify main reasons for 60% breaches occurring to improve processes and pathways which has 40% led to identification of the need for additional brachytherapy 20% capacity, diagnostic and treatment planning. • Development of timed pathways for both lung and prostate 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar cancer. Transformational money has been made available at STP level and this has been used to support the timed pathways % Achieved Post adjustment % 85% Target Trajectory implementation work at the trust. • Increased resource to monitor and track all cancer patients to 62 days following consultant upgrade ensure appropriate escalation of patients in order that they are 100% diagnosed and treated within appropriate timescales. 80% Recovery 60% The Trust is currently reprofiling activity to agree a trajectory to 40% achieve the required 85% against the 62 day standard. 20% 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar % Achieved Target 85% 27 ENHT | Accident & Emergency ׀ Comments A&E patients seen within 4 hours and Breaches Performance 100% 5000 Performance against the A&E 4 hour standard remains below the 90% 4000 95% threshold, with achievement of 79.6% and 80.2% in February and March 2018 respectively. 80% 3000 70% 2000 Actions A project to redesign non-elective pathways at Lister was launched in 60% 1000 March 2018. This project is designed to deliver the following 50% 0 outcomes: Apr May Jun Jul Aug Sep* Oct Nov Dec Jan Feb Mar * September data not available and October part month only • Support delivery of the 95% A&E standard; Breaches % Achieved 95% Target Trajectory • Reduced admissions through streaming to appropriate pathways and increased use of ambulatory care services; Emergency attendances and admissions • Improve patient flow and discharges; 20,000 * September data not available and October part month only 40% • Redesign of assessment units.

15,000 30% In addition the following actions are also in progress:

10,000 20% • Embedding of professional standards in A&E; • Development of a recruitment and retention plan for the medical 5,000 10% workforce; 0 0% • Specialty response times are now being tracked in real time; Apr May Jun Jul Aug Sep* Oct Nov Dec Jan Feb Mar • Red to green implemented across the inpatient wards, with work Type 1 and Other Admissions Non-admissions now focused on further embedding this to ensure it is consistent. Total Attends Conv The CCG is working closely with ENHT to support progress against Unplanned re-attendances within 7 days 10% key actions.

Recovery 5% It is expected that ENHT will achieve 90% by September 2018 and 95% by March 2019, in line with national guidance and a revised 0% trajectory is being set. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar % Achieved Target <5% 28 ENHT | Ambulance Handovers

׀ Handovers from ambulance to A&E within 15mins Comments 100% Performance 75%

50% ENHT has seen a reduction in ambulance handover performance 25% since December 2017. 42.8% of handovers were completed within 15 minutes during March 2018, which whilst higher than the regional 0% average of 34.9%, continues to be lower than the first half of 2017- Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 18. Also of note, is the fact that hours lost to handover delay in % <15mins Target 2017-18 is 55.7% lower than that during 2016-17, although this has also increased in recent months. Handover delays from ambulance to A&E 30-60mins 400 Actions

The new standard operating procedure was revised at the end of 200 February 2018 to ensure that clear processes are in place to enable clinical handover of ambulances within 15 minutes. These processes are working well in hours, but require further refinement to ensure 0 they are embedded out of hours. In addition, the CCG is working Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar with ENHT to finalise arrangements for additional nurses who will be 30-60mins responsible for ensuring timely handover at Lister A&E.

Handovers delays from ambulance to A&E >60mins ENHT has also worked alongside EEAST to ensure nationally agreed 150 actions to improve performance are put in place, including clear escalation, additional support for clinical handover and leadership. 100 This work forms part of the non-elective redesign work at Lister.

50 Recovery

0 An action plan and trajectory to ensure that no clinical handovers Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar take more than 30 minutes by September 2018 is currently being >60mins agreed, in line with national guidance. 29 ENHT | Cancelled Operations & Outpatients

׀ No binding date <28 days after cancellation Comments 20 Performance

10 Cancelled outpatient appointments continue to be higher than the 8% threshold, with 9.7% of appointments being cancelled in both February and March 2018. 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar There continues to be a small volume of patients who have not had a Number of patients Target = 0 new date confirmed within 28 days of a cancelled operation; 10 in February and 12 in March 2018. Reduction in cancellation of outpatient appointments 15% Actions

10% All patients without a binding date following a cancelled operation up to the end of February 2018 have been bought in or have a date 5% for treatment. Of the 12 reported for March 2018, further validation has found that three patients had not breached this standard, seven 0% patients have now been treated or have a definitive date to come in, Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar and the remaining two are being actively progressed by ENHT. % Achieved Target <8% Following the Lorenzo implementation, and in the lead up to the full Percentage with a binding date <28 days of cancellation implementation of e-referrals in September 2018, ENHT is in the 100% process of reviewing clinic availability. There are also a range of work streams underway focused on capacity and demand reviews, transformation of pathways to increase their efficiency and 50% identification of opportunities for virtual rather than face-to-face review.

0% Recovery Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar The CCG continues to work closely with ENHT to improve % Achieved Target 100% cancellations and waiting times for outpatient appointments. 30 ENHT | Serious Incidents

E&NHT : Type of Serious Incident Reported 2017/18 7

3 Number

0 Operatio Suboptim Surgical/I Informati Blood n/treatm Medical Unexpect Safeguar al care of nvasive Medicati on product/t Infection Diagnosti Maternit Treatmen Patient Major Screening ent given Equipme Pressure ed/Avoid VTE ding deteriora Procedur on Governa ransfusio control c Incident y Services t Delay Fall Incident Issues without nt ulcer able Incident adults ting e Incident nce n valid Incident injury patient Incident Breach incident consent Q1 0 3 0 1 4 1 1 1 0 1 1 1 0 0 0 0 0 0 Q2 1 2 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 Q3 0 4 1 1 4 1 5 2 0 2 0 0 1 0 0 0 0 0 Q4 0 3 0 0 2 0 6 2 1 1 0 0 0 1 1 1 1 1

Comments In Q4 ENHT reported 20 SIs across the organisation, which is a slight decrease from the previous quarter. The key themes are diagnostic incidents, sub-optimal care of the deteriorating patient, treatment delays and surgical/invasive procedures.

The Trust reported 2 Never Events in this quarter. One related to a patient being given the wrong blood and one related to a surgical foreign body left in situ. There were a total of 6 Never Events reported in 2017/18.

A further 2 Never Events have been reported in 2018/19 YTD. One relates to the unintentional connection of a patient requiring oxygen to an air flowmeter, and one relates to a misplaced naso-gastric tube.

31 ENHT | HCAI ENHT C-Diff cases 2017/18 assigned a total of one case during the year and their rate of infection remained below both regional and national rates. The Trust MRSA policy is 30 currently being updated with a view to moving to universal admission screening for MRSA rather than a risk based approach to screening as at 25 present. If this occurs, this should address the issue of omitted screening as 20 identified in post infection reviews. 2016-17 cumulative cases E coli Blood Stream Infection 15 2017-18 The Trust has reported a total of 36 cases. The ENHT rate of 17.73 per 100,000 10 cumulative cases occupied bed days is significantly below regional and national rates.

5 2017-18 Incidents cumulative limit Norovirus Outbreak – Ward 6B 0 A total of 9 confirmed cases of norovirus were reported during March 18. An

outbreak was declared and additional IPC measures implemented, The ward

Jul

Jan

Jun

Oct

Apr

Sep Feb

Dec

Aug

Nov Mar May was fully re-opened after one week.

C difficile (ribotype 027) Outbreak Clostridium difficile During March and the beginning of April a total of 8 cases of C diff (027) were At the end of January 2018, ENHT had C-Diff rate per 100,000 occupied bed reported. A joint NHSI and CCG peer review was undertaken in April. days below that of both the East of England, and England as a whole. Of the The report and recommendations have since been discussed by the Board and cases reported, the Trust successfully appealed 12 cases against contractual a Trust IPC Improvement Programme Steering Group has been established sanctions from the CCG. No lapses that contributed to these infections were which is chaired by the DON/ DIPC. The CCG is represented on this group. identified by the CCG appeals panel. The Trust therefore faces contractual sanctions for the 3 remaining cases above their ceiling.

Although not considered to have contributed to the infections, a number of areas of learning for the Trust were identified during these case reviews including: • No clear documentation regarding assessment of stool for sampling • Prevention of hospital acquired pneumonia and consequential antibiotic treatment should be considered in the prevention of CDI cases. • Gaps in stool chart completion Progress against these action plans is being monitored via the Trust QRM and will also be monitored through the CCG quality assurance visits.

MRSA Blood Stream Infection No cases of MRSA BSI were reported during Q4. The Trust was therefore 32

ENHT | Friends and Family

׀ ENHT Inpatient FFT Comments

100% Performance During Q4 ENHT remained above the national average for inpatient 80% score and above the national average for the response rate each 60% month with 97% of patients recommending the Trust in March, based on a response rate of 41.5%. 40% The Trust’s ED FFT score has been above the national average each 20% month during 2017-18 YTD, with 89% of patients recommending 0% the Trust in March. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actions Inpatient Recommended Inpatient Responses The Trust has a patient experience action plan for each division, incorporating actions identified from FFT feedback.

The Trust is currently working with the ED team to improve the ENHT A&E FFT response rate. FFT is being promoted through message of the week, being discussed during handovers to raise awareness. This 100% 5.0% has been added to the Trust’s Quality Priorities for 2018/19.

80% 4.0% The CCG continues to seek assurance through Quality Review Meetings and Quality Assurance Visits. 60% 3.0%

40% 2.0%

20% 1.0%

0% 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

A&E Recommended A&E Response Rate 33 ENHT | Pressure Ulcers

׀ Pressure ulcers determined to be ‘avoidable’ Comments

8 During Q4 2017/18 the Trust reported 10 hospital acquired 7 avoidable grade 2-4 pressure ulcers; this is a slight decrease 6 compared to the previous quarter. 5 4 Throughout the year the majority of cases reported relate to heels. 3 Key themes include equipment provision, reduced skin inspection 2 and repositioning. 1 0 Actions being taken to help prevent pressure ulcer development Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar include; • Pressure ulcer prevention study days Number of Patients Zero Tolerance • Reinvigorating the use of mirrors for skin inspection • Embed the practice related to care of skin under medical devices

34 ENHT | Maternity

׀ Planned Caesarean Section Comments

20% Performance The total c-section rate remained stable during January and 15% February, however it rose to 32% in March. The emergency c- section rate was 17% and elective c-section rate 16%. 10% The Trust continues to review all emergency c-sections to ensure 5% they were appropriate and that any learning is identified.

0% There is to be a maternity focus at the June Contract Quality Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Review Meeting with the Trust.

Number of Patients Target <11%

35 ENHT | Workforce | page 1 of 2

Sickness absent rate Sickness absence In March the in-month sickness absence rate decreased to 3.98% 10.0% from 4.11% in February. This is remains above the target of 3.5%.

8.0% The Trust has developed a detailed action plan specifically relating to sickness absence, which included the launch of a new policy at the 6.0% end of March, increased training for managers in managing sickness 4.0% absence and direct communications with individuals reaching informal triggers in relation to their absence. 2.0% Future actions will include the development of Divisional action 0.0% plans, focussing on proactive management during 2018/19. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

% Achieved Target <3.3%

Turnover Staff turnover rate During Q4 the Trust’s turnover rate increased slightly with a turnover 16% rate of 13.48% in March. 14% 12% The Trust has developed a new retention plan covering the following key areas; 10% - improved experience of staffing levels 8% - improved clinical management and team development 6% - enhanced employment offers and staff benefits 4% 2% 0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

% Achieved Target <10%

36 ENHT | Workforce | page 2 of 2

׀ Vacancy rate Comments

12% Vacancy rate 10% There continues to be a number of vacancies at the Trust including ED and ward areas; the vacancy rate has remained stable in Q4 8% with a rate of 8.4% in March; this is a slight improvement from 6% 8.5% at the end of Q3.

4% In February the vacancy rate for qualified nursing was 8%, and for 2% unqualified nursing was 16.2%, this is a slight improvement in both areas since December. The vacancy rate for band 5 nurses was 0% reported as 13.7% at the end of March. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar % Achieved Target <5% Each Division has recruitment plans in place, and a joint STP band 5 recruitment day is to be held in May.

Staff appraised in the last 12 months Appraisal rate The appraisal rate remains below the Trust target of 90%, with a 100% rate of 82.7% reported at the end of March. 80% The Trust continues to prevent automatic pay progression for staff 60% who have not received an appraisal.

40%

20%

0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar % Achieved Target 90%

37 ENHT | Safe Staffing ׀ Comments

Medical Vacancies (From previous slide) Performance The Trust vacancy rate for medical and dental staffing was 7.3% The March safer staffing data shows ENHT to have adequate overall at the end of February, this is above the target of 5%. There fill rate for qualified staff during the day and night; however the fill continues to be a number of key medical vacancies, particularly rate for non-qualified nursing staff during the day remained below in relation to acute medicine and ED. 90% throughout Q4. A number of wards remain below 90% fill rate for qualified staff during the day. Over the last 12 months there has The Trust’s resourcing team is working closely with Divisions to been an overall decrease in fill rate for qualified and non-qualified support recruitment plans and expedite recruiting processes. staff during the day and night. There is also ongoing work regarding the retention of medical The Trust monitors staffing levels on a daily basis, and action is taken staff. to address any ward areas flagging red to ensure safe levels of staffing are in place. Day Night Month Nurse HCA Nurse HCA Whilst there has been a decrease in nursing fill rates throughout 2017/18 there is currently no clear correlation between staff levels April 96.1% 104.3% 95.5% 112.8% and patient harm. However, there has been an increase in care May 96.3% 94.8% 95.1% 106.5% related complaints, and feedback during Quality Assurance Visits has been mixed. June 95.7% 91.5% 94.4% 108.2%

July 94.1% 93.3% 94.8% 112.3% Actions August 93.6% 91.4% 93.8% 111.2% Safer staffing is reviewed during Quality Review Meetings as well as during Quality Assurance Visits. September 92.1% 92.3% 93.8% 113.1% October 92.6% 86.5% 96.1% 107.0% The CCG continues to monitor vacancies by ward on a monthly basis to review improvement against the Trust’s trajectory. Sickness November 96.3% 90.0% 96.7% 109.2% absence and bank and agency usage is reviewed at the same time. December 94.1% 87.2% 95.9% 104.3% January 95.0% 87.7% 96.2% 108.4& February 95.2% 84.3% 96.7% 108.9% March 93.5% 85.3% 94.1% 108.2% 38 ENHT | Other

׀ Comments

Mortality (SHMI) The April release of SHMI data (covering the rolling year to September 2017) showed that ENHT has continued to maintain the previous improvements with a SHMI of 102.3. This is below the upper control limit. Following the publication of national guidance regarding learning from deaths progress in relation to the key requirements continues to be monitored through the regular Mortality Review Group.

Sepsis The Trust has continued to perform well in screening and identifying patients with sepsis, with 95% of patients appropriately identified in ED and 96% of inpatients appropriately identified, against a target of 90%. This is an improvement compared to Q3.

Performance relating to the timely treatment of patients with IV antibiotics remains disappointing although there has been an improvement compared to Q3; 67% of patients in ED, and 55% of inpatients received IV antibiotics within one hour.

Actions undertaken by the Trust to improve performance include; • Ongoing staff training and awareness sessions • General public awareness raising • Selection of sepsis patients mapped from arrival through to admission to analyse variance from sepsis six care bundle • Cross system working with EEAST, to promote use of common language (NEWS & Red/Amber Flags) for pre alerts and handover of sepsis patients • Work with Learning Disability liaison nurses to review care of patients with learning disabilities at high risk of sepsis

This remains a key focus of discussions at both the Quality Review Meeting and Mortality Review Group.

CQC Inspection During March the CQC undertook a further inspection of ENHT; the well led element of the inspection was undertaken in April. The result of the inspection is awaited with the report anticipated to be published in June.

39 PAH |

Increase/ decrease in YTD Description Target Month Current Prior performance Actual Month Month from last Month Consultant Led Referral to Treatment Times (RTT) Completed - Admitted patients None Feb 52.26% 58.80% 52.3%  Completed - Non-admitted patients None Feb 91.17% 93.79% 52.3%  Incomplete pathways 92% Feb 89.01% 89.29% 89.0%  Patients waiting at the end of the month None Feb 15,746 15,784 15,746  Number of 52 week breaches 0 Feb 2 0 2 

Diagnostic waiting times Total number on waiting list None Feb 4,694 4713 4,694  Patients waiting less than 6 weeks from referral 99% Feb 99.40% 99.51% 99.40% 

Cancer waits 2 weeks for urgent cancer GP referrals 93% Mar 97.29% 99.07% 98.31%  2 weeks for urgent breast symptom referrals 93% Mar 97.67% 97.71% 98.41%  31 days to first definitive treatment for all cancers 96% Mar 97.44% 98.59% 98.39%  31 days for subsequent surgery 94% Mar 100.00% 100.00% 98.81%  31 days for subsequent drug 98% Mar 100.00% 100.00% 100.00%  31 days for subsequent radiotherapy 94% Mar - 62 days to first definitive treatment for all cancers 85% Mar 78.95% 85.90% 88.44%  62 days following screening referral 90% Mar N/A 100.00% 95.30%  62 days following consultant upgrade 85% Mar 94.37% 92.45% 91.56% 

40 PAH |

Increase/ decrease in YTD Description Target Month Current Prior performance Actual Month Month from last Month Maternity Caesarean Section rate (total) 25% Mar 30.2% 32.6% 29.4%  Planned Caesarean Section None Mar 13.2% 15.1% 13.2%  Unplanned Caesarean Section None Mar 17.0% 17.5% 16.0% 

Friends and Family Inpatient Percentage Recommended None Mar 97.5% 98.3% 97.4%  Inpatient Response Rate None Mar 45.8% 42.8% 38.8%  A&E Percentage Recommended None Mar 95.0% 95.0% 92.9%  A&E (Type 1 & 2) Response Rate None Mar 31.3% 20.0% 24.9% 

A&E Total A&E attendances None Mar 8,546 7,584 101,288 - Percentage seen within 4 hours 95% Mar 64.54% 63.07% 70.90%  Total Emergency Admissions None Mar 2,272 2,025 26,722 -

Ambulances Handovers between ambulance and A&E <15mins 100% Mar 18.0% 18.0% 26.1%  Number of patients waiting >30 - <60mins None Mar 536 518 4,487  Number of patients waiting >60mins None Mar 117 125 939 

Mixed Sex Accommodation Number of clinically unjustified MSA breaches 0 Mar 11 5 68 

VTE VTE Risk Assessments 95% Feb 90. 98.06% 98.61% 98.49% 

HCAI 10 No. Clostridium - Hospital Acquired (annually) Mar 0 0 12  No. MRSA - Hospital Acquired 0 Mar 0 0 0  41 PAH | Referral to Treatment | page 1 of 2

׀ Comments

Performance: The issues causing the under performance against the RTT Standard at PAH relates to the national suspension of the elective surgery programme, in response to the increased urgent care demand over the winter period.

This has resulted in an increase in backlog size by over 1,000 patients as well as delays in first and follow up appointments. In addition, there has also been an increase in the number of patients on the ASI list.

Actions The Trust is exploring options to implement additional capacity to address the long wait patients.

Recovery The agreed trajectory is for PAH to return to the 92% standard in July 2018. The trajectory for the next five months is:

• March 2018 – 88% (met) • April 2018 – 89% • May 2018 – 90% • June 2018 – 91% • July 2018 – 92%

PAH | Referral to Treatment | page 2 of 2

׀ Number of Incomplete specialities not meeting standard Continued

Pathway February Performance

General Surgery 84.77% PAH had one 52 week breach in January, this patient has now been dated. In February, there were a total of eight breaches; 1 x T&O and Urology 75.08% 7 x Urology (2 ENHCCG patients in Urology).

Trauma & Orthopaedics 83.37% Actions • Monthly reports are submitted to NHS England with a position on Oral Surgery 82.47% the 52 week waiters • Harm reviews being undertaken for all patients over 52 weeks Gastroenterology 86.73% Urology Service: Neurology 88.03% • Executive oversight of the Urology service pressures at weekly Gynaecology 89.79% meetings at the Trust • The Trust is recruiting to the substantive posts in Urology 52 week breaches 8 • Adult Urology – Clinical support from The Royal London being provided for Adult Urology Service in line with the London Cancer Pathway. • Paediatric Urology – Agreement between PAH and Cambridge University Hospitals NHS Trust to support PAH with the backlog of activity.

PAH | Cancer

׀ days to first definitive treatment for all cancers Comments 62

100% Performance PAH failed the 62 day standard in March achieving 78.95%. 80% This was mainly due to the issues with staffing within the 60% Urology service. The standard was met however for 2017/18 year to date at 84.44%. 40% 20% Actions • Paediatric Urology service is currently closed to new referrals 0% and CUHFT have agreed to support PAH with the backlog Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar activity.

% seen Target 85% • Adult Urology, PAH is in discussions with UCLH and the Royal College regarding job descriptions.

• PAH is holding weekly internal Executive meetings to review the situation and has flagged to CCGs there are no immediate safety concerns.

• Clinical assurance meeting with Commissioners is being held on 15th May 2018.

Recovery PAH has also failed the standard for April, but is on track to achieve in May 2018.

44 PAH | Accident and Emergency

׀ A&E seen within 4 hours Comments Performance 100% The ED standard remains challenging for PAH. Weekly performance 90% reviews with NHS England and NHS Improvement continue with an 80% ongoing focus on capacity modelling. 70% 60% Staffing, Norovirus and the new assessment spaces being utilised as 50% escalation beds continue to be issues for the Trust.

40% PAH had a number of 12 hour trolley breaches in February and March. 30% In February, there were 14 breaches and in March this increased to 89. 20% This has been caused by delays in identifying patients with a Decision 10% to Admit, ED Consultants admitting rights and the ED re-set in March. 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actions % seen Target Trajectory • During March PAH undertook a re-set of the ED department to enable the newly opened assessment beds to be utilised appropriately. Emergency attendances & admissions • ‘Entry into ED’ – to pilot a single leadership model to deliver an 10,000 50% Integrated Urgent Care service at PAH, that provides a single entry point for all non ambulance patients arriving at the front door. The 8,000 40% clinical model has been signed off at the Expert Oversight Group. The CCGs and Trust are now working through the activity and 6,000 30% financial impact of this proposal. • A Point of Prevalence Audit is to be undertaken across the systems rd 4,000 20% on 23 May to help identify the registered capacity across the system. 2,000 10% • 7 day working and senior decision making in ED at weekends. Medical input and additional doctors on the wards at weekends to support discharges. 0 0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Recovery Admissions Non-admissions Attendances Conv There are ongoing actions to support recovery of the ED standard. 45 PAH | Ambulance Handovers

׀ Handovers from ambulance to A&E within 15mins Comments 100% Performance 15 minute ambulance handovers at PAH remain below standard. This 50% was partly as a result of the ED re-configuration work that is now complete. 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Performance against the 30-60 minute and >60 minute thresholds have seen improvement during the first quarter of the year. % <15mins Target

Actions Handover delays from ambulance to A&E 30-60mins • Review of cover to support handovers, which is still being 600 provided by agency Paramedics. 400 • Paramedics trained on COSMIC to enable full handover. 200 • Revised Rapid Assessment and Treatment (RAT) process to deliver 0 dedicated decision maker level medical cover to the ambulance Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar assessment area. 30-60mins Recovery PAH is continuing to focus on improving the performance to achieve Handovers delays from ambulance to A&E >60mins the Ambulance Handover Standard. 150

100

0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

>60mins 46 PAH | Serious Incidents

PAH: Type of Serious Incident 6 5 4 3

Numbers 2 1 0 Diagnostic Sub-optimal Treatment Maternity incident care of Slips, Trips Medication Surgical Environmen Infection Pressure Other Incident inc Services including deterioratin and Falls Incident Invasive tal Incident Control ulcer Delay delay g patient Q1 1 2 0 1 1 0 1 1 0 2 1 Q2 0 0 2 0 0 5 0 3 0 0 0 Q3 1 2 0 0 1 3 0 0 0 1 0 Q4 0 1 0 0 0 0 0 0 0 0 0

׀ Comments

In Q4 PAH reported one SI ; this was a diagnostic incident relating to an ENHCCG patient.

The Trust has not declared any Never Events in 2017/18.

47 PAH | HCAI

Clostridium difficile PAH C-Diff Cases 2017/18 Although above their ceiling for C-Diff cases during 2017/18, the Trusts rate of 8.78 infections per 100,000 occupied bed days remains 20 significantly below both regional and national rates. Of the 14 acute 18 2016-17 apportioned cases reported to the end of January 2018, 6 of these 16 cumulative have been successfully appealed against contractual sanctions 14 cases through West Essex CCG (and later through the Herts CCGs C-Diff 12 Appeals Panel). 10 2017-18 cumulative 8 MRSA Blood Stream Infection (BSI) cases 6 No cases of Trust assigned MRSA BSI were reported during 2017/18. 4 2017-18 2 cumulative E coli Blood Stream Infection (BSI) 0 limit During 2017-18 the Trust reported a total of 20 cases of E coli BSI. The

PAH rate of 12.55 per 100,000 occupied bed days is significantly

Jul

Jan

Jun

Oct

Apr

Sep Feb

Dec

Aug

Nov Mar May below regional and national rates.

Incidents None since last report.

48 PAH | Maternity

׀ Total caesarean section Comments 40% During March the total c-section rate was 30.2%, this is a slight improvement compared to February. 30%

20% The planned c-section rate was 13.2% and the unplanned c-section 10% rate was 17.0%. 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar The latest audits indicates that all C-sections were clinically appropriate. Total % Target <25% The Trust is currently developing an action plan in relation to Planned caesarean section unplanned c-sections. 20% 15% 10% 5% 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

planned %

Unplanned caesarean section 30%

20%

10%

0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

unplanned % 49 PAH | Mixed Sex Accommodation

׀ Comments Number of clinically unjustified MSA breaches

12 Performance Patients are reviewed regarding suitability for a ward bed, in 10 February, 3 patients were delayed due to ward beds not being 8 available, another waited for a cardiac bed and another for a hip 6 fracture bed.

4 Actions 2 Matrons are reviewing opportunities to prioritise the order of patients transferred to wards, where a gender breach may be the 0 likely outcome of delay. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar No. of breaches Escalation processes are in place to alert the site management team of any potential breaches to enable corrective action to be put in place.

50 PAH | Family and Friends

׀ PAH Inpatient Survey Comments

100% Performance The inpatient score and response rate for PAH have been above 80% national average in Q4, with 98% of patients recommending the 60% Trust in March.

40% The ED FFT score has also been above the national average during Q4 with 95% of patients recommending the Trust in March. 20% Action 0% When possible, ENHCCG accompanies WECCG on Quality Assurance Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Visits, during which patient feedback is sought. Recommended Response Rate

PAH A&E Survey

100%

80%

60%

40%

20%

0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Recommended Response Rate

51 PAH | Workforce

׀ Sickness absence rate Comments % 6% Vacancy Rate The overall Trust vacancy rate has remained fairly static over the last 4% three months at around 10%. The Registered Nurse vacancies for March stand at 24.5% while Midwifery is over established by 6.2%, 2% giving a Trust wide Registered Nurse and Midwifery vacancy of 20.2%. The rolling 12 month position shows there is a net gain of 0% 8.59 WTE registered nurses and midwives across the Trust. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Target <3.5% There are still some areas of highest risk in terms of RN vacancy with some above 50%. ED remains a challenge at 35%. Daily mitigating % Staff turnover rate actions and risk assessments are in place. 20%

Sickness The Trust-wide sickness rate reduced in February to 3.81%; this is 10% above the Trust standard of 3.5%.

Turnover 0% Staff turnover has remained largely static across the quarter, with Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 13.2 % rate at the end of February, it remains above the target of Total Target <11% 11%. The Trust is participating in a national retention programme sponsored by NHS Improvement. The Trust’s Recruitment and % Staff appraised in last 12 months 100% Retention Group continue to explore a host of retention initiatives focussing on staff development, career progression and valuing staff.

50% Appraisals The Trust compliance at the end of February for all staff was 86%; this continues to improve. Appraisal rates are scrutinised monthly 0% by the NHSE/NHSI Oversight group. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Target 92%

52 PAH | Safer Staffing

׀ Comments Day Night

Month Nurse HCA Nurse HCA Performance February shows an overall reduction in the Trust average percentage April 79% 89% 114.8% 92% fill rates for both day and night, registered and unregistered staff. May 81.8% 83.6% 101.9% 81.7% June 80% 77% 103.1% 79.5% Actions July 79.9% 75.5% 103.10% 91% Following daily review of patient acuity and dependency, staff are redeployed to optimise safety and meet the patients’ needs. August 75.0% 74.7% 98.6% 81.4% Recruitment and retention actions continue. The Trust continues to September 74.9% 79.2% 91.1% 84.3% work with NHS Improvement to review Clinical Workforce October 79.4% 80.3% 97.5% 86.5% efficiencies.

November 85% 81.6% 103.9% 92.5% Staffing levels are also monitored during Quality Assurance Visits, December 76.2% 74.7% 97.8% 87.5% and updates have been provided at the PAH oversight meetings January 75.0% 71.6% 88.9% 88.3% chaired by NHSI. February 73.5% 71.2% 88% 88.1%

53 PAH | Other ׀ Comments CQC The CQC Chief Inspector of Hospitals inspected the Trust in December 2017 and gave a rating of ‘Requires Improvement’ on 21 March 2018. As a result the Trust was removed from ‘Special Measures’.

The Trust were rated as ‘Requires Improvement’ in safe and responsive and has be rated as good for effective, caring and well led. The CQC ‘must do’s and ‘should do’ form the basis of the Trusts Quality Improvement plans.

Mortality rates The 12 month rolling HSMR for January 2017 to December 2017 is 116.4 and statistically “higher than expected” and lower than the previous month’s figure which is now 115.9 with Trust updated data. This is the 12th consecutive month of reporting “higher than expected”. The in-month HSMR was “as expected” for the previous 7 months but is now “higher than expected”. The quarterly HSMR has been as expected for the last 3 quarters.

Rheumatology Follow – ups: The Trust undertook a review of clinical pathways in outpatients which identified a cohort of patients on the rheumatology pathway who have not had follow up reviews by the service since their first appointment. As a result WECCG, ENHCCG and PAH agreed a review of the Rheumatology Pathway and Harm Reviews of all patients to be undertaken by 31st March, which to date have resulted in no harm being found; the outcome of the review is to be presented at the Service, Performance and Quality Review Group in May 2018. The MSK Expert Oversight Group are reviewing processes to ensure this does not happen again.

Paediatric Orthopaedics: The Paediatric Orthopaedic Service at PAH is a single handed service and had previously been flagged by PAH as vulnerable. Referrals are still being accepted, however, there are long waits to be seen in outpatients. PAH are working with the Royal London to agree a combined post, to provide one day per week of a dedicated paediatric orthopaedic surgeon. The Royal London is also looking to provide additional capacity in the immediate to medium term. Urology : The PAH Urology service in both adults and paediatrics has been flagged with the CCGs as vulnerable, this is due to a high number of Locum Consultants within the service. The Paediatric service is currently not accepting any new referrals. PAH is in discussions with CUHFTto support the paediatric service to help clear the current backlog, this is due to start imminently. For Adult Urology, PAH is in discussions with UCLH and the Royal College regarding job descriptions. PAH is holding weekly internal Executive meetings to review the situation and has flagged to CCGs there are no immediate safety concerns. The CCGs have written to PAH seeking assurance and a clinical meeting is being arranged across the three organisations. 54

RFH | Barnet & Chase Farm Hospital

Current Prior Increase/ Month Month decrease in YTD Description Target Month performance Actual Feb Jan from last Month Diagnostic waiting times Percentage carried out within 6 weeks from referral 99% Feb 99.4% 99.9% 99.77% 

Friends and Family Inpatient Percentage Recommended (Chase Farm) None Feb 95.9% 94.2% 94.9%  A&E Percentage Recommended (Barnet) None Feb 78.2% 87.9% 79.91% 

A&E ENHCCG patients only Total A&E attendances None Feb 514 531 5,825 - Percentage seen within 4 hours (Trust wide) 95% Feb 81.36% 77.63% 85.83%  Total Emergency Admissions None Feb 173 224 2,176 -

Ambulances Number of patients waiting >30 - <60mins None Feb No Data 269 384  Number of patients waiting >60mins None Feb No Data 118 182 

Mixed Sex Accommodation Number of clinically unjustified MSA breaches 0 Feb 33 40 369 

HCAI 36 No. Clostridium - Hospital Acquired (annual) Feb 3 2 30  No. MRSA - Hospital Acquired 0 Feb 0 0 0 

55 RFH | Barnet & Chase Farm Hospital

Current Prior Increase/ Month Month decrease in YTD Description Target Month performance Actual Feb Jan from last Month Cancer waits(Chase Farm Hospital) 2 weeks for urgent cancer GP referrals 93% Feb 89.5% 91.5% 91.94%  2 weeks for urgent breast symptom referrals 93% Feb 95.7% 95.1% 92.95%  31 days to first definitive treatment for all cancers 96% Feb 100.0% 100.0% 100.0%  31 days for subsequent surgery 94% Feb 100.0% 100.0% 100.0%  31 days for subsequent drug 98% Feb 100.0% 100.0% 100.0%  62 days to first definitive treatment for all cancers 85% Feb 92.9% 91.4% 89.65%  62 days following screening referral 90% Feb 100.0% 100.0% 100.0% 

Cancer waits (Barnet Hospital) 2 weeks for urgent cancer GP referrals 93% Feb 94.4% 92.4% 94.36%  2 weeks for urgent breast symptom referrals 93% Feb 94.7% 90.7% 94.25%  31 days to first definitive treatment for all cancers 96% Feb 100.0% 100.0% 99.89%  31 days for subsequent surgery 94% Feb 100.0% 100.0% 100.0%  31 days for subsequent drug 98% Feb 100.0% 100.0% 100.0%  62 days to first definitive treatment for all cancers 85% Feb 92.3% 88.2% 89.65  62 days following screening referral 90% Feb 100.0% 100.0% 100.0% 

56 RFH | Summary | page 1 of 2

׀ Comments

Cancer 2 week wait. The Trust overall achieved the standard in February, recording 93%. The RFH site recorded 94.1%, Barnet 94.4% and Chase Farm Hospital 89.9%.

Cancer 62 Days from GP referral. For February, the Barnet and Chase Farm site achieved 92.4% with the Royal Free site achieving 78.6% against the 85% standard. Compliant tumour sites were Bladder, Breast, Dermatology, Haematology, Lower GI, Lung and Prostate. All other sites were non-compliant.

Diagnostic 6 week wait The Trust achieved the 6 week diagnostic standard in March. Areas that remain non-compliant include cystoscopy, echocardiography and colonoscopy.

A&E The Trust achieved 84.1% against the 95% ED Standard in March. Neither site achieved the standard with RFH recording 80.9% and Barnet recording 82.0%.

Barnet Hospital DTOCs remain high but daily multiagency meetings continue to be held. Royal Free Hospital saw high volumes of attendances with increased ambulances leading to increased admissions. The ECIP recovery plan has been implemented and a new AAU is planned for May.

RTT incomplete In March 2018, the Royal Free London reported 83.1% compliance with the 92% standard. The Trust is continuing to develop recovery plans with commissioners and regulators.

52 week waits Trust wide 52 week wait breaches total 36 as at the end of March. All patients waiting over 52 weeks will undergo a clinical harm review following treatment.

57 RFH | Summary | page 2 of 2

׀ Comments HCAI – Clostridium difficile & MRSA Blood Stream Infections Overall during 2017-18, the Trust reported a total of 82 cases of C-Diff against a ceiling of 66. This was significantly above the national rate per 100,000 occupied bed days. Of the Trust cases, a total of 33 cases were reported at Barnet or Chase Farm Hospitals. This was below their locally set limit of 36.

Although three cases of MRSA BSI were reported throughout 2017-18, this equated to a rate below regional and national rates. None of the cases occurred at the BCFH sites.

Never Events During March the RF declared a further Never Event, relating to a retained foreign object post-procedure; this occurred at the Barnet site. This brings the total number of Never Events to 10 during 2017/18. Safer surgery and a reduction in Never Events remains a quality priority for the Trust during 2018/19.

ENHCCG has sought assurance from HVCCG regarding the learning from SIs and Never Events.

Workforce The overall Trust vacancy rate has decreased during Q4 with a rate of 12.96% reported in March, this compares to 13.5% in December. The turnover rate for RF has remained stable with a rate of 15.89% in March. At the Barnet site the vacancy rate remains below the threshold of 11%, with a rate of 9.53% reported in March. However, the Chase Farm vacancy rate has increased further during Q4 with a rate of 21.01% in March. The Trust continues to hold monthly open days and 2 assessment centres a month to ensure on-going recruitment.

Maternity services Following an increase in total c-section rate at Barnet Hospital during November and December there was a reduction to 28.9% in January. The emergency c-section rate fell to 17% which is within expected limits, and the elective c-section rate was 11.9%. In March the RF received a CQC outlier alert relating to emergency c-sections, indicating that the Trust had significantly high rates of emergency c- sections compared to expected rates using CUSUM analysis. The alert relates to the period October 2016 to June 2017. The Trust is currently reviewing the alert and completing a case review of a sample of cases from the identified timeframe. A review of current c-sections is also being undertaken, focussing on maternal request c-sections and c-sections undertaken in pregnancies of gestation less than 39 weeks.

58 HCT | Increase/ decrease in Current Prior YTD Description Target Month performance Month Month Actual from last Feb Jan Month Average Length of Stay Stroke (days) 42 Feb 34.6 36.1 36.3  Stroke rehab pathway (days) 42 Feb 27.0 34.2 33.4  Non-stroke (days) 21 Feb 31.3 23.5 25.2  Non-stroke rehab pathway (days) 21 Feb 21.8 18.0 19.5  Readmission rates within 30 days 1.0% Feb 0.0% 0.0% 0.0% 

Early Supported Discharge All new stroke patients discharged from Acute/Community inpatient care into ESD 35% Feb 44.90% 74.42% 54.78%  Percentage of patients assessed and discharged from an acute or inpatient setting within 1 working day of referral 70% Feb 100.00% 97.00% 91.55%  Percentage of patients whose treatment programme started within one working day of discharge from hospital 90% Feb 100.00% 100.00% 92.09%  Percentage of goals met on discharge / transfer from ESD 85% Feb No Data No Data 92.33%  6 month review patients to receive a stroke review 4-8 months 95% Feb No Data No Data 100.00% 

Consultant Led Referral to Treatment Times (RTT) Completed Non-admitted patients None Feb 91.6% 88.4% 91.6%  Incomplete pathways 92% Feb 93.20% 90.35% 93.20%  Patients waiting at the end of the month None Feb 1,808 3,875 1,808  Number of 52 week breaches 0 Feb 0 0 0 

Mixed Sex Accommodation Number of clinically unjustified MSA breaches 0 Feb 0 0 0 

HCAI No. Clostridium - Community Acquired 6 (annual) Feb 1 1 9  No. MRSA - Community Acquired 0 Feb 0 0 0 

Pressure Ulcers Number of Acquired Pressure Ulcers (Grades 3 & 4) None Feb 1 0 24  Number of pressure ulcers determined to be 'avoidable' 0 Feb 1 0 4  59 HCT | Average Length of Stay (ALoS)

׀ Non-stroke (ENHCCG Patients only) Comments

35 Performance 30 The non-stroke ALoS rose sharply in February to 31.3, against a target of <21. 25

20 As regard to the non-stroke rehab pathway, HCT had maintained 15 good performance since October, consistently achieving the target of <21. However, in February, performance deteriorated and HCT just 10 missed their target of <21 with an achievement of 21.8. 5 0 Actions Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb The CCG will monitor performance through Contract Review Meetings to understand improvement in Lengths of Stay and how LoS Target <21 HCT will maintain current year to daten achievement of the target.

Non-stroke rehab pathway (ENHCCG Patients only)

0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar LoS Target <21

60 HCT | Delayed Transfer of Care

׀ Comments

Performance DToCs remained static over January and February at 10.2% overall, and 9.8% and 9.0% for health delays respectively. This is a reduction in DToCs from December.

Actions HCT continue to embed Red2Green (R2G) and undertake daily and weekly internal and system-wide calls to support discharges. HCT have also worked proactively with system wide partners to establish the Discharge Home to Assess (DH2A) service to further support discharges out of ENHT. It has been agreed that HCT will continue to focus on implementing Best Practice Guidance – Flow in Community Providers. It has also been agreed that further capacity will be provided out of Herts and Essex Hospital to support flow.

HCT | Estimated Date of Discharge (EDD)

׀ Estimated Date of Discharge Comments

100% Performance HCT is still not meeting the target of 90% of patients achieving their 80% estimated date of discharge. In January there was a marked increase 60% to 58% but this dipped again in February to 53%.

40% Actions The percentage of patients meeting the Estimated Discharge Date 20% (EDD) has been around 50% all year. The Trust has worked internally 0% to re-write a professional standard for staff to adhere to (similar to Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb the work that was undertaken for DToCS and R2G). Under this new method, patients will now have a more accurate EDD set within 72 hours. It will take some time to see the outcomes of this work in Achieved achievements against EDD.

62 HCT | Serious Incidents

HCT (ENHCCG): Type of Serious Incident 2017/18 1.2 1

0.8 0.6

Number 0.4 0.2 0 Safeguarding Adults Fracture following a fall IG Breach Pressure ulcer Unexpected Death Infection Control Q1 0 1 0 0 0 0 Q2 0 0 0 1 0 0 Q3 0 0 1 1 0 0 Q4 0 0 0 1 0 1

׀ Comments

During Q4 HCT reported 7 SIs across the organisation, 2 of which related to an ENHCCG patient.

The Trust has not declared any Never Events in 2017/18.

63 HCT | Workforce| page 1 of 2

׀ Vacancy Rate by Community Team: Comments

Implementation of the Trust Resourcing Plan continues. A major Welwyn & North Mar 18 Stevenage Royston project is underway across the STP area, with a Heart Radio Hatfield Herts campaign and Metro/Evening Standard advertorial, leading to an STP Vacancy 15.1% 2.4% 5.5% 8.1% wide Recruitment Job Fair on the 12th May. Rate The focus on nurse retention continues as part of the NHSI Nurse Lower Lea Upper Lea Bishop Stortford Retention Programme, with a series of dates booked for career Mar 18 Valley Valley & Stort Valley clinics (building on the successful clinics already run) and work being done on support during preceptorship, including buddying. Vacancy Rate 13.5% 11.9% 25.9% All bed base units other than Danesbury had vacancy rates above the Trust target. Herts & Essex Hospital continue to have high vacancy rates and targeted recruitment is continuing. Herts and Essex are recruiting successfully to posts.

Vacancy Rate by bed base:

Herts and Mar 18 QVM Danesbury Essex

Vacancy Rate 22.79% 12.79% 9.15%

64 HCT | Workforce| page 2 of 2

׀ Staff turnover rate Comments

30% Staff turnover rates are currently at 14.7% for underlying turnover 25% and 21.29% for total turnover (which includes TUPE Transfers out). Total turnover has dropped from 24.42% in February. The focus on 20% nurse retention continues as part of the NHSI Nurse Retention 15% Programme, with a series of dates booked for career clinics (building on the successful clinics already run) and work being done on 10% support during preceptorship, including buddying. 5% 0% Vacancy rate narrative on previous page (64). Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

% Turnover Target <12%

Vacancy rate Apr 17 20%

15%

10%

0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

% Vacancy Rate Target <9% 65 HCT | Safer Staffing

Herts and QVM Day Danesbury Day Day Essex Month Nurse HCA Month Nurse HCA Month Nurse HCA April 86.7% 112.7% April 103.1% 96.8% April 86% 117.1% May 91.8% 97.0% May 97.0% 97.7% May 84.3% 167.3% June 95.8% 101.1% June 93.7% 109.1% June 78.8% 134.0% July 83.6% 95.9% July 91.1% 135.8% July 76.5% 134.2% August 84.5% 98.1% August 89.2% 138.0% August 68.0% 156.7% September 93.9% 118.8% September 92.7% 123.1% September 80.8% 177.7% October 78.8% 135.2% October 95.4% 93.0% October 92.6% 98.1% November 83.5% 107.1% November 93.5% 94.3% November 94.1% 112.1% December 80.5% 105.5% December 93.6% 91.9% December 96.7% 122.6% January 89.7% 98.3% January 100.1% 94.3% January 95.4% 97.6% February 89.3% 90.2% February 93.7% 97.8% February 90.5% 111.6% ׀ Comments

Whilst all units had staffing levels above the HCT target, Herts and Essex continue to have vacant Registered Nurse posts 3.22 WTE, the use of ‘Long line’ agency staff continues until vacancies are filled. Targeted work to improve recruitment and retention of staff to Herts and Essex is in place.

66 HCT | Palms | page 1 of 3 Performance

Actions

The demand for PALMS is above the commissioned capacity for the service which has increased access waiting times to the first appointment. PALMS is commissioned to actively work with 600 CYP per year, however, PALMS are working with over 800 children and young people (CYP) per year. The estimate for the whole of 2017-18 is 862 CYPs. The current baseline for the wait from referral to initial contact is 27 weeks. There are: • 87 CYP waiting for an initial assessment from E&N Herts CCG area of which 41 people who have waited longer than 18 weeks • There are 11 people from E&N Herts area waiting for treatment of which 2 have waited more than 18 weeks

The waiting times in the service remain extremely challenging. HCT PALMS continue to work with the commissioners to proactively address this challenge. The main challenge is the number of people waiting for an initial assessment rather than the number of people waiting for treatment which is a small number (11). 67

HCT | Palms | page 2 of 2 Action Waiting Times Initiatives: PALMS developed a remedial action plan to release capacity and allow the service to reduce waiting times to access the service. This includes implementation of the actions and recommendations from the Quality Assurance Action Plan and Tizard Review. Actions include: the pilot of a sleep group and development of a feeding group are due to begin in April 2018; targeted Initial Assessment Appointments with the aim of filling the possible group slots; completion of risk assessments for all PALMS’ CYP; caseload review and proactive recruitment.

PALMS’ Caseload and Capacity Review On 28th February 2018 a review of active caseloads was undertaken where clinicians scrutinised their current caseloads to consider the CYP’s pathway, length in service, the joint working and projected length of stay in service. Alongside the immediate aims of reviewing capacity within the service, the aim of the exercise was to remind clinicians of the need to utilise the Goal Based Outcomes as a baseline and guide to discharge, to ensure appropriate service provision and that clinicians are not inappropriately retaining CYP on the caseload rather than giving them the tools to self-manage . This was achieved by: • Reviewing the joint working criteria and asking clinicians to identify those CYP who may no longer need joint work (involving two clinicians per contact). • Undertaking this led to identifying 19 CYP where joint work could cease within the next month. This has then enabled the majority of CYP waiting for an intervention at that time to be allocated a clinician and identification of facilitators for the increased number of groups.

‘Length of service’ review PALMS have started the review of CYP that have been open to PALMS for a significant length of time. The aim of this is to ensure needs are met in the most effective and efficient way. It is anticipated that themes will emerge with regards to those CYP that require more sustained input from PALMS. The current review is focusing on CYP open for 111 weeks to 132 weeks (the longest LoS). A total of 87 CYP have been open for this length and the review reduced this to 67.

Group Interventions Group interventions are proving effective in meeting CYP and families’ needs and increasing capacity within the team. The groups have now been staggered in a rolling programme format to maximise the number of families that can attend. Across March 2018 and April 2018, 65 IAAs were offered to families targeted at those triaged as ‘likely to benefit from a group’. 59 IAAs were taken up with the majority of families attending the relevant group starting in April or May 2018. The group interventions PALMS offer are: Positive Behaviour Support Group - continues to be implemented with positive outcomes. Sleep Group –Piloted in April – June 18. Feeding Group – to begin on 25th April 2018. 68 HCT | Palms | page 3 of 3 Recovery: Waiting List Trajectory

69 EEAST

Increase/ decrease in YTD Description Target Month Current Prior performance Actual Month Month from last Month Cardiac Arrest (ENHCCG patients) Outcome from cardiac arrest measured by ROSC (Return of spontaneous circulation) at point of handover of the patient to hospital 27% Jan 28.6% 22.7% 24.5%  Percentage of patients who survive cardiac arrest to discharge from hospital 7% Jan 3.6% 0.0% 5.3% 

STEMI (ST segment elevation myocardial infarction) Percentage of patients suffering a STEMI PPCI and receive angioplasty within 150 minutes of call 95% Jan 85.7% 84.6% 89.1%  Percentage of STEMI patients receiving appropriate care bundle (ENHCCG) 81% Jan 100.0% 62.5% 87.9% 

Stroke (ENHCCG patients) Percentage of suspected stroke patients who received appropriate care bundle 98% Jan 100.0% 100.0% 99.7%  Percentage of FAST positive stroke patients who arrived at a hyper acute stroke centre within 60 minutes of call 56% Jan 41.7% 20.0% 31.8% 

Response Times - C1/C2/C3 and C4 Calls Mean C1 calls response time (<7 minutes) 7:00 Mar 8:47 8:42 8:41  Mean C2 calls response time (<18 minutes) 18:00 Mar 27:26 26:53 28:00  90th Centile C3 calls response time (<120 minutes) 120:00 Mar 209:15 187:36 212:03  90th Centile C4 calls response time (<180 minutes) 180:00 Mar 242:38 241:05 252:39 

Ambulances Turnaround % of handovers to clear <15mins - Lister 100% Feb 68.00% 68.00% 64.44%  % of handovers to clear <15mins - PAH 100% Feb 50.00% 48.00% 43.67%  70 EEAST | AQIs | page 1 of 2

׀ Percentage of patients who survive cardiac arrest to Comments discharge from hospital The Trust continues to review the cardiac arrest data closely to better 16% understand any clinical practice that may affect these fluctuations and 14% replicate best practice where possible. 12% Actions Trust are taking; 10% • 2018/19 Professional update (PU) programme being written to 8% include Cardiac Arrest. 6% • Cardiac Arrest Bootcamps ongoing. 4% • Cardiac Arrest Checklist available throughout stores, taught within 2% E&T environments and PU. 0% • Resuscitation Council (UK) ALS courses being planned throughout the Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar year. • Ongoing monitoring of OHCA performance through OHCA report on AuditR. % Achieved Target 7% • Cardiac arrest strategy pre-launch at Octobers clinical briefing. Due for full sign off and release by April 2018. • Cardiac care and cardiac arrest management group re-established to Percentage of patients suffering a STEMI PPCI and help support improvements in cardiac arrest survival. receive angioplasty within 150 minutes of call • CPD day on 28th March 2018 including cardiac arrest management.

100% PPCI The Trust has seen a increase in compliance against this ACQI to 85.7% 80% which is above the national average of 84%. The availability of 60% transportable resources is key to meet this target along with the timeliness of clinicians recognising a STEMI and transporting the patient 40% to a PPCI centre. ACLs continue to review calls to ensure the on scene times for the clinicians are kept to a minimum. 20% 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

<150 mins Target 95% 71 EEAST | AQIs | page 2 of 2

׀ Percentage of FAST positive stoke patients who arrived Comments at hyper acute stroke centre within 60 minutes of call (ENHCCG patients) Stroke 100% Work is being continued to support the recognition of strokes and to encourage patients to call if they have the symptoms highlighted in 80% the successful national FAST campaign. Transportable resources are 60% the key to ensure a timely delivery to the HASU. Equally, the ACLs are reviewing calls where the standard was not achieved to 40% understand the on scene times to identify opportunities to improve 20% overall time to HASU. Feedback is provided at Quarterly Quality Review meetings and Sector meetings. 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actions Trust are undertaking; • Ongoing monitoring of on scene times with a 'snap audit' % Achieved Target 56% undertaken by the ACL team. • Opportunity identified to ensure reduced on scene times for both STEMI and Stroke patients. • Feedback to local 'clinical' dlo (Duty Locality Officer) if learning required and feedback given. • End to End review presented to Commissioners, ongoing audit by all ACLs at monthly contract meetings.

72 EEAST | Response Times | page 1 of 2

׀ Ambulance Responses C1 calls (<7 minutes) Comments

10:00 Performance 08:00 06:00 Performance for category C1 response calls remain below the 04:00 expected standard although performance has remained fairly 02:00 consistent since January. Performance for category C2 response 00:00 calls demonstrates improvement on the December position Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar although through January to March has remained consistent. Av Response Time Av Target < 7 mins Category C3 and C4 response calls have improved since December 2017 and remain fairly consistent through January to March. Ambulance Responses C2 calls (<18 minutes) Achievement remains outside the targets of <120 minutes and 35:00 <180 minutes respectively. 30:00 25:00 20:00 December showed an increase in conveyances to Lister totalling 15:00 2,636 for March 2018. 10:00 05:00 00:00 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Av Response Time Av Target < 18 mins

Ambulance Responses C3 (<120 mins) and C4 calls (<180 mins) 06:00:00 05:15:00 04:30:00 03:45:00 03:00:00 02:15:00 01:30:00 00:45:00 00:00:00

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

C3 90th Centile Response Time C4 90th Centile Response Time C3 Target < 120 mins C4 Target < 180 mins

EEAST | Response Times | page 2 of 2

׀ Comments Actions

Following the risk summit a number of actions have been put in place to maximise Unit Hour Production (UHP). Staff vacancies are being addressed as part of EEASTs commitment to recruiting more paramedics. This has been demonstrated by EEAST now carrying a reduced vacancy rate of 10.5% from 18% in January for ENHCCG. It is to be expected that vacancy levels will increase again as the final ISR, which is due to be shared with the Commissioners in May 2018, will indicate an increase in staff and vehicles.

In order to support delivery of an efficient ambulance service NHS England, NHS Improvement, Commissioners and EEAST have agreed, as part of a binding mediation outcome to jointly commission a strategic service review. The review will assess and make recommendations as to the future resourcing required for EEAST to support the delivery of the constitutional performance standards and contractual key performance indicators. The work has been commissioned by NHS England and NHS Improvement, with input from EEAST and commissioners who will be joint recipients of the draft and final reports. At the time of writing, Commissioners await sight of the final report.

Performance is also discussed at the monthly EEAST sector meeting and monthly SLA meeting. CCGs are also invited to attend EEAST Operational Performance Improvement and Delivery Group meetings which are held fortnightly and information is provided regarding weekly performance.

Recovery

To date, improvements have been seen in the following areas:

• Response times to category C2 calls from December performance • Response times to category C3 calls from December performance • Handover delays at PAH in February reduced by 2% from January performance

74 EEAST | Turnaround Times | page 1 of 2

׀ Ambulance Handover to Clear <15 mins – Lister Comments Hospital 100% Performance

80% ENHT performance for ambulance handovers remains constant at 68% in February 2018. 60%

40% There were 17 delays over 30 minutes and 2 delays over 60 minutes.

20% PAH performance for handovers <15minutes rose to 50% in February 2018. There were 7 delays over 30 minutes and 2 delays over 60 0% minutes. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

<15mins Target 100%

Ambulance Handover to Clear <15 mins – PAH

100%

80%

60%

40%

20%

0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

<15mins Target 100%

75 EEAST | Turnaround Times | page 2 of 2

׀ Comments Actions

During the past 12 months, ENHT have revised the ambulance handover pathway. Although this is working well in-hours there is still some work to be done with ENHT to ensure the same processes are embedded as robustly during the out of hours period. EEAST has been able to provide weekly data during April 2018 which demonstrates this work is beginning to show benefits, as at week 4 the handover delays has shown early signs of recovery. Following the risk summit a handover protocol has been put in place to which escalation process are instigated at 30 minute delays to tactical and strategic level.

ENHCCG continues to commission HALOs working between 10am and 10pm daily to facilitate the clinical handover of patients. EEAST has introduced a Patient Safety Intervention Team (PSIT) to target hospitals with high handover delays. A generic tripartite/handover policy is being agreed.

Recovery

The ambulance handover performance will continue to be monitored during 2018/19 to ensure that escalation processes and handover pathways are fully embedded and become business as usual regardless of the patients time of arrival.

Ambulance handover performance is also discussed in a number of meetings including both the local and regional monthly contract meetings with EEAST as well as the Operational Performance Group meetings.

76 EEAST | Workforce

׀ Comments Sickness absence rate (E&N Herts) Performance 12% 10% East & North Hertfordshire sickness absence rates have dropped to 6.7% in February 2018 against the target of 5%. EEAST are 8% monitoring sickness absence, especially long term sickness, by 6% maintaining contact with staff and ensuring certificates are received 4% in good time. This is discussed at the fortnightly OPID meeting.

2% 0% Vacancy Rate Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar East and North Hertfordshire vacancy rates have decreased to 10% % Outcome Target 5% in April from 18% in January. This equates to 26.1WTE. Active recruitment also continues.

77 EEAST | Other

׀ Comments

Quality

In Q3 it was reported that a process was put in place to review 22 cases and all locality CCG leads would attend a weekly panel to scrutinise the cases. ENHCCG is the locality lead for Beds, Herts and Luton and has 2 cases attributed to those CCGs out of the 22 cases.

A Harm review process has been undertaken led by an independent ED consultant which ENHCCG participated in to ascertain levels of harm in each of the 22 cases. The review will be finalising their review of the 22 cases and will be reporting back to the risk summit in May 2018 informing that all 22 cases have been closed with action plans in place.

78 HPFT |

Increase/ decrease in YTD Description Target Month performance Current Prior Actual Month Month from last Month Feb Jan Monitor Patients on a Care Programme Approach (CPA) for at least 12 months who had a CPA review within the last 12 months 95% Feb 93.6% 95.4% 95.8%  Admissions to acute wards that were gate kept by the Crisis Resolution Home Treatment (CRHT) teams 95% Feb 96.9% 100.0% 97.4%  Patients on Care Programme Approach (CPA) who were followed up <7 days after discharge from psychiatric inpatient care 95% Feb 95.0% 97.8% 95.6%  Number of new cases of psychosis served by early interventions teams 6 Feb0 9 8 126 

Access Routine referrals: community eating disorder services <28 day wait 98% Feb 100.0% 88.9% 98.3%  Routine referrals: community mental health team <28 day wait 98% Feb 100.0% 89.3% 92.4%  CATT Referrals meeting <4 hour wait 98% Feb 100.0% 100.0% 99.9%  Routine referrals: Specialist Community Learning Disability Services <28 day 98% Feb 100.0% 100.0% 95.5%  Referrals: 18 weeks for all mental health and learning disability services 98% Feb 99.5% 99.5% 98.9% 

Safe & Effective Emergency re-admissions to hospital within 28 days of discharge 8% Feb 7.7% 1.8% 5.1%  People with severe mental illness who have received a list of physical checks (inpatients) 90% Feb 100.0% 90.7% 95.5%  Employment of people with mental illness 8% Feb 12.3% 12.1% 9.0% 

79 HPFT |

Increase/ decrease in YTD Description Target Month performance Current Prior Actual Month Month from last Month Feb Jan Child and Adolescent Mental Health Services (CAMHS) Referrals: Assessment waiting time standards - Crisis (4 Hours) 95% Feb 88.6% 92.3% 92.6%  Referrals: Assessment waiting time standards - P1 (7 days) 75% Feb 33.3% 66.7% 71.7%  Referrals: Assessment waiting time standards - Targeted service (14 days) 85% Feb 100.0% 71.4% 84.6%  Referrals: Assessment waiting time standards - Routine (28 DAYS) 95% Feb 91.8% 74.6% 69.3% 

Dementia Number of service users going through EMDASS who have been diagnosed with dementia None Feb 46 67 63 - Number of service users going through EMDASS who have been diagnosed with mild cognitive impairment None Feb 12 18 8 - Service users with dementia offered an end of life plan None Feb No Data No Data No Data  Service users with dementia with an end of life plan in place None Feb No Data No Data No Data 

HCAI No. Clostridium occurring onset of symptoms 2 days following admission 0 Feb 0 0 0  No. MRSA occurring onset of symptoms 2 days following admission 0 Feb 0 0 0 

Workforce Sickness absence rate 4% Feb 4.31% 5.02% 4.40%  Staff turnover rate None Feb No Data No Data No Data 

80 HPFT | Monitor

׀ Comments Patients on a Care Programme Approach (CPA) for at least

12 months who had a CPA review within the last 12 Performance months 100% East and North CCG are just below the 95% target in February (93.59%). This is only the second time, in the financial year that it has 80% been below target (365 reviews completed out of 390). Actions 60% Priority is being given to ensure that CPA reviews are carried out in a way that recognises the feedback from the Adult Community service 40% user review. This requires pre-planning and ensuring the service users and carers are prepared well for reviews. As a result this can impact on 20% the overall target levels if meetings are missed or need to be rescheduled. 0% Recovery Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Ongoing work shows positive impact and that March has achieved at % Achieved Target 95% 97.97%.

81 HPFT | Access

׀ Early Memory Diagnosis Service <6 week wait (Herts) Comments Performance The EMDASS 6 Week Assessment waiting target of 90% will be replaced 100% by a new diagnostic waiting time target in 2018/19. This is in line with 90% the One Stop Pathway where patients receive an assessment and 80% diagnosis together. 70% 60% Actions 50% The one stop pathway is already in place in East quadrant and will be 40% introduced in North quadrant in June. 30% 20% 10% Recovery 0% Performance in the North quadrant will improve in line with the Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb implementation of the one stop pathway.

<6 week Target 90%

Performance Number of people entering IAPT treatment In ENHCCG the number of people entering treatment in February for HPFT was 744/761 at 97.77%, under target by 17 people. 1,200 Actions 1,000 No actions are required as ENHCCG overall is year to date exceeding the set year end target for IAPT access 800

600 Recovery In February, the year end target has been exceeded by 1,304 people 400 (8823/7519). 200

0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Number Entering Target 82 HPFT | Safe and effective| page 1 of 2

׀ Service users with a completed up to date risk Comments assessment (ENHCCG) Performance A slight dip overall in Hertfordshire for February to 92.89%. 100% Actions 95% Adult Community services have shown a clear improvement in completing risk assessments. This is due to continued focused work including; oversight and scrutiny of individual and team caseloads, 90% weekly actions identifying those overdue or who require CPA review and review of medical and outpatient clinic caseloads for incomplete 85% risk assessments. Individual clinicians are being reminded of need to complete risk assessments. 80% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Recovery Overall year end outcome is not clear at this point due to lower Number of service users Target 95% performance in CAMHS (children’s services) and MHSOP (Mental Health Services for Older People). However, March has shown a slight increase to 94.36%. Settled accommodation for adults with mental health problems (Herts) Performance A small decrease from 78.58% in January to 77.10% in February. 100% Actions 80% Although progress continues, it has slowed significantly due to a rise in referrals into HPFT from January. Referrals do not routinely convey the 60% settled accommodation information. 40% Recovery 20% From April these indicators will become part of routine work and the cohort of service users without employment and accommodation 0% statuses will be targeted for completion. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Number of settled accomodation for adults Target 90% 83

HPFT | Safe and Effective| page 2 of 2

׀ Comments Emergency re-admissions to hospital within 28 days Performance of discharge (E&N only) 10% 7.69% (5/65) in February, 0.16% over the 7.5% maximum permitted readmissions. 8% Actions 6% Statistical analysis has been carried out for both ENHCCG and HVCCG's trend data for the last 25 months. This has shown that the overall 4% average for each year, is within the performance threshold for both 2% CCG’s (i.e. 7.5%).

0% Recovery Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Due to the small numbers of readmissions on a monthly basis, as seen Achieved on the graph on the left hand side, there is fluctuation, but overall Maximum permitted readmissions 7.5% HPFT is to achieve the maximum permitted readmissions in the YTD position financial year from April to March.

84 HPFT | CAMHS | page 1 of 2

׀ Referrals: Assessment waiting time standards Comments - Crisis (4 Hours) Performance Under performance due to high number of referrals into C-CATT at 100% both A&E departments and vacancies.

80% Actions 60% Recruitment is underway. Delays are monitored daily and staff are moved between the acute 40% Trusts as appropriate.

20% Five cases went over the 4 hour waiting time target, all are attributed to days in A&E where there were high numbers of referrals to be 0% assessed i.e. 4 or 5 young people in A&E at one time. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb <4 Hours Target 95% Recovery At the next Contract Review meeting in May, HPFT will be presenting to commissioners on their recovery actions.

85 HPFT | CAMHS | page 2 of 2

׀ Comments Referrals: Assessment waiting time standards (7 days) Performance Six P1 cases (Priority 1 – to be seen within 7 days) breached out of a total 100% of 9 for ENHCCG in February.

80% Actions For 3 of the 6 cases appointments had to be cancelled on the day due to 60% staff sickness and because of the tight timeframe there was no opportunity to re-offer within the 7 day period. 40% The service has seen a significant increase in P1s over December, January and February, which is proving difficult for the team to offer urgent slots. 20% East Quadrant has particularly seen an increase although some referrals have been appropriate to downgrade to routine. 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Recovery <7 Days Target 75% All breaches have subsequently been seen.

Performance North Herts were at 92% in February and have seen an improvement in Referrals: Assessment waiting time standards - their waiting times. East & South East were at 95.56%. Routine (28 DAYS) Actions 100% North Herts have improved over the last month. East & South East are now under pressure to be able to maintain improvement for March and April, 80% due to later triage times in SPA which leaves little time to rescue any potential breaches. 60%

Recovery 40% The DNA (Did Not Attend) protocol has now been fully implemented and is 20% expected to help teams to remain within the 95% assessment waiting time standard by the end of March. 0% HPFT will be presenting at the next Contract Review meeting in May their Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb recovery action plan including actions already implemented to recover the position. <28 Days Target 95% 86

HPFT | Serious Incidents

HPFT (ENHCCG): Type of Serious Incident Reported 2017/18 25

0 Major Safeguarding Apparent/actu Unexpected Self-inflicted Disruptive/Viol incident, Unauthorised Vulnerable Slip, Trip, Fall IG Breach Accident Alleged abuse al/suspected Death harm ent Behaviour emergency absence Adult homocide preparedness Q1 1 0 0 6 1 1 1 0 0 0 0 Q2 3 0 1 2 0 0 0 0 0 0 0 Q3 0 0 2 4 0 0 0 0 0 0 0 Q4 0 0 5 22 4 0 0 3 1 1 1

׀ Comments In Q4 37 SIs were reported across the organisation, 22 of which related to ENHCCG patients or services.

The Trust has declared no Never Events in 2017/18.

87 HPFT | Workforce

׀ Sickness absence rate Comments

6% Performance Sickness absence rate reduced from 5.02% in January to 4.31% in February. 5% Actions 4% HPFT focus on supporting operational managers to manage long term sickness absence cases has resulted in no live cases of sickness absence for 3% staff of more than a year. The Sickness Absence Boards continue as a forum for the Employee Relations team to support managers dealing with sickness 2% in the SBUs (Service Business Units), and ensure consistency in approach. The Employee Relations team will be collating information concerning the 1% number of return to work interviews to ensure compliance and supporting 0% managers to carry these out. Return to work meetings have established to Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb reduce repetitive sickness absence, as well as being a helpful measure for staff returning to work. The Business Partner team will carry out sickness % Achieved Target <4% absence audits in the SBUs to ensure that the information required for collation has been documented. This approach is intended as a supportive measure for managers. Recovery Staff with a current PDP and appraisal Work carried out is reflected in the reduction in sickness absence this month. 91% Performance 90% Staff with a current PDP has decreased from 88% in January to 87% in 89% February. PDP rates this month were maintained in Corporate and East and North SBU. There has been a 2% decrease in LD&F (Learning Disability and 88% Forensic). 87% The following service lines are above the Trust target of 95% - Hertfordshire Forensics, Mental Health Rehab services, SPA and West Herts Management. 86% The latter two service lines have achieved 100%. 85% Actions East and North SBU managers have been tasked with completing all 84% outstanding PDPs by the end of March with regular time being allocated to Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb complete this work. Recovery % Achieved Target 90% East and North SBU’s to reach 95% compliance by the end of March 2018. 88

HPFT | Workforce

׀ Registered Nursing – Inpatient Services Comments Performance Sum of Strategic Sum of Sum of FTE The 24.9% overall nursing vacancy rate continues to be a major issue. Position % Vacancy Business Unit Actual FTE Variance FTE HCA vacancies are at 19.4%.

Learning Actions Disability & HPFT are pursuing every option to try to increase recruitment and Forensic 168.31 133.97 34.34 20.4% retention, including housing options; a loan scheme for deposits; East and initiatives for hotspot areas; and attending a recruitment event in North SBU 95.55 66.98 28.57 29.9% Leeds.

West SBU 91.07 65.65 25.41 27.9% Recovery Total 354.93 266.61 88.32 24.88% There is also a strong focus on reducing agency staff, but HPFT are adopting a pragmatic approach and will not put service users at risk. Registered Nursing – Inpatient Services Sum of Inpatient Sum of Sum of FTE Position % Vacancy Service Actual FTE Variance FTE Robin Ward 11.60 5.80 5.80 50% Elizabeth 12.14 10.44 1.70 14% Court Albany Lodge 13.80 7.50 6.30 46% Oak Unit 13.50 8.00 5.50 41% Swift Ward 17.50 17.00 0.50 3% Sovereign 6.00 4.44 1.56 26% House Lambourn 11.20 7.24 3.96 35% Lodge 89 Seward Lodge 12.00 8.80 3.20 27% HPFT | Other ׀ Comments

Memory Services National Accreditation - Royal College of Psychiatrists The North, Northwest and Southwest EMDASS teams have all been awarded MSNAP re-accreditation for the next 2 years. The teams were recognised for their hard work to gain the status again. The East team gained their accreditation in 2017.

CQC Report CQC released their report into HPFT on 25th April 2018. The overall rating remains as ‘Good’. CQC had visited a range of inpatient services across the Trust in January. There have been some changes in individual areas, including an ‘outstanding’ rating for LD inpatient services which is a significant improvement. The overall rating for the ‘safe’ domain remains as ‘requires improvement’. The other domains were all rated as ‘good’ (Effective, Caring, Responsive and Well led). The outcome of the review is summarised in the table to the right.

90 HUC | IUC

Increase/ decrease in YTD Description Target Month performance Current Prior Actual Month Month from last Month Mar Feb Home Visits Urgent visits undertaken within 2 hours 95% Mar 84.5% 78.7% 82.0%  Routine visits undertaken within 6 hours 95% Mar 85.2% 80.6% 83.4% 

Base face to face consultations following definitive clinical assessment Urgent consultations undertaken within 2 hours 95% Mar 82.0% 82.7% 85.2%  Routine consultations undertaken within 6 hours 95% Mar 91.3% 93.6% 94.3% 

NHS 111 % abandoned calls after 30 seconds 5% Mar 6.4% 7.1% 3.6%  Average time to call answer (secs) 60 Mar 75 86 48  % Ambulance dispatches 10% Mar 7.6% 8.1% 8.0% 

AiHVS % of calls answered within 60 seconds 95% Mar 93.0% 93.7% 90.1%  Average number daily visits 90 Mar 52 54 48  % Routine visits <6 hours 95% Mar 97.4% 95.6% 97.0%  Visits Passed to the OOH service 0 Mar 15 27 156  Clinican Staffing Percentage 95% Mar 97.6% 95.0% 95.2% 

91 HUC | IUC

Increase/ decrease in YTD Description Target Month performance Current Prior Actual Month Month from last Month Mar Feb Clinical Assessment Service Navigator % answered within 60 Seconds 95% Mar No Data No Data% 92.4%  CAS % of cases warm transferred 75% Mar 6.8% 3.9% 8.4%  CAS % of calls called back <15mins 100% Mar 60.6% 52.5% 55.6%  % of Green Ambulance revalidated by CAS GP 100% Mar 96.1% 94.7% 89.9%  % of Green Ambulance calls called back <15mins 100% Mar 63.3% 56.3% 60.0%  % of revalidated CAS cases diverted away from ambulance service None Mar 89.7% 80.7% 87.1%  % of ED revalidated by CAS GP 100% Mar 72.8% 71.4% 67.1%  % of ED calls (<1 hour) called back <15mins 100% Mar 48.0% 37.7% 45.9%  % ED cases given disposition other than ambulance or ED None Mar 81.5% 81.5% 73.2% 

92 HUC | Integrated Urgent Care

׀ abandoned calls after 30 seconds Comments % 111 Performance 8% February 7% The total number of calls was 29,429 of which 2,458 were 6% abandoned after 30 seconds, achieving 7.1% against the 5% threshold. The average time to call answer was 86 seconds above 5% the current 60 second target. 4% 3% March 2% The total number of calls was 32,917, of which 2,367 were abandoned after 30 seconds, achieving 6.4% against the 5% 1% threshold. The average time to call answer was 75 seconds, above 0% the current 60 second target. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar % Answered Target 5% Staff sickness and absence levels impacted upon the average time to call answer which resulted in an increase of calls being abandoned. There were over 4,000 more calls in February compared to the same 111 Average time to call answer period in 2017. An Easter message was deployed on the telephony system to warn the public of potential delays which may have 00:01:44 impacted on patients abandoning the call. 00:01:26 Actions 00:01:09 HUC has drafted a remedial action plan to address these issues. 00:00:52 Letters have been sent to staff with particularly high sickness and absent rate levels. The ‘potential delays’ answering machine 00:00:35 message has been removed. 00:00:17 Recovery 00:00:00 The recovery date was April 2018 and early indications show that Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar HUC has met this trajectory. Average time (secs) Target <1 minutes

93 HUC | Integrated Urgent Care

׀ Home Visits: Urgent visits undertaken within 2 hours Comments Performance 100% The total number of Out of Hours (OOH) cases in February was 10,257 of which 1,194 (11.6%) of patients received a home visit. In 80% March, this was 12,510 of which 1,407 (13.7%) of patients received 60% a home visit.

40% In February, 78.7% of urgent visits were undertaken in 2 hours and increased to 82% in March against the 95% target. For routine visits 20% within 6 hours, HUC achieved 80.6% in February and this improved to 91.3% in March. 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar The overall shift fill for GPs in February was 84%, however, in March this improved to 89%. Urgent <2hrs Target 95% Trajectory

Actions Home Visits: Routine visits undertaken within 6 hours • ENHCCG has continued to hold meetings with HUC who have implemented action plans to address the underperformance. 100% • HUC continues to recruit to vacant positions and have inducted 6 80% GPs and 1 ANP in March with a further 1 GP and 2 UCPs in April.

60% • HUC monitors staff productivity regularly to ensure full utilisation of resource and addresses any training gaps. 40% • HUC will analyse the home visit breaches by hour to further 20% understand if the resource is being utilised effectively.

0% Recovery Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar HUC are performing to the agreed trajectory with the aim to achieve Routine <6hrs Target 95% Trajectory the 95% target by July 2018.

94 HUC | Integrated Urgent Care

׀ Base Face to Face Consultations: urgent consultations Comments undertaken within 2 hours Performance 100% In February 5,091 (49.5%) of patients received a base appointment 90% and in March 6,491 (51.8%) of patients received a base appointment. 80% In February, 82.7% of patients had an urgent face to face 70% consultation within 2 hours and performance remained consistent in 60% March at 82%.

50% For routine face to face consultation within 6 hours, HUC achieved Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 93.6% in February, however, this slightly decreased in March to 91.3%. Urgent <2hrs Target 95% The rota fill at weekends ranged from 78% to 93% which impacted on performance. Where there was a shortage in rota fill, visiting GPs would be called back in to cover bases which then delays Base Face to Face Consultations: Routine appointments and impacts on the home visiting targets. consultations undertaken within 6 hours

100% Actions Vacant slots have been allocated to ensure urgent patients can be 90% seen in a timely manner. These slots are closely monitored by shift 80% managers and the management team at weekends to ensure these appointments are utilised efficiently. 70% Plans are in place to address the staffing issues with home visiting 60% performance, which will have a positive impact on the base face to 50% face consultations. This will allow HUC to manage the services more Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar effectively and move the resource to where it is most required.

Routine <6hrs Target 95% 95 HUC | Integrated Urgent Care

׀ CAS % of calls called back <15mins Comments

Performance 100% February 80% The total number of CAS cases were 3,755 with the total number of 60% call backs at 3,608. The average duration of each case was 11.58 minutes 40% 20% March The total number of CAS cases were 4,207 with the total number of 0% call backs at 3,922. The average duration of each case was 11.44 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar minutes.

Achieved Target 100% Actions

A review of the performance metrics for the 2018-19 contract CAS % of cases warm transferred variation has been completed to ensure that the metrics and targets meet the CCG’s clinical, operational and quality requirements. This will be implemented from 1st April 2018. 80%

70% Recovery 60% 50% 40% Performance will be reviewed following implementation of the new 30% metrics and targets, however, it is anticipated that there will be a 20% positive impact on performance. 10% 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Achieved Target 75%

96 HUC | Integrated Urgent Care

׀ Comments % of ARP Category 3 & 4 revalidated by CAS GP Performance 100% The total number of ARP Category 3 & 4 dispositions in February was 2,313 of which 2,191 (94.7%) were revalidated by a CAS clinician. In 80% March, there were 2,662 of which 2,557 (96.1%) were revalidated by 60% a CAS clinician.

40% 89.0% of calls in February and 89.7% of calls in March that were referred to the CAS for a GP review with a category 3 or 4 ambulance 20% disposition were diverted to an alternative appropriate service.

0% Actions Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar HUC review all cases that should have been revalidated by the CAS Achieved Target 100% and feedback is given to call handlers to ensure that future cases are revalidated by the CAS as appropriate. In addition, HUC ensures that training is in place to ensure appropriate pathway is followed. % of ARP Category 3 & 4 calls called back <15mins 100% A review of the current local performance targets has been completed in line with clinical, quality and operational requirements.

80% The CAS continues to be monitored closely by the CCGs via the contract and quality review meetings. 60% Recovery 40% Update local performance targets to be in place for 2018-19.

20%

0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Achieved Target 100% 97 HUC | Integrated Urgent Care

׀ of ED revalidated by CAS GP Comments % Performance 100% The total number of ED dispositions in February was 2,301 of which 1,165 (71.4%) were revalidated by a CAS clinician. In March, there 80% were 2,551 of which 1,258 (72.8%) were revalidated by a CAS clinician. 60% 81.5% of calls in February and 81.5% of calls in March that were 40% referred to the CAS for a GP review with a ED disposition were re- directed to an alternative appropriate service. 20%

The less than 1 hour call back target has been amended for 2018-19 0% in line with local requirements. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Achieved Target 100% Actions HUC review all cases that should have been revalidated by the CAS and feedback is given to call handlers to ensure that future cases are % of ED calls (<1 hour) called back <15mins revalidated by the CAS as appropriate. In addition, HUC ensures that 100% training is in place to ensure appropriate pathway is followed. 90% 80% A review of the current local performance targets has been 70% completed in line with clinical, quality and operational requirements. 60% The revised metrics will be reported on in the next IPQR. 50% 40% The CAS is monitored closely by the CCGs via the contract and quality 30% review meetings and work with HUC continues to improve the 20% service. 10% 0% Recovery Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar There were no Never Events reported in 2017/18.

Achieved Target 100% 98

HUC | Integrated Urgent Care

׀ AiHVS Average number daily visits Comments 100 February There were 1,077 visits with an average of 54 a day and 27 visits were passed into the OOH period. 95.6% of routine visits were 50 carried out within 6 hours. Clinical rota fill was 95%. March There were 1,091 visits with an average of 52 per day and 15 visits 0 passed into the OOH period. 97.8% of Routine visits were carried out Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar within 6 hours. Clinical rota fill was 97.6%. No. of Visits Target (60-90) The service has not been receiving enough referrals to achieve the winter target of 90 visits per day. There was three occasions in AiHVS % of calls answered within 60 seconds March where the service was suspended due to shortage on Rota Fill and minimising the handing over of visits to the Out of Hours service 100% and capacity reached due to high number of Flu cases. 95% The call answered within 60 seconds has underperformed mainly due to most of the calls coming in around the same time of the day. 90% Actions 85% HUC send out regular communications when required to practices to inform them of their availability to take referrals 80% The referral criteria has been reviewed and updated to improve the Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar number of referrals being received and support local practices, this % <60 secs Target 95% has been communicated out to the GP practices in March with the hope of increased referrals. AiHVS Visits Passed to the OOH service HUC have reviewed the rotas to address the call answering target 40 and added more staff to the mornings when the service is most busiest. So far this has not had an improved impact on achieving the call answering target, so further analysis is being undertaken to 20 understand the cause. HUC are to submit an options appraisal around the service to help improve the delivery of the service and a review of the performance 0 metrics and targets is being undertaken for the 2018-19 contract Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar variation. No. of Visits Target = 0 . 99

HUC | Integrated Urgent Care

Tier 1 Base Staffing % Filled Rota fill for March has increased from 84% last month to 89%; HUC have inducted 6 GPs and 1 ANP since the beginning of Watford 100% March. GP vacancies are advertised via different sources and all successful candidates are invited to HUC for inductions. HUC contacts GPs regularly in regards to supporting the service with additional shifts. There is 1 induction booked for Hemel Hempstead 94% April.

Lister 73% It has been identified that some bases are more favourable than others which can affect the base fill. Some of the base fill has decreased at Tier 1 bases, so HUC has used the visiting resources to ensure Tier 1 bases are covered. QEII 93% There has been a decrease in GP sickness in March but there has been an increase in the number of cancelled shifts HQ 78% The rota is released three months in advance so GPs are able to plan ahead via the online Rota system. Any unallocated shifts are highlighted to the management and clinical teams on a daily basis and communicated to the Clinicians by Tier 2 Base Staffing % Filled telephone and email.

Bishops Stortford * 73% Recruitment remains a high priority with HUC and the management teams continue to meet on a daily basis to work towards a complete rota fill. Borehamwood 82% Sickness and lateness is recorded on a daily basis, logged and monitored by the management team and addressed with St Albans 84% individuals if required.

Hertford 69%

Tier 3 Base Staffing % Filled

Cheshunt 0%

Potters Bar 0%

100 HUC | Serious Incidents

HUC: Type of Serious Incident Comments

1.2 In Q4 HUC declared 2 serious incidents, one related to ENHCCG and one 1 0.8 related to C&PCCG. The SI relating to ENHCCG was about a treatment 0.6 delay. 0.4 0.2 There were no Never Events reported in 2017/18. 0 Q1 Q2 Q3 Q4 Treatment Delay 0 0 0 1 Serious Incidents are monitored through the monthly quality review Medical Equipment meeting. 0 0 1 0 Incident Confidential 0 0 1 0 information leak/IG

101 HUC | Workforce

׀ Vacancy rate Comments

25% Performance The average vacancy rate for February and March is 11.2%, above the 20% target range of <6% and higher than the previous months of December 2017 and January 2018. Staff turnover was an average of 15% 1.4%, within the target range of 10%. Staff appraisal was 83%, lower 10% than the target range of 90%.

5% Actions 0% Staff recruitment remains a problem, mostly with high turnover of Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar health advisers. HUC is currently working on improving retention and performance. HUC have streamlined their recruitment process by use Achieved Target <6% of DocuSign for all contracts of employment and DBS with an external company and is now advertising using a new 2 interview structured process approach which may help with appraisals and mandatory Staff appraised in last 12 months training.

100%

80%

60%

40%

20%

0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Achieved Target 90% 102 HUC| Rota fill

׀ of Pharmacy hours filled Comments %

100% Performance

80% 85% rota fill for pharmacist shifts in March.

60% The CAS GPs pick up any pharmacy calls when there is no pharmacist available to ensure that there is no gap in support for patients. 40%

A review of this target is to be undertaken by the CCG as part of the 20% 2018-19 contract variation. The CCG will continue to monitor this through the Quality and Contract review meetings and work with 0% HUC to ensure all avenues are being taken to address gaps within the Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar pharmacy rota fill and to ensure that feedback is given by the current Achieved Target 100% pharmacists within the IUC to help and further develop this role as it becomes busier within the CAS.

103 The Pathology Partnership (TPP)

׀ Comments

During Q4 8 enquiries were received via the GP hotline relating to pathology services, this is an increase compared to the 3 enquiries received in Q3.

Reported queries related to the communication of test results, cancelled tests , the recall process as well as the quality of results received.

Following the organisational change of pathology services in May 2017, the CCG continues to liaise with Cambridge and Peterborough CCG regarding any issues identified relating to CUHFT.

104 Private Providers | page 1 of 3 ׀ Comments

Ramsay

Performance Ramsay continues to achieve the RTT incomplete target at CCG level, meaning that the required numbers of ENHCCG patients are waiting 18 weeks or less for treatment. This performance has been consistently achieved throughout 2017/18.

In addition to this, the diagnostic standard was also achieved at CCG level, with all patients being seen within 6 weeks for diagnostics tests at Ramsay.

RTT – February 2018 • Pinehill Hospital – 99.0% vs. 92% target • Rivers Hospital – 99.1% vs. 92% target

Diagnostic Wait Times – Q4 Performance • Pinehill Hospital – 100% vs. 100% target • Rivers Hospital – 100% vs. 100% target

Serious Incidents Ramsay has reported three Serious Incidents for 2017-18, (April, August and December). There have been no Never events reported YTD.

105 Private Providers | page 2 of 3 ׀ Comments

Spire

The contract with Spire is hosted by HVCCG.

Both sites met the incomplete standard and had no 52 Incomplete Under 18 Over 18 52+ week week breaches in February 2018. Performance weeks weeks patients

Bushey Site 99.6% 272 1 0 Harpenden Site 97.7% 335 8 0

Quality • No Never Events reported in the period. Friends and Family score is 99% with 90% extremely likely to recommended the service, with a 40% response rate in this period. 4 formal complaints have been received by the service in this period, but none upheld. No issues to highlight at this time. • 1 case of MRSA in March 2018 and 1 case of Hospital Acquired C-Difficle in 2017-18 • Safeguarding training compliance is 98%, above the 95% trajectory, for safeguard level 1 and 2, DoLs and PREVENT.

106 Private Providers | page 3 of 3 ׀ Comments

BMI

The contract with BMI is hosted by HVCCG

Incomplete Under 18 Over 18 52+ week Both sites met the incomplete standard and had no 52 Performance weeks weeks patients week breaches in February 2018. The Kings Oak Hospital 95.7% 762 33 0 The Cavell Hospital 95.6% 370 17 0

Quality • The QTR 4 report is due in May 2018. • No issues to highlight at this time. • No Never Events reported in the period to December 2017.

Performance is closely monitored and any under achievement will be discussed at future contract review meetings.

107 Glossary Acronyms used in this report Acronyms used in this report A&E Accident and Emergency EIP Early Intervention of Psychosis ACL Area clinical Lead EMDASS Early Memory Diagnosis & Support Service ACQI Ambulance Clinical Quality Indicators East and North Hertfordshire Clinical Commissioning ACS Adult Care Service ENHCCG Group AIHVS Acute in Hours Visiting Service ENHT East and North Herts NHS Trust ALOS Average Length of Stay FFT Friends & Family Test ANP Advanced Nurse Practitioners GI Gastrointestinal Any Qualified Professional – Counsellors who have a GP General Practitioner AQP contract with ENCCG for IAPT H&SM Hertfordshire and South Midlands ARP Ambulance Response Programme HASU Hyper Acute Stroke Unit ASU Acute Stroke Unit HCA Health Care Assistant BCF Barnet and Chase Farm Hospital HCT Hertfordshire Community NHS Trust BSI Blood Stream Infection HPFT Hertfordshire Partnerships Foundation Trust Cambridge and Peterborough Clinical Commissioning HSAB Hertfordshire Safeguarding Adult’s Board C&PCCG Group HSCB Hertfordshire Safeguarding Children’s Board CAMHS Child and Adolescent Mental Health Services HSMR Hospital Standardised Mortality Ratio CCG Clinical Commissioning Group HUC Herts Urgent Care C-Diff Clostridium Difficile HVCCG Herts Valley Clinical Commissioning Group COSMIC The new Patient administration system used by PAH IAPT Increased Access to Psychological Therapies CQC Care Quality Commission IDVA Independent Domestic Violence Advisors CT Computed Tomography IPC Infection Prevention Control CUHFT Cambridge University Hospital Foundation Trust KPI Key Performance Indicators CYP Children and Young People LAC Looked After Children DA Domestic Abuse LMC Local Medical Committee DH2A Discharge Home to Assess LSCB Local Safeguarding Children’s Board DNA Did not Attend MRSA Methicillin-resistant Staphylococcus Aureus DoLS Deprivation of Liberty Safeguards MSK Musculoskeletal DToC Delayed Transfer of Care NHSE NHS England ECIP Emergency Care Improvement Programme OOH Out of Hours EDD Estimated Date of Discharge OP Out Patient EEAST East of England Ambulance Service NHS Trust PAH Princess Alexandra Hospital NHS Trust 108 Glossary Acronyms used in this report Acronyms used in this report Positive behaviour service for Autism, Learning disability, PALMS Mental health Service PPCI Primary percutaneous coronary intervention PSIT Patient Safety Intervention Team R2G Red 2 Green RAT Rapid Access and Treatment RFH Royal Free Hospital NHS Trust ROSC Return of spontaneous circulation RTT Referral To Treatment SHMI Summary Hospital-level Mortality Indicator SI Serious Incident SPA Single Point of Access SRG System Resilience Group SSNAP Sentinel Stroke National Audit Programme STEMI ST segment elevation myocardial infarction STP Sustainability Transformation Plan TCI To Come In TDONTD To Dip or Not To Dip TIA Transient Ischemic Attack UCLH University College London Hospital NHS Foundation Trust UHP Unit Hour Production UTI Urinary tract infections WECCG West Essex Clinical Commissioning Group WHHT West Herts Hospital Trust WTE Whole Time Equivalent YTD Year to Date

109 Agenda Item No: 6

Date of Meeting: 24th May 2018

Governing Body Meeting

Paper Title: Workforce Report

Decision or Approval Discussion Information

Report author: Mandy Wilson, Human Resources Business Partner

Report signed off by: Louise Thomas, AD HR and ODL on behalf of Hein Scheffer, Director of Workforce

Executive Summary: The Quarter 4 2018 Workforce Report summarises the workforce information run from the Electronic Staff Record (ESR) system from January 2018 to March 2018. The report covers all departments at East and North Herts CCG including HBLICT (Hertfordshire, Bedfordshire and Luton ICT). Information includes staff turnover rates, sickness absence rates, mandatory training and appraisal compliance rates.

Recommendations to the members: The Governing Body is asked to note the Workforce Report for information.

Conflicts of Interest No conflicts of interest identified involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Page | 1 1. Executive summary The Quarter 4 2018 workforce report summarises the workforce information run from the Electronic Staff Record (ESR) system from January 2018 to March 2018. The report covers all departments at East and North Herts CCG including HBLICT (Hertfordshire, Bedfordshire and Luton ICT). Information includes staff turnover rates, sickness absence rates, mandatory training and appraisal compliance rates.

2. Background

This is the Workforce Report to be submitted twice a year to the Governing Body in this format.

3. Issues

N/A

4. Options

N/A

5. Resources implications

N/A

6. Risks/Mitigation Measures

N/A

7. Recommendations

The Governing Body is asked to review the Workforce Report.

8. Next Steps (including when the decision will be reviewed)

Workforce Report to be presented to the Governing Body twice a year during the business cycle. Quarter 2 as at October 2018 will be presented to the Governing Body in May 2019.

Page | 2 East & North Herts CCG

Workforce Report Quarter 4: 2017-2018

April 2018

This Workforce Report provides an overview on key HR and ODL metrics as at end of Quarter 4 (31 March 2018). Areas covered include sickness absence, employee turnover, establishment, vacancy rates, training and equality monitoring

1 Table of Contents

Staff Turnover, Absence & Establishment ...... 3 Workforce Establishment & Vacancy Rates ...... 3 Staff Turnover ...... 3 Agency/Interim Spend ...... 3 Agency Spend by Directorate ...... 3 Sickness Absence ...... 3 Absence Rate by Directorate ...... 3 ODL Activity & Workforce Equality Information ...... 4 Mandatory Training ...... 4 Training Presented ...... 4 Appraisal Rate ...... 4 Workforce Profile by Pay Band ...... 4 Pay by Age ...... 4 Gender & Pay ...... 4 Workforce Equality Information ...... 5 Ethnicity & Pay ...... 5 Starters – Ethnic Origin ...... 5 Age & Gender ...... 5 Workforce Narrative – Q4 Report...... 6 Narrative ...... 6

2 Staff Turnover, Absence & Establishment

Workforce Establishment & Vacancy Rates Staff Turnover Agency/Interim spend Turnover % Turnover % National of FTE of CCG 2017-2018 Budgeted WTE 328.46 Headcount Average % Actual WTE 267.93 £140,000.00 Q1 16/17 4.02% 4.58% 1.25% CCG Vacancy Rate (%) 18.43% £120,000.00 Vacancies 60.53 Q2 16/17 5.95% 6.66% 2.25% Q3 16/17 £100,000.00 1.89% 2.57% 1.63% Vacancy Rate Q4 16/17 3.83% 4.06% 1.32% Directorate Vacant WTE £80,000.00 % Q1 17/18 4.62% 4.64% 1.66% Commissioning 17.70% 6.51 Q2 17/18 3.13% 3.05% 1.73% £60,000.00 Directors Office 27.66% 4.51 Q3 17/18 5.20% 5.21% 1.22% £40,000.00 Finance 13.35% 7.09 Q4 17/18 2.63% 3.10% 1.28%** £20,000.00 ICT Shared Services 21.17% 28.39 Medical 16.30% 3.00 £0.00 **Figure calculated from average of previous 3 months. Data not Nursing & Quality 21.55% 6.30 yet released by HSCIC. Operations 9.60% 3.60 Strategic Partnership 37.78% 1.13 Total number of leavers in Q4: 10

Q4 expenditure: £286,231 YTD expenditure: £764,625 March spend: £115,892 Agency Spend by Directorate Sickness Absence Absence Rate by Directorate

Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 Period Absence National Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 £160,000.00 (%) CCG Average (%) Q1 17/18 Q2 17/18 Q3 17/18 Q4 17/18 £140,000.00 Quarter 1 (2016/2017) 2.95% 2.67% 9.00% £120,000.00 Quarter 2 (2016/2017) 3.26% 2.59% 8.00% £100,000.00 Quarter 3 (2016/2017) 3.30% 2.91% 7.00% £80,000.00 Quarter 4 (2016/2017) 2.91% 2.94% 6.00% £60,000.00 Quarter 1 (2017/2018) 2.17% 2.54% 5.00% Quarter 2 (2017/2018) 1.87% 2.65% 4.00% £40,000.00 Quarter 3 (2017/2018) 2.54% 3.10% 3.00% £20,000.00 Quarter 4 (2017/2018) 2.85% 3.10%** 2.00% £0.00 1.00% 0.00% -£20,000.00 **Figure calculated from average of previous 3 months. Data not yet released by HSCIC.

3 ODL Activity & Workforce Equality Information

Mandatory Training Compliance Training Presented Appraisal Returns

2016-2017 2017-2018 Session Attendees Active Headcount Returns IG Compliance 17-18 Managing Attendance & Ill Health 8 60 1 50 Corporate Induction 10 0.9 40 0.8 Risk Management Renewal 89 30 0.7 0.6 Recruitment & Selection 6 20 0.5 10 0.4 0 0.3 0.2 0.1 0

Overall Compliance Rate: 92.17% Overall Compliance Rate: 85.21%

Workforce Profile by Pay Band Pay by Age Gender & Pay

70 <20 yrs 20-29 yrs 30-39 yrs 40-49 yrs Female Male 60 50-59 yrs 60-69 yrs 70-79 yrs 50 VSM 2.00% 1.60% 100% 40 Non AFC 7.50% 13.60% 90% 30 62 Band 9 0.00% 0.80% 52 80% 45 Band 8d 4.00% 3.20% 20 37 70% 30 32 10 27 Band 8c 4.50% 4.80% 6 15 12 1 6 60% Band 8b 7.50% 9.60% 0 50% Number of individuals by Pay Band Band 8a 11.00% 6.40% 40% Band 7 22.00% 14.40% 30% Band 3 Band 4 Band 5 Band 6 Band 6 15.00% 17.60% 20% Band 7 Band 8a Band 8b Band 8c Band 5 10.00% 13.60% 10% Band 4 14.00% 13.60% Band 8d Band 9 Non AFC VSM 0% Band 3 2.50% 0.80% Acronyms 30% 20% 10% 0% 10% 20% VSM – Very Senior Manager Non AFC – Non Agenda for Change

4 Workforce Equality Information

Ethnicity & Pay Starters by Ethnic Origin Age & Gender BME Other Undeclared White

Band 3 - 16.67% 16.67% 66.67% Female Male A White - British B White - Irish Band 4 15.56% 2.22% - 82.22% Band 5 27.03% 8.11% 2.70% 62.16% D Mixed - White & Black Caribbean H Asian or Asian British - Indian 70-79 yrs 0.50% 0.80% Band 6 17.31% - 3.85% 78.85% N Black or Black British - African Band 7 20.97% 6.45% 3.23% 69.35% 60-69 yrs 2.5 10.00% 8.80% Band 8a 26.67% 3.33% - 70.00% 50-59 yrs 29.00% 20.00% Band 8b 7.41% 7.41% - 85.19% 2 Band 8c 6.67% - 6.67% 86.67% 40-49 yrs 28.50% 31.20% Band 8d 16.67% - - 83.33% 1.5 Band 9 - - - 100.00% 30-39 yrs 21.00% 24.80% Non AFC 28.13% 9.38% 18.75% 43.75% 1 VSM - - - 100.00% 20-29 yrs 10.00% 14.40% 0.5 <20 yrs 1.00% 0.00% 0 Band 4 Band 5 Band 6 Band 7 Band 8b Non AFC 40% 20% 0% 20% 40%

5 Leaving Reasons: Long Term Sickness: CCG: Two cases Directors Office: 1 Work Life Balance CT Shared Services: One case Commissioning Directorate: 1 Work Life Balance Finance: 1 Promotion Sickness Cost: ICT Shared Services: 2 Better Reward Package NHS East and North Hertfordshire CCG £71,072.40 Medical: 2 Relocation, 1 Better Reward Package Commissioning Directorate £6,213.57 Nursing & Quality: 1 Promotion Directors Office £243.68 Strategic Partnership: 1 has not worked Finance Directorate £8,894.15 ICT Shared Services £28,163.34 CCG Turnover Medical Directorate £967.50 Nursing & Quality Directorate £8,223.90 Rolling 12 months turnover rate: 16.07% Operations Directorate £18,366.27 Labour Stability Index: 85.41 Strategic Partnership Nil

This quarter highlights at staff turnover of 3.10% (headcount), which is below the previous The HR Advisor continues to work with managers in line with policy, to manage and quarter of 5.21% but above the national CCG average of 1.28%. support employee who are not well.

Following the results of the National Staff Survey 2017, a retention plan has been drawn up to look at activities that will enhance organisation stability and make the CCG an Workforce Narrative: employer of choice. Workforce Establishment & Vacancy Rate Sickness Absence: By the end of this quarter ENH vacancy rate was 18.43% with the total number of vacancies being 60.5. The actual WTE is currently 267.93 which is under the budgeted Sickness absence trend has seen an increase on the previous quarter. This is reflected in WTE of 328.46. the top absence reason was cold, cough and influenza, which is expected in the winter months and accounted for 206 days. The ICT vacancy rate is shown as 21.17% for the period. During April 2018 there was a consultation with staff to reorganise the ICT business structure and going forward this Top Sickness Reasons: vacancy rate will have reduced to reflect establishment under the new structure.

Cold, cough, flu - influenza (206 days) 29.14% Mandatory Training and Appraisal Compliance Genitourinary & gynecological disorders (89 days) 12.59% The compliance rate for the quarter is 92.17%, which is higher than the same period last Gastrointestinal problems (88 days) 12.45% year.

By Directorates: The appraisal compliance rate is 85.21%. The appraisal cycle is due to start for 2018-19 ICT Shared Services 37.34% (returns May – June 2018). Operations Directorate 33.95% Finance Directorate 10.04% Establishment & Vacancy rate: Work needs to be carried out to ensure ESR reflects the CCG organisation structure and 2018 -19 budgets. This will provide better accuracy when Total number of sickness episodes 135 reporting. Total number of calendar days lost 707

6 Agenda Item No: 7

Date of Meeting: 24th May 2018

Governing Body Meeting

Paper Title: EEAST – INDEPENDENT SERVICE REVIEW (FINAL)

Decision or Approval Discussion Information

Report author: Deloitte

Report signed off by: Alan Pond, Chief Finance Officer

Executive Summary: NHS England (NHSE) and NHS Improvement (NHSI) jointly commissioned an independent service review as part of the 2017/18 mediation settlement for the EEAST 999 service Contract.

Undertaken by Deloitte LLP and ORH Limited with input and final sign off from a Project Steering Group comprising representatives from NHSE, NHSI, EEAST and Commissioners, the aim of the review was to understand the operational and financial change required to meet national performance standards and to develop a contracting framework to sustainably fund the services. The review is intended to assist the local health economy in delivering an improved service for patients in the East of England.

The review found that EEAST requires more investment in the core service to increase its staffing and capacity to improve the service and meet the requirements of National Ambulance Response Programme (ARP).

Page | 1 Recommendations To note the report and the investment being made into the to the members: ambulance service in order to meet the national standards.

Conflicts of Interest No conflicts of interest identified involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Page | 2 Independent Service Review of EEAST 999 Services – Final Report

Introduction NHS England (NHSE) and NHS Improvement (NHSI) jointly commissioned an independent service review (Appendix 1) as part of the 2017/18 mediation settlement for the EEAST 999 service Contract.

The review followed the introduction of the National Ambulance Response Programme (ARP), which set out new constitutional performance standards for ambulance providers. At EEAST, the two-year transition to this model began in October 2017. The ARP aims for the most appropriate resource to be sent to patients the first time, by allowing call handlers additional time to identify a patient’s needs.

The current Consortium arrangements for the EEAST 999 service contract involve 19 CCGs jointly commissioning the service with Suffolk CCGs as the lead commissioner. To ensure local needs are reviewed and services are adapted for patients in each area, there are four localities. These localities (Essex; Bedfordshire & Hertfordshire; Norfolk & Waveney; and Suffolk & Cambs) will align to the new system-wide Sustainability and Transformation Partnership footprints – of which there are six – to ensure the Contract remains flexible to local patient needs and care pathway planning.

The full report can be found here: http://www.eastamb.nhs.uk/EEAST-ISR-Report-March-2018.pdf

Purpose of this document For CCG governing bodies’ information only, sharing the main outcomes of the review, including the agreed split of contract shares between Consortium CCGs.

Main findings The review found that EEAST requires more investment in the core service to increase its staffing and capacity to improve the service and meet the requirements of ARP.

The estimated core service cost requirements are c£225m for 2018/19 and dependent on activity projections, up to c£240m for 2019/20 respectively. This is anticipated to cover the full year costs of additional staffing but excludes paramedic re-banding costs which were out of scope of the review. Increased capacity estimates are for circa 330 new WTEs in post and an extra 160 Double Staffed Ambulances (DSAs) on the road. The modelling in the report shows that the ambulance service is predicted to see improved response time performance for the sickest patients, particularly in the least densely populated areas of east of England such as Norfolk and Suffolk (see page 75 and 76 of the report). The review provides for a 3 year workforce plan which is expected to deliver an additional 330 FTE, in addition to normal workforce planning requirements. While Ambulance Trusts are expected to transition to a BSc Programme (4 year), Health Education England have agreed to support a continuation of the EEAST 3 Year Student Paramedic Programme.. Hence, Student Paramedics recruited in Year 1 would be expected to qualify at the end of Year 3 while those recruited in Year 3 are expected to qualify in Year 5.

The frontloading of the workforce plan in Year 1, together with the continuation of PAS and overtime capacity to cover educational abstraction, is expected to enable EEAST to deliver ARP standards in aggregate across the consortium from Q1 2019/20. These estimates were based on a detailed set of assumptions that were agreed by the Project Steering Group as part of the review. These assumptions are set out in the report, and changes to these assumptions would affect the overall estimates.

The review reflects discussions in the Project Steering Group, which resulted in their recommendation that a six-year service contract be agreed from 2018/19 to provide stability and certainty to EEAST, with two year intervals to review key aspects of the contract around quality and performance. To allow key risks to be managed by both parties, the review sets out contract levers around activity, performance, and accounting for handover delays at hospitals. These levers were developed collaboratively and agreed with the Project Steering Group and will be applied from 2019/20 to allow for a transition year whilst EEAST build up their capacity.

The review was used as the basis of discussions on contract funding between EEAST and Commissioners for the 999 contract. Based on these discussions, the contract funding for 2017/18, 2018/19 and 2019/20 is estimated by EEAST and Commissioners as follows:

2018/19 2017/18 to to 2018/19 2019/20 Financial Summary £m £m Core Services 213.5 225.0 Paramedic Rebanding (CCG Allocation 17/18 to 18/19) 2.6 1.6 Non-Core Services 8.9 8.9 CQUIN 4.9 5.4 Total 229.8 240.8

The contract funding splits for the above, and estimated contract values for 2018/19 onwards, were agreed based on a vote by Consortium Accountable Officers on behalf of their CCGs. It was carried by a 73% majority. It means contract allocations are based on individual CCG estimated activity levels, at standard HRG costs and adjusted by the (average) length of job cycle times for responses. Contract shares will be reviewed again at the proposed two-year contract interval points. Sustainability and Transformation Partnership Level Contract Shares under the agreed option are as follows, subject to agreement of phasing arrangements:

Core Contract Shares 2017/18 2018/19

Core Core Contract Contract Contract Contract STP Shares Value Shares Value % £m % £m Cambs & Peterborough 14.3% 30.5 14.6% 32.8 Herts & West Essex 20.8% 44.4 21.3% 47.9 Mid & South East Essex 19.1% 40.8 19.1% 43.0 Beds & Luton 9.5% 20.3 9.1% 20.5 Norfolk & Waveney 20.4% 43.6 19.8% 44.4 Suffolk & North Essex 15.9% 33.9 16.1% 36.3 Total 100% 213.5 100% 225

Performance

The regional aggregate improvement in Category 1 Mean time of Response is forecast as follows:

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Quarter 17/18 18/19 18/19 18/19 18/19 19/20 19/20 19/20 19/20 FTES in 2,785 2,930 2,973 3,060 3,033 3,066 3,146 3,166 3,118 Post Category 1 Mean Time (7 08:25 08:11 08:05 08:06 07:37 06:58 06:58 06:57 07:00 min target)

The review sets out three core levers, which will be adopted in the contract:

• Activity – marginal rate adjustments at 80% of HRG cost for activity variations above or below plan; • Handover delays – lost hours not exceeding forecast assumptions; • Performance – Quarterly Cat 1 mean forecast times to be met.

Handover delays and performance trajectories not being on forecast in any given year will result in a change to the following year’s contract value, based on a sliding scale. These levers operate at a trust-wide level in line with the review recommendations.

Activity variations are to be settled on an agreed Indicative Activity Plan that is based on demand estimates provided by commissioners during the review workshops. There are principally three HRG currencies: for Calls, Hear & Treat and ‘See’ response volumes. This lever will be applied at a CCG level from 2019/20 onwards.

Key opportunities • Regional aggregate response times are estimated to improve from the outset as ARP continues to become normal practice. • The framework is designed for there to be benefits for frontline staff, and thus support workforce retention. For example, a greater proportion of frontline staff taking their meal break and finishing on time. • The framework is designed for EEAST to become operationally and financially sustainable, whilst meeting national performance standards and supporting the wider system. • The framework is designed for Commissioners to have greater certainty around their expenditure and service performance.

Key risks • Workforce recruitment and retention and key rostering changes are key performance drivers – these dependencies were recognized by the Project Steering Group as the highest risk elements if not implemented as forecast; • Rising handover delays will denude Dual Staffed Ambulance capacity on the road and this has high impact on high acuity response times; • Rising demand above forecasted levels of activity could impact on performance, especially where higher acuity demand continues to rise. • Reductions in activity will reduce EEAST expected income in 2019/2020, requiring a reduction in the workforce plan to remain within the available cost envelope.

Actions and next steps • EEAST and lead commissioner to organise quarterly briefing for east of England MPs on progress with the implementation of the associated EEAST Transformation Programme. • EEAST to produce monthly progress update report for CCGs. • Commissioners to join the EEAST Transformation Programme Board to ensure transparency of progress, risks and opportunities. CCG Funding 2018/19 Agenda Item No: 8

Date of Meeting: 24 May 2018

Governing Body Meeting in Public

Paper Title: Draft Annual Report and Accounts 2017/18

Decision or Approval Discussion Information

Report author: Sarah Feal, Company Secretary Susan Haigh, Communications Service Manager Thomas Kwok, Financial Controller, Financial Services Report signed off by: Alan Pond, Chief Finance Officer

Executive Summary: The Governing Body is asked to approve the CCG’s Annual Report and Accounts for 2017/18.

The Governance and Audit Committee reviewed the draft report on 14 March 2018 and 16 May 2018 and are recommending it for approval by the Governing Body.

At the time these papers were published, some performance data remains outstanding due to external publishing timescales. The operations team will update pages 40 and 49 of the report with any data that becomes available and this updated section of the Annual Report will then be tabled at the Governing Body meeting.

Recommendations 1. Governing Body members are asked to read the Annual to the members: Report and Accounts 2017/18 and confirm that:

• So far as the member is aware, there is no relevant audit information of which the Clinical Commissioning Group’s auditor is unaware that would be relevant for the purposes of their audit report.

• The member has taken all the steps that they ought to have taken in order to make him or herself aware of any relevant audit information and to establish that the Clinical Commissioning Group’s auditor is aware of it.

2. Governing Body members are asked to approve the Annual Report and Accounts 2017/18.

Page | 1 Conflicts of Interest There are no conflicts of interests identified. involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Page | 2

ANNUAL REPORT AND ACCOUNTS

2017/18

DRAFT 15: Started 17 May 2018

Annual Report and Accounts 2017/18 ______1

01707 685000

[email protected]

Charter House, Parkway, Welwyn Garden City, Hertfordshire AL8 6JL

Get involved

www.enhertsccg.nhs.uk www.facebook.com/ENHertsCCG

www.twitter.com/ENHertsCCG

Annual Report and Accounts 2017/18 ______2

CONTENTS

WELCOME 5

OVERVIEW OF PERFORMANCE 6

Types of commissioning 9 Providing care 10 A Healthier Future – Hertfordshire and West Essex STP 12 The CCG’s work in 2017/18 15 Improving mental health and wellbeing 15 Improving urgent care 17 Improving primary care 19 Supporting older people 25 Personalising care 29 Our work infographic 31 Summary of key performance 33 Chief Executive’s statement on performance 34

PERFORMANCE ANALYSIS 35 Quality Premium 39 Performance against NHS Constitution rights and pledges 42 My NHS 51 Ensuring our patients receive high quality care 52 Caring for vulnerable residents 57 Preparing for emergencies 63

Reducing Health Inequalities 64 The role of Hertfordshire’s Health and Wellbeing Board 64 The role of Hertfordshire Healthwatch 65 Health inequalities in Hertfordshire 66 Hertfordshire Health and Wellbeing Strategy 70

CCG 360 stakeholder survey 72

Annual Report and Accounts 2017/18 ______3

Patient and Public Engagement Foreword from Dianne Desmulie 73 Highlights of public involvement projects in 2017/18 74 Patient experience and quality improvements 76 The year ahead 76 Engaging with our patients – in their own words 77

The work of Hertfordshire, Bedfordshire & Luton (HBL) ICT Services 79

Sustainability 81

Review of Financial Performance 85 Summary 85 Funding allocated to the CCG 86 Financial business rules for 2017/18 89 Locality level performance 90 Mental health parity of esteem 91 Future financial strategy 92 Review of statutory duties 95

ACCOUNTABILITY REPORT 96 Part one: Corporate Governance report 97 Members’ report 97 The CCG Governing Body as at 31 March 2018 99 Statement of Accountable Officer’s responsibilities 109 Governance Statement 112 Head of Internal Audit Opinion 139

Part one: Remuneration report and staff report 141 Salaries and allowances 143 Pensions benefits 148 Staff Report 154

Part three: Parliamentary accountability and audit report 167 External audit opinion (to follow) Xxx The Accounts xxx

Annual Report and Accounts 2017/18 ______4

WELCOME to our annual report and accounts for 2017/18

This has been another busy year for the NHS nationally and here in Hertfordshire too.

Our CCG plays a key role in helping to ensure that health and care services meet the growing health needs in our communities. This is only possible thanks to the commitment of our staff, our GP members, the positive relationships we have developed with partner organisations and the dedication of our active and committed patient representatives and volunteers.

Limited resources and increasing levels of need mean that health and social care services in our area are continuously challenged to keep up with demand. In the last 12 months, more members of the public have got involved than ever before in commissioning local health services. By attending public meetings, taking part in online and paper consultations, visiting hospitals and care homes and a wide range of other voluntary activities, thousands of local residents have worked with us to shape the services that you and I will rely on in the years ahead.

We’ve made some tough decisions throughout the year – with your help. Thank you for your overwhelming support for our increasing emphasis on a shared responsibility for staying healthy and making the best use of limited NHS resources. In the year ahead, we are committed to working with you to support you and your family to live healthy and active lives, supported by local services wherever possible.

In 2016/17, our organisation was judged by NHS England to be ‘outstanding’. This was due to a real team effort – and I’d like to thank everyone who has played an active part in commissioning, providing or using health services wisely.

If you would like to get more involved in your local NHS, then the year of the NHS’ 70th birthday is the ideal time to give the gift of your time. This report includes many examples of residents who have made a positive difference – please get in touch if you would like to be one of them.

Beverley Flowers Dr Hari Pathmanathan Chief Executive Chair, East and North Hertfordshire CCG East and North Hertfordshire CCG GP, Bridge Cottage Surgery, Welwyn

Annual Report and Accounts 2017/18 ______5

OVERVIEW OF PERFORMANCE

This section contains a summary of our performance as an organisation during 2017/18 plus a flavour of the work we do. You can read more about our work at: www.enhertsccg.nhs.uk

We are the local NHS organisation which plans, designs and pays for the health services used by the 597,000 people who live in our area. This report looks back at the past twelve months and aims to give you a flavour of our work and what we’ve achieved. Led by local GPs, the CCG works closely with clinicians, patients and partner organisations to decide how our annual budget of almost £724m should be spent.

We aim to:

 work closely with patients, partners, managers and clinical colleagues from all sectors to commission the best possible healthcare for our patients within available resources

 reduce health inequalities and achieve a stable and sustainable health economy by working together, sharing best practice and improving expertise and clinical outcomes for patients

What is commissioning?

We use information and evidence about local services and people’s experiences of them to look at whether those services are meeting people’s needs. If improvements or changes are needed, we work with our GP members, the organisations which provide services and local people to put forward new ideas or ways of delivering care.

Our role is to:

 ensure health services are high quality  involve local people in planning and improving services  make the most effective use of the money given to us to improve services for patients

Annual Report and Accounts 2017/18 ______6

Annual Report and Accounts 2017/18 ______7

Every GP practice is a member of the CCG and works with nearby practices in a network, called a locality, to find solutions to their area’s particular health challenges.

Each of our six localities is represented on the Governing Body by at least two GPs who have been selected by their peers. Our GPs and their practice nurses and healthcare assistants understand the health needs of their patients, and we believe that our locality-based approach to “As one of the locality GPs on commissioning helps us to make sure that our population the Governing Body, I am the has access to good quality services that meet the needs in direct link between the their area. practices in my local area and the CCG. Each locality receives a fair share of the CCG’s financial resources, with budgets set and financial reports presented “Because GPs see patients at GP practice and locality level. Member practices every day, we can bring both influence commissioning decisions and alert the CCG clinical expertise and local management team to issues, especially those related to knowledge of patients’ needs to patient experience or where clinical treatment pathways are the role of commissioning. not working as intended. Many of the successful projects developed by the CCG began with ideas from local practices.

“During the past year, our six locality areas have evolved and GPs have formed six ‘federations’ which will help practices to collaborate and find smarter ways of delivering primary care services in the future. It’s a challenging time for primary care but there is enthusiasm to rise to that challenge.”

Dr Nicky Williams, Ware GP and CCG Deputy Clinical Chair

Annual Report and Accounts 2017/18 ______8

TYPES OF COMMISSIONING

East and North Hertfordshire CCG buys services from a number of organisations which provide patient care, including NHS hospitals, mental health and community trusts, voluntary organisations and independent organisations. We also fund the cost of medicines and treatments prescribed by GPs and nurse prescribers.

In 2017/18, we commissioned services in the following ways:

• as the coordinating commissioner, where our CCG has the biggest share of activity and holds the contract, allowing other commissioners to be associates to the contract. Examples of this include contracts with East and North Hertfordshire NHS Trust and Hertfordshire Community NHS Trust.

• as an associate commissioner, where another commissioner has the biggest share of activity and holds the contract, allowing East and North Hertfordshire CCG to be a party to the contract. Examples of this include contracts with Princess Alexandra Hospital NHS Trust, Royal Free London NHS Foundation Trust and Cambridge University Hospitals NHS Foundation Trust.

• as a joint commissioner, where funding is pooled with partners and services are commissioned using that pooled budget. Examples include mental health and learning disability, where funding is pooled with Hertfordshire County Council (HCC) and Herts Valleys CCG to commission services, mainly from Hertfordshire Partnership University NHS Foundation Trust and from HCC’s Health and Community Services. We also jointly commission services from community and voluntary sector organisations with Hertfordshire County Council.

• as lead commissioner, where we procure services on behalf of other CCGs. For example, we led the development of the new Integrated Urgent Care service to cover our CCG area and the Herts Valleys CCG area.

Annual Report and Accounts 2017/18 ______9

• as a co-commissioner, where we are jointly responsible alongside NHS England for commissioning GP services. The national organisation NHS England commissions specialised services and primary care services, including the majority of services provided by GP practices, dentists, pharmacists and optometrists. Every CCG has a duty to assist and support NHS England to carry out these functions and secure continuous improvement in the quality of primary medical services. In December, member practices voted to take on the responsibility of commissioning GP services from April 2018. You can read more about this decision and what it means on page 19.

We have strong governance arrangements in place to oversee the delivery of the priorities for patient care identified in the CCG’s operational plan. We work together with other organisations in our local health and social care system to achieve these priorities, where appropriate. For example, the Urgent Care Network involves representatives from across health and social care. This means that joint decisions can be made to ensure that people are not admitted to hospital when there is a better option for their care. Good partnership working also helps patients to be discharged from hospital in a timely way when it is the right time for them to leave.

PROVIDING CARE

As a commissioning organisation, we do not directly care for patients. Acute hospital services - where a patient receives active but short-term treatment for a severe injury or illness, an urgent medical condition, or during recovery from surgery - are provided for our residents by NHS trusts, NHS foundation trusts and other independent providers of health services. The CCG has contracts with more than twenty providers and we also pay for care at other Care Quality Commission (CQC)-registered providers where needed.

Community services - such as district nursing, therapy and rehabilitation - are mainly provided by Hertfordshire Community NHS Trust. Mental health and learning disability services are mainly provided by Hertfordshire Partnership University NHS Foundation Trust.

Annual Report and Accounts 2017/18 ______10

The healthcare organisations with whom the CCG spent more than £5m in 2017/18 – together with the broad categories of care they provided - are set out here.

Provider Service Category East and North Hertfordshire NHS Trust Acute Royal Free London NHS Foundation Trust Acute Cambridge University Hospitals NHS Foundation Trust Acute North Middlesex University Hospital NHS Trust Acute Princess Alexandra Hospital NHS Trust Acute Ramsay Healthcare UK Acute University College London Hospitals NHS Foundation Trust Acute East of England Ambulance Service NHS Trust Ambulance Hertfordshire Community NHS Trust Community Hertfordshire Partnership University NHS Foundation Trust Mental Health and Learning Disability Millbrook Wheelchairs Herts Urgent Care Integrated Urgent Care Service

Annual Report and Accounts 2017/18 ______11

You can read our previous Annual Reports and see how we’ve performed over time on our website.

Challenges we face A HEALTHIER FUTURE  a 37% predicted increase in improving health and care in over-75s in the next 10 years across Hertfordshire Hertfordshire and west Essex and west Essex. More older people and people living

with long-term conditions As well as making sure we meet the needs of local people, means higher care costs it is important that the NHS and local councils think differently in order to respond to challenges in the wider  obesity, smoking, alcohol health system. We want to make sure that no matter and not enough exercise are where people live, they have excellent, high quality care all causing health problems and experiences.

 recruiting enough doctors, As part of the Healthier Future Sustainability and nurses and care staff is Transformation Partnership (STP), CCGs, councils, difficult – high living costs health and ambulance services, GPs, patient make it hard to attract and representative groups and the voluntary and community retain people with the right sector across Hertfordshire and west Essex have come skills together to improve health and care and join up our plans for the years ahead.  some patients are admitted

to hospital who don’t need This new way of working brings lots of new opportunities to be there, or stay in and will lead to practical changes to how health and social hospital for longer than care works in this area. necessary Watch this video to find out more about STPs.  health and care systems and technology don’t always work together effectively

 some buildings are not fit for purpose.

Annual Report and Accounts 2017/18 ______12

Annual Report and Accounts 2017/18 ______13

In its second year, the STP has started to deliver a number of improvements for patients.

Extra funding for cancer care The STP has secured more than £200,000 from the East of England cancer alliance to speed up treatment for people with suspected lung and prostate cancer. We know we need to improve outcomes for people with these cancers, so this money to diagnose cancers earlier and begin treatment faster will help more people to live long lives after their diagnosis.

Making the money for medicines go further

Across the STP area, CCG pharmacists have been working together to identify where savings can be made in the cost of medicines. So far the project has identified 23 drugs where there are cheaper, unbranded versions or ‘biosimilars’ which work in the same way as the more expensive versions. If we switched these medicines it would save around £2.5m over the next two years. So far, across Hertfordshire and west Essex, savings of £1.1m have already been made freeing up money for more patients to be treated.

Creating a Single Care Plan

In January, health and social care experts and patient representatives from across the STP area got together to start work on creating a single care plan for frail patients. The aim is to better co-ordinate care, help patients to feel more involved in their treatment and ensure that their wishes are clearly recorded and followed. A new single plan would replace the multiple plans currently used by different organisations. It would help clinicians work better together and patients to understand the full picture of their health condition.

Find out more about the work of the STP by reading our newsletters. Remember to sign up to receive future copies.

Annual Report and Accounts 2017/18 ______14

THE CCG’S WORK IN 2017/18

The projects on the following pages are some examples of what we’ve achieved over the past twelve months. There isn’t space to include all of our projects here, but you can read and watch more about what we do by visiting our website.

IMPROVING MENTAL HEALTH AND WELLBEING

MENTAL HEALTH SUPPORT IN GP PRACTICES

This year we piloted new schemes in Stevenage and Hertford to make it easier for people to get mental health support in their local community. Community Psychiatric Nurses are now holding regular clinics in GP practices, which means that patients do not have to wait for a referral to the hospital team and can be seen much more quickly. The project also aims to make seeking help for mental health issues as ‘normal’ and accepted as seeing your GP for a problem with your physical health.

CHILDREN AND YOUNG PEOPLE’S MENTAL HEALTH

One of our goals for improving mental health services for children and young people living in Hertfordshire is ensuring that they can get early help when they start to feel worried or unwell.

More than 4,000 10 to 25 year olds are now registered to use the online counselling website www.kooth.com, which offers confidential, one-to-one support with emotional wellbeing “Each year, young people and issues. Young people give great feedback about Kooth. youth organisations are invited Anxiety and stress, family relationships and depression are the to apply for up to £500 from most common reasons for logging on. Hertfordshire’s two CCGs and We were part of Hertfordshire’s successful stigma-busting the county council towards ‘Just Talk’ campaign encouraging young people, especially Feeling Good Week activities. boys and young men, to talk about their mental health. Visit “I worked with young people our YouTube channel or search #JustTalk to watch some in Hertfordshire to improve celebrity videos. the funding application process, which is hosted on FEELING GOOD! our website, and like to get involved with scoring bids and 52 projects in east and north Hertfordshire were given visiting projects. Feeling Good ‘Feeling Good Week’ funding this year. Young people from YC Week is such a great initiative, Hertfordshire (Youth Connexions) judged which bids should improving the physical and get a share of the £40,000 pot earmarked by the county’s two emotional health of children CCGs and county council for wellbeing projects. Examples of and young people across the the projects funded this year include anxiety workshops and county.” mindfulness sessions. www.healthyyoungmindsinherts.org.uk Frankie Walsh, aged 20, Youth Engagement Officer for Hertfordshire Healthwatch.

Annual Report and Accounts 2017/18 16 ______

IMPROVING URGENT CARE

NHS 111 BECOMES A NEW INTEGRATED URGENT CARE SERVICE

Since June 2017, patients in Hertfordshire who call NHS 111 receive help from the county’s new ‘integrated urgent care’ service, 24 hours a day, 7 days a week. The new service combines the out-of-hours GP service with NHS 111 plus a new ‘clinical advisory service’ where GPs, pharmacists, dental nurses, palliative care nurses and mental health professionals advise patients and health professionals.

The 111 call centre is open day and night and is staffed by trained call handlers who assess patients and give them the advice they need or triage them to the most appropriate clinician or service. Those patients that need further clinical support will be referred to the clinical advisory service for help. Patients who need to see an out-of-hours doctor or nurse in person have their appointment confirmed while on the phone.

Since it launched, the service provided by Herts Urgent Care has handled more than 272,000 calls, with its busiest month being December. Having a wide range of clinicians available to speak to patients has helped to reduce the number of non-emergency ambulance call-outs by around 12,000. More than 7,000 patients found that they didn’t need to visit a hospital emergency department because they had spoken to a clinician as part of their call to NHS 111.

Annual Report and Accounts 2017/18 17 ______

GREAT IMPROVEMENT IN AMBULANCE HANDOVER TIMES

Changes made at the Lister Hospital’s emergency department during the past year have seen a greater percentage of ambulances handing over patients to hospital staff within the overall national 15-minute standard. Previously, fewer than 20% of handovers achieved this standard. With the support of the ambulance service, the process for paramedics to transfer patients to the emergency department was streamlined to be more efficient. This means that patients who are the most unwell are now being identified sooner and their hospital care can begin much more quickly.

In response to criticisms of the ambulance service for delays in reaching patients over the Christmas period, in February hospitals were asked to further improve handover performance to help ambulances get back on the road and attend to new patients faster than before.

KEEPING THE HOSPITAL MOVING

The CCG, East and North Hertfordshire NHS Trust and social care colleagues have continued to make improvements to the systems in place in the Lister hospital. By focusing on efficient and effective care, we can help to keep beds available for patients who need to be admitted.

Multi-agency teleconferences happen every morning to tackle any problems that could prevent patients from going home on time. Our work has meant that there are very low numbers of ‘delayed transfers of care’ in our area. Over the past year the Lister has improved its processes and the way it collects data which means that fewer patients are staying in hospital beds longer than they need to. The ‘impartial assessor’ nurse employed jointly by the hospital and the Hertfordshire Care Providers Association, is also helping to speed up the acceptance of patients into care and nursing homes, releasing 10-20 hospital beds per week that can be used for new patients.

Annual Report and Accounts 2017/18 18 ______

IMPROVING PRIMARY CARE

COMMISSIONING GP SERVICES

When CCGs like ours were first established in 2013, the responsibility for commissioning GP services was given to the national organisation NHS England. Whilst CCGs have always had a statutory duty to support GP practices to offer high-quality care, more recently individual areas have been able to choose whether they wished to get more involved in commissioning these services.

Since April 2015, we have been jointly commissioning GP services alongside NHS England. At a meeting of all our GP practices in December 2017, the decision was made, following a vote, to fully take on the responsibility for commissioning general medical services from April 2018. This will include renewing and awarding contracts to provide GP services and performance-managing contracts. Find out more here.

PHARMACY AND GPS WORKING TOGETHER

This year CCG pharmacists, working closely with GPs to make sure patients receive the most cost-effective medicines for their condition, have saved almost £1 million. We have also helped GP practices in Hertford, Ware, Hoddesdon, Hatfield and the Bishop’s Stortford area to employ five pharmacists to work alongside GPs and practice nurses, advising on the most effective use of medicines.

Annual Report and Accounts 2017/18 19 ______

TAKING ACTION ON ANTIBIOTICS

The CCG continues to take the lead locally on tackling the misuse and over-prescription of antibiotics. Taking these medicines inappropriately enables bacteria to become resistant and antibiotics may not then work when we need them to. Our CCG pharmacists support GPs to ensure the right and safe use of antibiotics for their patients. During 2017/18, antibiotic prescribing rates in the CCG have decreased by 5.4% and are within the guidelines set by NHS England.

We are also working hard on antibiotic prescribing for urinary tract infections in care homes. It is hoped that a change in the way these infections are diagnosed will result in better antibiotic prescribing and reduced hospital admissions for vulnerable care home residents. We will evaluate the success of this scheme as it progresses.

Hertfordshire’s antibiotic prescribing guidelines have been updated this year to take into account local resistance patterns and the latest national guidance. A free smartphone app puts this information at clinicians’ fingertips. So far the app has been downloaded more than 3,000 times.

EVENING AND WEEKEND GP AND NURSE APPOINTMENTS AVAILABLE

From March 2018, patients registered with GP practices in Welwyn and Hatfield have been able to book appointments to see a GP, nurse or other healthcare professional at a wider ranges of times in the evening or at the weekend. Local people were asked about when they would find it convenient to see a GP and this feedback helped the CCG to plan how the new extended opening hours would work.

Improved access to evening and weekend appointments for patients in the rest of our CCG area will be coming later in the year. www.enhertsccg.nhs.uk/extended-access

Annual Report and Accounts 2017/18 20 ______

GENERAL PRACTICE FORWARD VIEW

The GP Forward View, published by the government in April 2016, commits to an extra £2.4 billion a year to support general practice services across the country by 2020/21. It will improve patient care and access, and invest in new ways of providing primary care and dealing with the challenges of rising demand, ageing facilities and a limited workforce.

To deliver this in east and north Hertfordshire, as well as extending GP opening hours in the Welwyn Hatfield area, we have helped all our practices to improve their productivity through better IT and training reception staff so they can assist patients who need help accessing other local services. Administration staff have also been trained to help them feel more confident in managing medical correspondence to improve the efficiency of practices. Each locality has come up with its own plans, funded by the CCG, to work more sustainably together, create new healthcare roles in practices and be more innovative in the types of consultations they offer to patients.

Over the coming year, we will continue to make more GP and nurse appointments available across the CCG area outside of normal hours and will invest in systems to enable patients to have online consultations with their practice, which will be both more convenient and more sustainable.

NEW PRIMARY CARE PRESCRIBING POLICIES

During 2017, the two CCGs in Hertfordshire consulted with local people on proposed changes to a number of policies. You can read more about the public consultation on page 74 of this report or on our website. The feedback from that process was considered by a joint committee and as a result, changes to the prescribing of over-the-counter medicines and gluten-free products were implemented in early 2018. These will now no longer be routinely prescribed. You can read more about these changes in this leaflet, which is available in all GP practices.

Annual Report and Accounts 2017/18 21 ______

IMPROVING GP PREMISES

After many years and a number of setbacks, Amwell Surgery in Hoddesdon finally moved to its new building in July 2017. After the project developer fell into administration weeks before completion in 2011, Broxbourne Borough Council stepped in to purchase the entire development and secure its future. Throughout this challenging period, the practice has remained focused on patient care and are now enjoying their new premises.

NHS England, through its Estates Technology Transformation Fund, is working with the CCG on schemes which involve bringing together eleven surgeries into six new, or significantly refurbished premises in Bishop Stortford, Sawbridgworth, Ware, Welwyn Garden City, Stevenage and Puckeridge. Projects are at various stages but three are dependent upon changes being made to national directions which will raise the funding limit for such schemes from 66% to 100%.

Work is also taking place with practices in Letchworth, Baldock, Hertford and Cheshunt to scope new options for new buildings.

Annual Report and Accounts 2017/18 22 ______

A GP WORKFORCE FIT FOR THE FUTURE

One of the biggest challenges facing primary care across the country is the recruitment and retention of clinical staff. The GP and practice nurse workforce is ageing, with 30% of GPs and practice nurses likely to retire in the next 5 years.

The CCG’s primary care workforce and education network brings together health and social care staff in our area to help plan for the future. “We face significant recruitment challenges and As well as looking at how we can recruit and retain suitably there are no quick fixes. We qualified staff, the network is also exploring ways of working know there are solutions and collaboratively, to make best use of the wide-ranging skills we these are starting to be already have. implemented. In 2017/18, the network has delivered a number of key successes, including: “Integrated community services, the ‘Primary Care  Submitting a GP workforce plan to NHS England, with our Home’ model and the network model being recognised as good practice concept of ‘place-based care’, with a focus on people  Preparing a bid to recruit international GPs to work across and not organisations, are Hertfordshire and west Essex the way forward and will help to make us resilient and  Appointing seven GP ‘Fellows’. The two most recent improve access for patients.” recruits work at Wallace House Surgery in Hertford. These qualified GPs gain valuable experience of wider health management and can undertake special projects and Robin Christie, GP lead for further learning, as well as seeing patients the Primary Care and Workforce Network  Supporting an additional 23 GPs to become associate trainers, enabling them to assist with GP registrar tutorials and clinical supervision

Annual Report and Accounts 2017/18 23 ______

 Recruiting 11 Clinical Pharmacists to work alongside the GP team as part of an NHS England pilot to support people with long term conditions, carry out telephone consultations with patients and deal with prescription queries and medication changes

 Supporting our practice nurses through training, peer support and improving career pathways. The work of our practice nurse coordinator and nurse tutors has been applauded nationally

 Partnering with the representative organisation the Local Medical Committee on training for practice managers

 Securing more than £90,000 in funding to provide additional development opportunities for practice staff

 Holding mock interviews for local pupils who want to attend medical school

We also built on the success of last year’s inaugural Hertfordshire Health and Social Care Careers Expo, ‘Future Heroes’. This year nearly 700 pupils aged from 14 – 18 years and their tutors met clinical professionals from across Hertfordshire and through interactive, inspirational activities and demonstrations, were guided to make the link between their studies and interests and a fulfilling and rewarding career in health or social care.

Annual Report and Accounts 2017/18 24 ______

SUPPORTING OLDER PEOPLE

BETTER CARE FOR OUR CARE HOME RESIDENTS

The health and wellbeing of our 3,000 plus elderly care home residents has been the focus of our ‘vanguard’ programme for the past three years.

This partnership between our CCG, Hertfordshire County Council and the Hertfordshire Care Providers Association has delivered some impressive results: improving the health and care of residents and contributing towards £11.5m of savings on ambulance call-outs, A&E attendances and emergency discharges for over 65s in east and north Hertfordshire.

We have developed a series of successful initiatives that can be rolled out across the STP and the UK as part of NHS England’s ‘new models of care’ programme. Our showcase event in November aimed to share our learning with colleagues from across the country.

These include:

 Two Early Intervention Vehicles which provide an immediate response to emergencies such as falls at home via screened 999 calls, helping to care for people safely in their own homes. The service started with one vehicle and will be expanded to four during 2018/19.

 Pharmacists and pharmacy technicians work with care home staff and GPs to review and monitor residents’ medications, looking for drugs which may adversely interact with one another or increase the risk of falls. So far, more than 1,700 residents in 49 care homes have been reviewed. Dieticians help to identify residents who might be at risk of malnutrition, supporting staff to offer specially nourishing food first, before considering oral nutritional supplements. 17% of medications have been stopped resulting in improvements to residents’ health and wellbeing and savings of £400k.

Annual Report and Accounts 2017/18 25 ______

 55 of our care homes now have NHS.net email so they can quickly and securely share patient information with hospitals, GP surgeries, community and mental health trusts. Managers and staff have undertaken mandatory training which qualifies them to use the secure NHSmail system.

 Developing the skills of care home staff to make them more confident in dealing with the conditions of elderly residents, and liaising with health care professionals. ‘Champions’ are trained in dementia, nutrition, falls and fragility, wound management and health, including end of life care, cascading their learning to colleagues within their individual care homes. More recently we have been delivering ‘End of Life’ training to care homes to ensure residents have a ‘good death’ in their preferred location, avoiding hospital admission at the end of their lives.

 Pioneered at the Lister Hospital, the impartial assessor - who is a qualified healthcare professional, reviews patients who are medically fit to leave hospital in order to speed up their discharge back to their care home. This service has been expanded in the Lister to include a care home choice facilitator, who works to support patients and their families who are looking for a care home, who will be paying for their own care. As part of our STP collaboration, we have extended this project to Princess Alexandra Hospital, Harlow and Watford Hospital.

Annual Report and Accounts 2017/18 26 ______

NEW PROVIDER OF NON-EMERGENCY PATIENT TRANSPORT

When the provider of non-emergency patient transport services suddenly ceased trading in September 2017, the CCG worked with its counterparts across Hertfordshire and Bedfordshire to rapidly put in place contingency measures and start planning for a new contract. As a result, disruption to patients’ journeys was kept to a minimum and the East of England Ambulance Service NHS Trust was appointed to take over the contract for an initial two years. The patient transport service runs around 75,000 journeys for patients living in east and north Hertfordshire and is a lifeline for patients that have regular appointments for treatment such as dialysis, radiotherapy and chemotherapy.

RECOVERY AT HOME - SUPPORT FOR ELDERLY PATIENTS

Elderly patients who’ve had a spell in hospital are being supported to return home to continue their recovery, under a new scheme being piloted in North Herts, Welwyn and Hatfield and Stevenage.

The ‘Discharge Home to Assess’ service, launched in November 2017, enables patients who are well enough to be discharged from hospital, to go home with extra help and support to complete their recovery. For example, someone who has had a fall might be supported with physiotherapy in their home, some help to keep up with cleaning and cooking and a regular visit from a community nurse. Find out more.

COMMUNITY NAVIGATORS AND NEW HOSPITAL DISCHARGE SERVICE Teams of trained staff are now available across Hertfordshire to make sure that vulnerable people or those who are unsure or anxious find the right service to help them. Community Navigators are local experts in voluntary sector services in their area. They can arrange for people to receive community support from voluntary organisations, to complement the clinical help they are getting.

Annual Report and Accounts 2017/18 27 ______

Patients who need a bit of extra practical help or emotional “Within a short time the support to settle back home after a hospital stay can also now ambulance crew arrived, access this across the county. This new service allows people to attended to me at home and maintain their independence, reduces unnecessary hospital decided to take me to A&E at discharge delays and helps to prevent re-admission to hospital. Lister. I was seen afterwards by a steady stream of These new services are provided by the NHS, Age UK professionals. Throughout Hertfordshire, British Red Cross and HertsHelp. A Community the episode I was treated Navigator specifically for the East Herts Council area has also well and as speedily as can been funded by the council. More details are available here. be expected and I am pleased to report that I am progressing from the low point I was at when I was taken ill.” BETTER CARE FOR STROKE PATIENTS

People who have a stroke in east and north Hertfordshire now receive care from a stroke service which is rated amongst the “My husband was rushed to best in the country. After a brief spell of a few days in the A&E with symptoms of a Lister’s specialist stroke unit, most patients are supported to stroke. In the A&E recover either in their own homes with specialist help, or in the department he was treated highly-regarded Danesbury Neurological Centre in Welwyn. In by two amazing stroke human terms, this means that local people are both surviving doctors from Pirton ward and thriving after a stroke who may have been permanently where he was eventually disabled in the past. transferred to. His entire stay was for 12 days where I believe he received a truly brilliant service.”

Stories from Hertfordshire stroke survivors and their families

Annual Report and Accounts 2017/18 28 ______

GP NOW PART OF RAPID RESPONSE TEAM

This year, the ‘rapid response’ service in the Upper Lea Valley locality was enhanced with a GP. The team aims to visit very complex patients at home, to prevent a health condition getting worse and people needing to go into hospital. The new GP role reviews all patients on the caseload giving medical input. Having a GP in the team means diagnostic tests can be ordered and results reviewed quickly. The wider community team also benefit from the GP’s knowledge and experience of supporting acutely unwell patients at home.

PERSONALISING CARE

100 DAY CHALLENGE ACCEPTED

During 2017/18, Hertfordshire was selected by NHS England as the second area of the country to benefit from investment and support to complete a ‘100 day challenge’. Helped by Nesta, an innovation charity, the aim of the challenge was to try out integrated and personalised practice. Teams from Hertford and Hoddesdon made up of a GP, social workers, rapid response nurses and therapists, mental health professionals, voluntary sector representatives, a person with experience of receiving care and a carer came up with ideas and shared inspiring stories and experiences. By the end of the 100 days, more patients had personal care plans put in place, frontline staff had received training in dementia awareness and plans had been developed to better support older people with mental health needs and reduce A&E attendances. Senior leaders from all organisations were asked to respond to the challenge and make these plans a reality.

Annual Report and Accounts 2017/18 29 ______

PERSONAL HEALTH BUDGETS

In autumn 2016, Hertfordshire was named as one of 17 new Integrated Personal Commissioning (IPC) areas. With support from NHS England the IPC programme has been working with patients and professionals across the health, social care, community and voluntary sector to provide joined-up, personalised care for people.

One of our objectives is to increase the number of Personal Health Budgets being taken up. A personal health budget is an amount of money a patient can use to support their health and wellbeing needs. This money is planned and agreed between the patient and their local NHS team. It allows people to manage their support, equipment and personal care, in a way that suits them.

There are around 650 integrated packages of care and Personal Health Budgets in Hertfordshire. We are working to train staff to understand personalised care, so that more services can be purchased by patients in the future.

Annual Report and Accounts 2017/18 30 ______

Annual Report and Accounts 2017/18 31 ______

Annual Report and Accounts 2017/18 32 ______

SUMMARY OF KEY PERFORMANCE

CHIEF EXECUTIVE’S STATEMENT ON PERFORMANCE

Looking back over the 2017/18 financial year, East and North Hertfordshire CCG has many reasons to be proud of the work we have done to ensure our patients have access to good quality healthcare services. Our innovation in improving the care of frail, elderly patients in care homes has been highlighted on the national stage and we have seen the work we’ve done in partnership with others to transform child and adolescent mental health care held up as good practice.

More than 81% of people were satisfied with their experience of their GP practice, and over the coming months as we introduce better access to evening and weekend appointments, we hope to further improve on that percentage.

Significant improvements have also been achieved in a number of key areas during 2017/18, including:

 reducing unnecessary antibiotic prescribing to below target levels  increasing the number of people being treated within 18 weeks – an improvement in performance that was recognised by the Secretary of State in autumn 2017 and which we continue to build upon  Launching an integrated urgent care service to provide people with fast access to the services they need

Despite these key achievements, it has not been an easy year. The NHS, both locally and nationally, has been under significant pressure over the past 12 months. The challenges of meeting the 4-hour national A&E standard have been well documented and the CCG has been using contractual levers to drive forward improvements in performance with East and North Hertfordshire NHS Trust - our main provider. In response to this our hospital colleagues have introduced new ways of delivering the emergency service which makes best

Annual Report and Accounts 2017/18 33 ______

use of the available clinical staff and minimises waits for patients and I look forward to seeing an improved achievement against the A&E standard over the coming months. In the spring, a team from the Care Quality Commission returned to East and North Hertfordshire NHS Trust to carry out a full inspection of all services provided by the trust. Results from this inspection are due later in the year. The CCG will work with the senior leadership team at the trust to support the implementation of any improvements that are identified.

As detailed elsewhere in this annual report, we recognise the additional work that needs to be carried out across the whole health system to improve early diagnosis of cancer and ensure that as many people who receive a diagnosis of cancer begin their treatment within the national 62-day target. NHS organisations across our STP area have recently secured additional funding to improve cancer services and have begun to invest that money in improving services along the patient pathway.

Helping more people to survive cancer and live healthy, independent lives requires the health service, local authorities and other voluntary organisations to tackle the issues in partnership. Results of the CCG stakeholder survey this year demonstrated that our clinical and non-clinical partners believe that the CCG provides clear and decisive leadership. We will continue to work closely with all our stakeholders and patients to commission of integrated, sustainable and good quality services over the coming year.

Annual Report and Accounts 2017/18 34 ______

PERFORMANCE ANALYSIS

______

Annual Report and Accounts 2017/18 35 ______

SUMMARY OF PERFORMANCE

The information on pages 36-38 is a summary of performance during 2017/18. Full performance data follows on pages 40-50.

ACCIDENT AND EMERGENCY (A&E) DEPARTMENT PERFORMANCE

There is a national requirement that patients attending an Accident and Emergency (A&E) department should be discharged, transferred or admitted within four hours at least 95% of the time. In 2017/18, both East and North Hertfordshire NHS Trust and Princess Alexandra Hospital failed to meet the standard.

AMBULANCE RESPONSE TIMES

The CCG commissions services from the East of England Ambulance Service NHS Trust (EEAST). The ambulance trust has had a challenging year, particularly over the winter period.

As part of the Ambulance Response Programme, new ambulance performance standards came into operation at the end of October 2017 to measure ambulance response times. The changes focus on making sure the best, high quality, most appropriate response is provided for each patient first time. Call handlers will be given more time to assess 999 calls that are not immediately life-threatening, which will enable them to identify patients’ needs more clearly and send the most appropriate response. Ambulance services are measured on the time it takes from receiving a 999 call to a vehicle arriving at the patient’s location. There are four categories of call with associated required average response times:

o C1 People with life threatening injuries and illness (less than 7 minutes) o C2 Emergency calls (less than 18 minutes) o C3 Urgent calls (less than 120 minutes) o C4 Less urgent calls (less than 180 minutes)

Annual Report and Accounts 2017/18 36 ______

REFERRAL TO TREATMENT TIMES

One of the performance targets under the NHS Constitution states that 92% of patients should be treated within 18 weeks. This target has not been met consistently for East and North Hertfordshire CCG patients during 2017/18. The CCG ended the year with 89.46% of patients being treated within 18 weeks. However it is important to note that this position doesn’t include figures from East and North Hertfordshire NHS Trust as the trust has been unable to report their figures since September 2017 as a result of issues relating to the implementation of a new software system.

STROKE

National stroke performance targets state that stroke patients should spend 90% of their time in hospital in a specialist stroke unit. This target has been met consistently throughout 2017/18, with performance similar to 2016/17. Patients who have had a stroke should also be admitted directly to a specialist stroke unit within 4 hours. Performance against this standard fell in the second reporting period in 2017/18 to 63.6% (against a target of 90%) and, although still above national average, was lower than for 2016/17.

CANCER

We believe that our patients should receive high quality care without unnecessary delay and where cancer is suspected, patients have the right to be seen by a cancer specialist within two weeks of a referral being received. Patients should expect to be treated according to clinical priority and for patients diagnosed with cancer; their first definitive treatment to remove or shrink the tumour should be within 62 days of the date the referral was first received and within 31 days of the decision to treat date.

The ‘two week referral to first outpatient appointment’ standard has been met for 2017/18 for our patients, and although there was a slight decrease in performance in suspected cases of breast cancer in the summer months, this standard has been met for 2017/18.

Annual Report and Accounts 2017/18 37 ______

 The 31 days to first definitive treatment standard has been meeting the required standard since October 2017.

 The 62 day target of 85% has only been achieved in December at CCG level throughout 2017/18, largely due to performance issues at ENHT. The trust’s achievement at year-end was 76.92% following adjustments made for late referrals. Considerable work has been undertaken between the trust and the CCG to identify improvement actions.

DIAGNOSTIC WAITS

There is a national requirement that patients should have their diagnostic tests within six weeks with a performance target of 99%. Although this standard was met consistently in 2016/17 it has been just under the required 99% in 2017/18. CCG-level performance figures exclude ENHT figures from September 2017 onwards following issues with new software.

DIAGNOSING DEMENTIA

For 2017/18, GPs in east and north Hertfordshire recorded a rate of 64.36%, against a standard of 66.7% of the expected number of people over 65 diagnosed with dementia. Work is ongoing to improve the diagnosis rates of people with dementia, including the introduction of one-stop pathways and support to GP practices.

Annual Report and Accounts 2017/18 38 ______

QUALITY PREMIUM (2017-19)

All CCGs have the potential to earn a ‘Quality Premium’ (QP) which is in recognition of improving the quality of services that they commission and for associated improvements in health outcomes and reducing inequalities.

The 2017-19 Quality Premium is a two-year scheme and will be paid to the CCG in 2018/19 and 2019/20 to reflect the achievements in 2017/18 and 2018/19 of national and local measures based on the priorities of the Five Year Forward View, NHS Mandate and Right Care Programme.

CCGs must use any QP payment awarded to them to improve the quality of care or health outcomes and/or reduce health inequalities.

In 2016/17 the CCG was awarded 20% of the available Quality Premium, which after adjustments in line with delivery of NHS Constitution rights and pledges, equated to £196,611. In 2017/18 the total maximum amount payable to CCGs for achievement of the QP is £5 per registered patient which, for East and North Hertfordshire CCG, with a registered population of around 590,000, equates to around £2.95m.

The national measures, based on the Five Year Forward View and NHS Mandate are:

 Cancers diagnosed at an early stage - worth 17% of the Quality Premium;  Overall experience of making a GP appointment - worth 17% of Quality Premium;  Reduction in bloodstream infections and inappropriate antibiotic prescribing in primary care - worth 17% of Quality Premium;  Improvements in continuing healthcare pathways - worth 17% of Quality Premium;  Improvements in mental health pathways - worth 17% of the Quality Premium.

The local measure, based on priorities for East and North Hertfordshire CCG and agreed with NHS England, is: Increase in breast cancer screening - worth 15% of Quality Premium.

Annual Report and Accounts 2017/18 39 ______

Domain/Measure Detail Performance at year end Data for this metric is produced annually Cancers diagnosed Improvement in the proportion of and information for 2017/18 will not be at an early stage cancers diagnosed at stages 1 and 2 available until end of May 2019. To be updated Increase in the percentage of Overall experience The data for this metric will be released in respondents to the GP Patient Survey of making a GP the July 2018 publication of the GP who said they had a good experience appointment Patient Survey. To be updated of making an appointment. Part A: Reduction in the number of Information available to February 2018 gram negative blood stream indicates that this metric is unlikely to be infections achieved. To be updated Part B: Reduction of inappropriate Information available to February 2018 Blood Stream antibiotic prescribing for urinary tract indicates that this metric is on track to be Infections infections in primary care achieved. To be updated

Part C: Items per STAR-PU must be Information available to February 2018 equal to or below England 2013/14 indicates that this metric is on track to be mean performance achieved. To be updated

Measure 1: Increase in percentage of CHC eligibility decisions made within This metric was not achieved for 2017/18. 28 days of receipt of Checklist Continuing Healthcare Measure 2: Decrease in percentage of full NHS CHC assessments taking place This metric was not achieved for 2017/18. in an acute hospital setting

Information available to end of Qtr 2 Improved access to Children and (September 2017) indicates that this Mental Health Young People’s Mental Health metric is unlikely to be achieved. To be services updated Information available to end of Qtr 2 Increase in the percentage of women (September 2017) indicates that this Local Measure aged 50-70 who were screened for metric is unlikely to be achieved. To be breast cancer in the last three years updated

Annual Report and Accounts 2017/18 40 ______

The total payment to CCGs, based on performance against the national and local measures detailed above, is further reduced if the NHS Constitution rights or pledges are not met for its patients:

• Maximum 18 week wait from referral to treatment (incompletes) – 33% reduction; • Maximum four hour wait in A&E –33% reduction; • Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer – 33% reduction;

Failure to meet these pledges results in a percentage reduction to the amount of Quality Premium earned for each standard not met, with the risk of losing the whole payment if none are met. CCGs must also manage within their total resource envelope for 2017/18 and not be in serious quality failure 1 in order to qualify for any Quality Premium payment. Failure to meet these criteria will result in CCGs not being awarded any of their Quality Premium payment.

1 ‘Serious quality failure’ means that: a local provider has been subject to enforcement action by the Care Quality Commission; or has been flagged as a quality compliance risk and/or have requirements in place around breaches of provider licence conditions; or has been subject to enforcement action based on a quality risk; and the CCG, has been judged as not making an appropriate, proportionate response with its partners to resolve the above quality failure; and this continues to be the position for the CCG at the end of year assessment.

Annual Report and Accounts 2017/18 41 ______

PERFORMANCE AGAINST NHS CONSTITUTION RIGHTS AND PLEDGES The table below shows our performance against the NHS Constitution Rights and Pledges. For 2017/18, none of the required three performance standards have not been met which means that no quality premium will be payable to the CCG this year.

The Quality Premium payment to the CCG for 2017/18 will not be finalised until late September 2018.

NHS Constitution Performance at Detail Standard Right / Pledge year end

Patients on incomplete non- 92% or improving Maximum 18 emergency pathways (yet to performance as Target not met week wait from start treatment) should have agreed with NHS for 2017/18 referral to been waiting no more than 18 England treatment weeks from referral

Patients should be admitted, 95% or improving Four hour wait in transferred or discharged performance as Target not met A&E within four hours of their agreed with NHS for 2017/18 arrival at an A&E department England

Maximum two month (62-day) 85% or improving Cancer two wait from urgent GP referral to performance as Target not met month (62-day) first definitive treatment for agreed with NHS for 2017/18 wait cancer England

Annual Report and Accounts 2017/18 42 ______

A&E four hour operational standard There is a national requirement that 95% of patients attending A&E are treated, admitted or transferred within 4 hours of arrival. Significant pressures over the winter period have affected performance at both ENHT and PAH. Nationally there is an expectation that all trusts will meet 90% by September 2018 and 95% by March 2019. This will require both trusts to submit a plan to show how they will improve to meet these standards.

A Contract Performance Notice was issued to ENHT in December 2017, which resulted in the Trust submitting a remedial action plan to explain the key actions that will be undertaken to improve performance. These actions included:  The redesign of streaming model at Lister A&E to ensure that patients are seen by the most appropriate clinician  Increased utilisation of alternative urgent care pathways, including ambulatory care, frailty and discharge home to assess;  Capacity and demand modelling of assessment space within the Trust;  Implementation of professional standards and escalation protocols.

Actions undertaken at Princess Alexandra Hospital to improve performance included:  Focusing on patient ‘flow’ in the department;  Changes to the allocation and use of medical and surgical assessment areas;  Early identification of patients to be discharged from wards;  Review of the GP streaming service  Consultant presence in Rapid Assessment Team to lead and support early assessment.  The introduction of an improvement action plan and ‘Every Minute Matters’ work to improve the pathway for patients with urgent care needs, ensuring that they are treated by the most appropriate professional.

Annual Report and Accounts 2017/18 43 ______

Response times to ambulance calls New ambulance performance standards came into operation at the end of October to measure ambulance response times. There are 4 new categories of call with associated required average response times:

 C1 People with life threatening injuries and illness (<7 minutes)  C2 Emergency calls (<18 minutes)  C3 Urgent calls (<120 minutes)  C4 Less urgent calls (<180 minutes)

Discussions have been held locally and nationally to work collaboratively with 111 providers to reduce the number of C3 and C4 ambulances that are dispatched. The performance standards are not expected to be met until potentially October 2019.

Ambulance Response Target Q1 Q2 Q3 Q4 2017/18

C1 People with life <7 threatening injuries and 8:56 8.41 8.47 minutes illness

<18 C2 Emergency calls 28.14 27.50 28.00 minutes

<120 C3 Urgent calls 230.15 199.55 212.03 minutes

<180 C4 Less urgent calls 273.41 238.38 252.39 minutes

Annual Report and Accounts 2017/18 44 ______

Waiting times for cancer treatment The NHS Constitution sets out rights for patients with suspected cancer. There are a number of government pledges on cancer waiting times:

Two-week waits

 A maximum two-week wait to see a specialist for all patients referred with suspected cancer symptoms;  A maximum two-week wait to see a specialist for all patients referred for investigation of breast symptoms, even if cancer is not 14 initially suspected.

31 days

 A maximum one month (31-day) wait from the date a decision to treat (DTT) is made to the first definitive treatment for all cancers;  A maximum 31-day wait for subsequent treatment where the treatment is surgery;  A maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy; 31  A maximum 31-day wait for subsequent treatment where the treatment is an anti-cancer drug regimen.

62 days

 A maximum two month (62-day) wait from urgent referral for suspected cancer to the first definitive treatment for all cancers;  A maximum 62-day wait from referral from an NHS cancer screening service to the first definitive treatment for cancer;  A maximum 62-day wait for the first definitive treatment 62 following a consultant’s decision to upgrade the priority of the patient (all cancers).

Annual Report and Accounts 2017/18 45 ______

East and North Hertfordshire NHS Trust

Although East and North Hertfordshire NHS Trust has performed well against the 2-week standard in 2017/18, the 31-day standard and the 62-day standard to definitive treatment have proved more difficult to achieve.

A Contract Performance Notice was issued to the Trust by the CCG in December 2017 and monthly cancer performance meetings were re-established. An agreed recovery plan to drive improvements in cancer pathways is in place. At year-end, the trust was treating 76.92% of patients within the 62-day standard – missing the target of 85%. Work has been ongoing between the Trust and CCG to improve timed pathways for lung and prostate cancer.

The CCG also has a Cancer Steering Group which discusses issues of performance against the national cancer waiting standards, national guidance and reviews and agrees ways in which cancer pathways can be improved.

Princess Alexandra Hospital NHS Trust

Performance at Princess Alexandra Hospital against the cancer waiting time standards has been good with all metrics meeting required standards for 2017/18 overall.

The table below shows cancer performance at CCG level which is for ENHCCG patients attending any hospital. With the majority of ENHCCG patients attending ENHT, the performance at ENHT has a significant impact on CCG performance.

Annual Report and Accounts 2017/18 46 ______

Table: Cancer waiting times for all CCG patients

Cancer Waiting Times at CCG level Target Q1 Q2 Q3 Q4 2017/18 Maximum two-week wait for first outpatient appointment for 93% 97.61% 97.28% 97.52% 97.30% 97.43% patients referred urgently with Two suspected cancer by a GP Week Maximum two-week wait for first Waits outpatient appointment for patients referred urgently with 93% 95.52% 93.31% 94.03% 95.88% 94.69% breast symptoms (where cancer was not initially suspected) Maximum one month (31-day) wait from diagnosis to first definitive 96% 94.30% 96.76% 97.31% 96.97% 96.33% treatment for all cancers Maximum 31-day wait for subsequent treatment where that 94% 94.09% 91.75% 91.24% 94.91% 93.00% treatment is surgery 31 Day Maximum 31-day wait for Waits subsequent treatment where that 98% 97.10% 96.51% 97.57% 95.99% 96.79% treatment is an anti-cancer drug regime Maximum 31-day wait for subsequent treatment where that 94% 93.60% 95.76% 94.06% 92.63% 94.01% treatment is a course of radiotherapy Maximum two month (62-day) wait from urgent GP referral to first 85% 76.90% 78.50% 82.76% 82.83% 80.25% definitive treatment for cancer Maximum 62-day wait from referral from an NHS screening 90% 71.20% 77.84% 82.28% 91.52% 80.71% 62 Day service to first definitive treatment Waits for all cancers Maximum 62-day wait for first definitive treatment following a consultant's decision to upgrade 85% 83.94% 94.87% 89.87% 91.82% 90.12% the priority of the patient (all cancers)

Annual Report and Accounts 2017/18 47 ______

Referral to Treatment Times (RTT) Under the NHS Constitution there is a performance standard related to patients waiting for treatment; the standard being that 92% should wait less than 18 weeks.

The table below details the RTT performance for East and North Hertfordshire CCG patients for 2017/18. 2

RTT Waiting Times Target Q1 Q2 Q3 Q4 2017/18 Patients on incomplete non- emergency pathways (yet to 18 start treatment) 92% 90.69% 92.13% 91.47% 89.46% 89.46% Weeks should have been waiting no more than 18 weeks from referral

Diagnostic test waiting times There is a requirement that 99% of patients have diagnostic tests within 6 weeks of clinician request. 3

Diagnostic Test Target Q1 Q2 Q3 Q4 2017/18 Maximum six week wait 99% 99.35% 97.96% 98.13% 98.61% 96.61% for diagnostic test

2 and 2 ENHT figures have not been included since September as ENHT has been unable to report their figures as a result of issues relating to the implementation of a new software system.

Annual Report and Accounts 2017/18 48 ______

Stroke performance Stroke performance is monitored nationally and reported publically, via the Sentinel Stroke National Audit Programme (SSNAP). East and North Hertfordshire NHS Trust performance has been good against the 90% of time on a stroke unit and this has also been met at CCG level. The 4-hours to direct to stroke unit standard has been more challenging at trust and CCG level, although remains above the national average. ENHT is working hard to achieve the required standard. Stroke nurses have been trained during 2017/18 to directly request CT scans. The trust successfully recruited 15 overseas nurses who started in February 2018, and is actively recruiting an additional stroke consultant.

The Trust attained an ‘A Rating’ on SSNAP for the period August to November 2017.

The CCG continues to monitor and support stroke services through its stroke programme board. Dec to Jan data to be updated when released.

Apr-Jul Aug-Nov Dec-Mar Stroke Performance Target 17 17 18 4 hours direct to stroke unit (ASI 2) 90% 71.20% 63.60%

90% of time on the stroke unit (ASI 3, IPMR) 80% 87.30% 85.70%

Thrombolysed within 3 hours 12% 13.10% 9.30%

Annual Report and Accounts 2017/18 49 ______

Dementia diagnosis By diagnosing patients more promptly with dementia, we will be better able to support them and their families. For 2017/18, GPs in east and north Hertfordshire recorded a rate of 64.36%, against a target of 66.7% of the expected number of people over 65 diagnosed with dementia.

GP practice visits have been undertaken to ensure that dementia diagnosis is correctly recorded. A one stop dementia Early Memory Diagnosis and Support Service (EMDASS) service started in 2018 with triage and same day appointments. In addition, increased funding was given to EMDASS to increase consultant capacity to reduce waiting times.

Improving Access to Psychological Therapies (IAPT) The national targets for the numbers of people accessing psychological therapies and the proportion of people assessed as having recovered as a result of their treatment have both been met for 2017/18. We have also been achieving against the national waiting time targets of 75% of people starting treatment within six weeks, achieving 85.55% at the end of 2017/18, and 95% of people within 18 weeks, achieving 100% at the end of 2017/18.

Annual Report and Accounts 2017/18 50 ______

MY NHS – HOW ARE YOUR LOCAL HEALTH SERVICES PERFORMING?

My NHS is a website where organisations, professionals and the public can compare the performance of services across health and care, over a range of measures, and on local and national levels.

In 2016/17, the CCG was rated as ‘outstanding’. To get to this rating, CCGs are assessed in four key areas:

 Better Health: how the CCG contributed towards improving the health and wellbeing of its population;  Better Care: focusing on care redesign, performance against national standards, and outcomes in important clinical areas;  Sustainability: how the CCG is remaining in financial balance, and is securing good value for patients and the public from the money it spends;  Leadership: assessing the quality of the CCG’s leadership, our plans, how the CCG works with its partners, and our governance arrangements

At the time of writing (May 2018) the results for our 2017/18 assessment have not been published on My NHS.

Our ratings on My NHS show that we perform well in mental health, diabetes care and antibiotic stewardship. Areas where we need to make improvements include dementia and cancer care – where we recognise the need for patients to be diagnosed earlier and start their definitive treatment as quickly as possible.

You can keep up to date with the performance of the CCG and the wider local NHS by typing your postcode into www.nhs.uk/mynhs

Annual Report and Accounts 2017/18 51 ______

ENSURING OUR PATIENTS RECEIVE HIGH QUALITY CARE

Our ambition is to commission high quality, safe and clinically effective services for our patients. The indicators in the NHS Outcomes Framework; clinical effectiveness, patient experience and patient safety, allow the CCG to gain assurance about the quality of services being delivered by our providers and enables us to challenge and intervene when necessary.

The CCG’s quality assurance strategy sets out our approach to commissioning and monitoring services in order to deliver high quality care to our patients.

The quality team:

 sets key safety, experience and effectiveness measures which are monitored regularly through quality review meetings, quality assurance visits and contract review meetings

 provides an integrated performance and quality report for the Governing Body

 has a robust Quality Committee which reports to the Governing Body, providing assurance on the quality of services we commission. The committee receives a quality dashboard detailing key metrics for all providers as well as a quarterly quality report detailing performance for all providers

 monitors and reviews data from a number of sources, including the GP hotline, to ensure early warnings of a potential decline in quality are identified and appropriate action taken. The GP hotline is a direct way for GPs and practice staff to let the CCG know if there are any issues with healthcare providers

 has put in place a robust programme of quality assurance visits to providers, using the expertise of patient representatives to support visits. We use visits to identify concerns and ensure appropriate actions are taken

Annual Report and Accounts 2017/18 52 ______

 has a well-informed patient network group which plays an integral role in quality monitoring. All localities are represented on this group and provide feedback on the quality of services commissioned by the CCG

 works in partnership with providers and other commissioners to ensure quality priorities are aligned to the current and future health needs of the local population. Where appropriate, improvements are incentivised through the commissioning for quality and innovation (CQUIN) national schemes

 hosts the ‘designated professionals’ for Hertfordshire, who are members of local safeguarding boards. For further details of their work please see pages 57-59

 works with NHS England to monitor the quality of primary care. The CCG supports practices undergoing CQC inspections and uses the expertise of our own specialists and external partners to help practices improve the quality of their services

 manages the ‘prior approval’ process which ensures that clinical procedures are carried out at the optimum time for patients in line with best available clinical evidence and in accordance with clinical thresholds agreed by the Bedfordshire and Hertfordshire Priorities Forum. There will always need to be a process for considering NHS funding for an individual based on either individual clinical circumstances or exceptional clinical circumstances. The team has clinical expertise and administration support to process applications for prior approval and ‘individual funding requests’ for both the Hertfordshire CCGs

 reviews complaint themes and trends from our main providers. ‘Serious incidents’ in healthcare are adverse events, where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified. The CCG’s Serious Incident panel meets weekly to review investigation reports from serious incidents to make sure they are robust and have considered all aspects of how an incident happened and what is being done to learn from it.

Annual Report and Accounts 2017/18 53 ______

‘Never Events’ are particular types of serious incidents which meet the following criteria:

 They are wholly preventable, where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers  They have the potential to cause serious patient harm or death, although serious harm is not required to have happened in order to classify as a Never Event  There is evidence that the category of Never Event has occurred in the past (nationally) and a risk of recurrence remains.

In January 2018, NHS Improvement published a revised Never Event List 2018. For further information please visit their website.

In 2017/18, six Never Events were reported regarding East and North Hertfordshire CCG’s patients; all from East and North Hertfordshire NHS Trust:

Incident Detail Retained foreign object Patient found to have retained needle post discharge, following post-procedure delivery of her baby Retained foreign object post- Patient found to have retained gall bladder bag following surgery procedure the previous year Misplaced naso or oro-gastric tubes Patient found to have a misplaced naso-gastic tube Wrong site surgery Patient had procedure undertaken on an incorrect finger Transfusion of incompatible blood Patient given wrong blood type during transfusion components Retained foreign object Patient found to have retained guidewire following procedure post-procedure

Annual Report and Accounts 2017/18 54 ______

ACHIEVEMENTS OF THE QUALITY TEAM IN 2017/18

Throughout the year, the quality team has been involved with a number of workstreams that have improved quality, patient experience and clinical effectiveness:

Trained and recruited We continued with our programme of Quality Assurance more patient reps Visits, involving patient reps who provide valuable insight.

Improved our complaints We revised the complaints policy, to include learning handling processes from a complex complaint in relation to meeting with families.

Helped to improve Worked with East and North Hertfordshire NHS Trust to cancer care develop robust processes to find out if patients have come to harm as a result of waiting for cancer diagnosis or treatment.

Supported GP practices During 2017/18, eight GP practices improved their CQC to get better after CQC rating from ’requires improvement’ to ‘good’ and one practice improved its CQC rating from ‘inadequate’ to inspections ‘good’.

Continued excellent Through better partnership working, we can show that health assessment rates 92% of ‘initial health assessments’ were completed on time. The number of ‘review health assessments’ for Looked After Children completed on time has also increased from 91% in March 2017 and to 93% to date this year.

Annual Report and Accounts 2017/18 55 ______

Ensured quality is at the The quality team works with colleagues across the CCG heart of new contracts to make sure that quality, safety and patient experience is prioritised in new contracts. They played a key role in the transfer of the non-urgent patient transport contract and in the procurement of vasectomy, anti-coagulation, wheelchair and GP services.

Developed, published The new ‘prioritisation framework’ has been integrated and shared the with the existing ‘quality impact assessment’ to provide a comprehensive assessment of any new or proposed Prioritisation Framework service changes. This framework has provided the CCG governing body with assurance that the impact on all of our patients and staff of a new service or service change has been considered and actions put in place to mitigate negative impact where necessary.

Annual Report and Accounts 2017/18 56 ______

CARING FOR VULNERABLE RESIDENTS The CCG works hard to keep people who are known to be vulnerable safe, particularly children in the care of the local authority. We are active members of the Hertfordshire Safeguarding Children Board and the Hertfordshire Safeguarding Adults Board, both groups work to protect the welfare of all children and vulnerable adults.

SAFEGUARDING CHILDREN

Children have the right to be protected from being hurt and mistreated, physically or emotionally, and to be enabled to develop as healthy individuals.4 This is called ‘safeguarding’. Safeguarding children is a priority for the CCG and we are committed to minimising the risk of physical, sexual or emotional harm to all children and young people in Hertfordshire.

Designated professionals are employed to assure the CCG that the services we commission have measures in place to safeguard and protect children at risk of harm. This takes place through analysing contracts, training providers, reviewing processes and policy, constructive challenge, monitoring, attendance at safeguarding committees and the supervision of named professionals. There are robust systems in place to ensure that all provider health organisations are fully compliant with Section 11 of the Children Act (2004), including scrutiny through action planning, audit scheduling and quality meeting reporting.

4 (UNCRC, 1989).

Annual Report and Accounts 2017/18 57 ______

The CCG is a committed partner in the Hertfordshire Safeguarding Children Board. Designated professionals also sit on the board’s sub-groups, which monitor and evaluate the effectiveness of local organisations to individually and collectively safeguard and promote the welfare of children. This enables the CCG to oversee how all providers of health and care safeguard children in their organisations.

Key achievements in 2017/18

 Launched a number of multiagency workstreams that will develop safe, robust and high quality safeguarding practice across all partner agencies  Implemented Serious Case Review actions and developed new protocols where needed, to ensure safe and effective safeguarding practice  Developed a pathway to identify and manage cases of female genital mutilation in the county  Developed a multiagency neglect protocol and information leaflet  Trained primary care professionals on female genital mutilation, honour-based violence, forced marriage, the national ‘Prevent’ strategy, child sexual exploitation, domestic abuse and safeguarding leadership  Devised and implemented care pathways for looked-after children and those leaving the care system  Reviewed safeguarding supervision across Hertfordshire, following recommendations from a Serious Case Review. A Safeguarding Supervision Strategy is awaiting ratification.

You can read more about our work to safeguard children here.

Annual Report and Accounts 2017/18 58 ______

SAFEGUARDING ADULTS

The CCG is committed to working with partner agencies to support the identification and prevention of all forms of abuse and mistreatment so that everyone is able to make a full and positive contribution to society within Hertfordshire. We are an active member of Hertfordshire’s Safeguarding Adults Board (HSAB). In 2017/18, the CCG achieved the following outcomes:

 Trained GP practice staff in adult safeguarding and key staff from provider organisations on Prevent – protecting people and communities from the threat of terrorism  Developed a strategy for adult safeguarding  Supported GP practices in relation to domestic homicide reviews  Developed a CCG statement on Modern Slavery for the public facing website, in line with NHS England requirements.  Met all the standards of NHS England’s Safeguarding Assurance Tool  Alongside the chair of the HSAB, undertook a series of assurance visits to non-health partners

The key areas of focus for the Adult Safeguarding lead in 2018/19 will be to:

 Develop systems to ensure the learning identified from domestic homicide reviews is implemented across organisations  Carry out an audit of Mental Capacity Act practice across provider organisations  Launch the online safeguarding adult resource for primary care staff  Provide safeguarding adults training for GPs through training days and locality meetings

This report demonstrates the progress made in delivering the CCGs safeguarding adult responsibilities to date, the strengthening of systems and processes and the focus for the future.

Annual Report and Accounts 2017/18 59 ______

IMPROVING THE HEALTH OF PEOPLE WITH LEARNING DISABILITIES

People with a learning disability die on average 20 years younger than the general population. The LeDeR programme (Learning Disability Review of Mortality) began in Hertfordshire on 1 April 2017 to tackle this health inequality. The deaths of every person with a learning disability are reviewed to identify where clinical/social care practice could be improved to try and prevent unnecessary deaths in the future. To date in Hertfordshire, the programme has received reports of 47 deaths.

Key activities to improve the health of people with a learning disability this year have included:

 Promoting the Hertfordshire ‘Purple Star’ strategy as a quality standard tool and increasing the number of health services achieving the purple star accreditation. The New QEII achieved its first star this year  STOMP: Stopping the overmedicating of people with a learning disability to address where there is inappropriate over prescribing of psychotropic medication  Developing pathways to make it easier for people with a learning disability to access cancer screening, dementia diagnosis and epilepsy support  Raising awareness of conditions such as swallowing problems and constipation  Setting up a group from across health and social care to look at how we can reduce deaths from pneumonia, sepsis, cancer, dementia and epilepsy  Working with other commissioners to ensure mainstream health care services are able to offer support to people with a learning disability.

Annual Report and Accounts 2017/18 60 ______

Community Learning Disability Nurses (CLDNs) work within TRANSFORMING CARE social care locality teams to support people with a learning disability to manage their own health conditions. Each CLDN is linked to several GP practices and can discuss individual cases and offer advice to GPs to ensure the needs of people are well managed.

Ensuring people with a learning disability have an annual health check and are offered a flu jab are key health promotion messages and CLDNs encourage people to attend these appointments. Each practice has a register of people The national Transforming with a learning disability. The CLDNs keep this up to date, Care Programme (launched in enabling practices to be aware of all their patients who have 2012) found that too many additional learning needs. people with learning disabilities were being placed This year, GPs have been using a new template to help them in inpatient settings often far to complete annual health checks. In 2016/17, 56.1% of from home, and staying there people registered as having a learning disability received a for too long. health check (compared to the national figure of 44%). Work to increase this percentage during 2017/18 has taken place The report set out clear, and the aspiration is for practices to achieve 75% by 2020. timetabled actions for health and local authority Hospital staff have access to specialist learning disability commissioners to work nurses from the health liaison team to help them make to together to transform care make adjustments to their normal practices when patients and support for people with come for their appointments. These adjustments could learning disabilities or autism include a staff member not wearing their uniform, or using who also have mental health easy-read leaflets to help to explain procedures or conditions or behaviours treatments, for example. Specialist learning disability nurses which are viewed as also monitor whether patients with a learning disability have challenging. a good experience when they are admitted to, or discharged from hospital. Read more about

Hertfordshire’s progress here.

Annual Report and Accounts 2017/18 61 ______

In February, people with a learning disability from across the county came to the ‘Better Health, Better me’ event to find out how to help keep themselves healthy and what symptoms to talk to a health professional about.

Learning disability service users taking part in the ‘Better Health, Better Me’ event

Annual Report and Accounts 2017/18 62 ______

PREPARING FOR EMERGENCIES The CCG has a responsibility in law to be fully prepared and able to respond effectively in the event of an incident which challenges the capacity or capability of the local health system.

In 2017/18 we remained fully compliant with all eight areas of NHS England’s Core Standards for Emergency Preparedness, Resilience and Response (EPRR).

We have focused on:

 our ability to deal with the most concerning issues on the community risk register  helping to develop the ‘Hertfordshire Care of People Framework’  developing an activation pathway for commissioned minor injuries units as P3 centres – these are centres for people who need medical help, but are not urgent cases  supporting our providers and GPs to improve their business continuity arrangements  ensuring our IT systems are resilient

In 2018/19 our priorities will be:

• to further develop our capability to deal with the most concerning issues on the community risk register • to embed the National Joint Emergency Service Interoperability Programme (JESIP) principles into major incident, business continuity and communications plans and training packages • to contribute to the Hertfordshire pandemic flu plan, incorporating national learning • to update business continuity plans to strengthen our ability to respond to mass IT failure and cyber-attack.

Annual Report and Accounts 2017/18 63 ______

REDUCING HEALTH INEQUALITIES

The role of Hertfordshire’s Health and Wellbeing Board

Hertfordshire Health and Wellbeing Board brings together the NHS, Hertfordshire County Council and local district and “borough councils, the Office of the Police and Crime Commissioner and Healthwatch Hertfordshire, to plan how best to meet the needs of Hertfordshire’s population and tackle local inequalities in health. East and North Hertfordshire CCG is one of the key decision makers represented on the Board.

“The things that affect our health and wellbeing vary over the course of our lifetime so the Board’s partnership strategy for Hertfordshire 2016-2020 has been developed using four significant stages of the life course: Starting well; developing well;

living and working well; and ageing well.

“The CCG and our other partners are taking a joined up approach to tackle the causes of poor health as well as supporting people to make healthier lifestyle choices and improving healthcare.

“Hertfordshire has a strong history of partnership working and to date has had one of the largest pooled Better Care Funds in the country (£280m). The fund pools NHS and social care money into a single shared fund to provide innovative ways to prevent older Cllr Colette Wyatt-Lowe, and vulnerable people going into hospital when they don’t need to and provide them with support in their community. Chair, Hertfordshire Health and Wellbeing Board, “Among other things, this has led to new models of support for Hertfordshire County Council care homes, including East and North Hertfordshire’s ‘Enhanced Care in Care Homes’ vanguard programme. ”

Annual Report and Accounts 2017/18 64 ______

Healthwatch Hertfordshire is the independent consumer champion for health and social care.

We help people to find out about local health and social care services, and listen to people’s views and experiences of using “these services. Using this information, we work with decision makers, like East and North Hertfordshire CCG, to help improve services and champion the involvement of patients, carers, and service users in changes to care.

“We have worked closely with the CCG over the past year,

representing patients and involving the public in the CCG’s work. We have shared information and intelligence on service providers to enhance the CCG’s quality monitoring activities and improve patient experience. We were also involved with the ‘Let’s Talk’ events; acting as the independent chair of the community meetings to ensure there was a balance between the views of commissioners and the public.

“We also provided a route for patients, communities and specialist interest groups to feed back. The CCG attends our Sensory and Physical Disability Service Watch Group which brings together patients, carers, providers and commissioners to share good practice and identify improvements from the perspective of people with sensory and physical disabilities. Finally, in partnership with Hertfordshire County Council we worked with the CCG on ‘Feeling Good Week’ encouraging young people to bid for small grants to run projects to promote emotional wellbeing and mental Geoff Brown health. We hosted the application process on our youth website Chief Executive and were delighted to receive over 100 submissions. We would like to take this opportunity to thank the CCG for its continued support, and look forward to continuing to work in partnership to improve services for patients. ”

Annual Report and Accounts 2017/18 65 ______

HEALTH INEQUALITIES IN HERTFORDSHIRE

The health and wellbeing of people in some of our communities is not improving at the same rate as others. Every year, far too many people suffer avoidable ill health or die earlier than they should – this is known as health inequality. These inequalities need to be tackled to make life better for everyone living in our area.

Overall, Hertfordshire generally has better health outcomes compared with the rest of the country. This reflects the fact that Hertfordshire is a more prosperous area than average – as we know that health outcomes are closely linked with levels of deprivation. If we compare health outcomes for Hertfordshire with those in other areas that have similar levels of deprivation, there are opportunities for improvement.

Looking at Hertfordshire as a whole, this can mask the differences in people’s health outcomes in different districts5. For example:

 Life expectancy for women in east Hertfordshire is two years longer than in north Hertfordshire

 More people in the borough of Broxbourne have been diagnosed with diabetes than other areas of the county

 Deaths from heart disease are more common in Stevenage than the rest of Hertfordshire

Health inequalities also occur between different sections of the population, as well between different geographical areas. For example, levels of physical activity and smoking vary significantly across ethnic groups. The NHS Five Year Forward View sets out the need to address the health and wellbeing gap, preventing any further widening of health inequalities.

5 Herts Health Evidence

Annual Report and Accounts 2017/18 66 ______

CCGs also must consider the need to reduce inequalities During 2017/18 we have: between patients with respect to their ability to access the health services they commission. This involves:  Trained managers on how to conduct assessments of  Knowing the local population and local needs, the impact of our policies. building in insight from the beginning – using The CCG can also call upon a available data, evidence and experience. dedicated equalities officer Commissioning through the use of joint strategic for support and guidance needs assessments (JSNAs) and additional supporting data such as local health profiles and  Introduced a ‘prioritisation qualitative information sources. framework’ – enabling a thorough review of  Identifying local health inequalities and evidence and impact to take commissioning for all of the population in the area, place before proposals for not just those registered with a GP. service developments or changes are put forward for  Identifying evidence of what has previously worked consideration to reduce inequalities and evaluating good practice, whilst also considering that some groups face a  Been part of a group which number of risk factors. Services should aim to reduce meets regularly with the inequalities by being aimed at those who need them gypsy and traveller most. community and seeks to address their health needs  Carrying out evidence-based service reviews. and priorities, specifically addressing public health and cultural needs and learning from existing patients’ experiences.

Annual Report and Accounts 2017/18 67 ______

Our approach to addressing health inequalities means we: HERTFORDSHIRE  place emphasis on patients and the quality of the care HEALTH EVIDENCE they receive. This is the focus of everything we do. We commission services based on the quality of patient is a collaboration between outcomes and we listen to people so they are county council and CCG empowered to choose care on the basis of quality and intelligence teams and brings outcomes. together health-related statistics, data briefings and  use the information we have about the health of our reports. residents to understand variation, benchmarking and set targets to reduce inequalities. 6 The website makes finding and using health evidence simple  make important commissioning decisions in partnership and quick and helps the CCG and informed by evidence and health intelligence. This make evidence-based process is supported by the county-wide priorities set by commissioning decisions which the Health and Wellbeing Board and informed by aim to reduce the disparities stakeholder and patient engagement. within our area.

 take account of the priorities identified by each of our six localities. www.hertshealthevidence.org

 understand the role that primary care can play in tackling health inequality. We are specifically focusing on using tools to identify and plan care for people who are the most at risk, such as the electronic frailty index and data about care home residents, to identify the 5% of adults most at risk of hospital admission or death in the next 1-3 years.

6 Including NHS Right Care, Public Health England Fingertips, CCG data packs, STP packs, atlases of variation, casebooks, long term condition scenarios, optimal value pathways and Commissioning for Value tools produced by NHS England.

Annual Report and Accounts 2017/18 68 ______

Examples of some projects supported by the Health and Wellbeing Board and its member organisations:

 Personalised weight management and family nutritional support in the Broxbourne and Stevenage borough council areas – which have been identified as having higher than average levels of obesity and deprivation.

 The care home ‘vanguard’ project has worked to ensure that people living in residential and nursing homes have better access to medicines reviews and health care in the home to reduce unnecessary trips to hospital – people living in these settings are more likely to attend A&E (96% of patients in nursing homes, compared to 34% of the general over 65s population).

 The police and health organisations working as part of Hertfordshire’s Mental Health Crisis Care Concordat, have continued to provide ‘street triage’ where mental health care professionals provide direct support to police officers dealing with people who are vulnerable because of their mental health condition – this has helped to ensure that no one experiencing a mental health crisis in Hertfordshire has needed to be detained in a police cell over the past year.

 Providing healthcare support to a number of Syrian refugees and their families who have been placed in Hertfordshire.

Annual Report and Accounts 2017/18 69 ______

HERTFORDSHIRE HEALTH AND WELLBEING STRATEGY

The Hertfordshire Health and Wellbeing Board brings together the NHS, public health, adult social care and children’s services, elected councillors and Hertfordshire Healthwatch, to plan how best to meet the needs of Hertfordshire’s population and tackle local inequalities in health.

The CCG plays an active role on this board and is represented by our chair and our chief executive. The board met four times in 2017/18 and discussed issues such as the progress of the Hertfordshire and west Essex STP, a review of children’s mental health services and the better health for care home residents project.

The board oversees the delivery of the Hertfordshire Health and Wellbeing Strategy 2016- 2020. This plan sets high level priorities, which all organisations must work together to achieve. The priorities are based on four life stages:

Starting Developing Living Ageing well well well well

Annual Report and Accounts 2017/18 70 ______

Health and Wellbeing Strategy priority areas

Starting well Developing well Living and Ageing well - babies and very - children and young working well - people aged 65 young children people aged 6-25 - working age adults years and above including maternity

Improved mental Narrowing the gap Increasing activity health and wellbeing Reducing falls across localities levels in children

Narrowing the Reducing Perinatal mental Reducing obesity outcomes gap across preventable winter health levels localities deaths

Reducing Improving activity Identifying vulnerable children and families preventable and reducing frailty disability levels in older people

Improving mental Improving outcomes for ‘looked after Reducing social health prevention children’ isolation and resilience

School readiness

These objectives align with the key areas of work for the CCG and for the wider STP. You can see what progress is being made by visiting the Hertfordshire County Council website:

 ‘Ageing well’ dashboard  ‘Developing well’ dashboard  ‘Living and working well’ dashboard  ‘Starting well (aged 0-5)’ dashboard

Annual Report and Accounts 2017/18 71 ______

CCG 360 STAKEHOLDER SURVEY

The CCG was very pleased with its results in the 360° stakeholder survey carried out by NHS England which puts us ahead of other CCGs both nationally and locally in almost all categories.

The annual survey which has been conducted online and by telephone since 2014, allows a range of key stakeholders to provide feedback on working relationships with their CCG. The results are used to support CCGs’ ongoing development and feed into improvement and assessment conversations with NHS England.

Conducted in January and February, the survey results showed a further improvement on last year’s performance. A 100% score from most of the respondents and more than 75% of GP member practices as given to the question about effectiveness of working with our CCG, while confidence in the leadership of the CCG to deliver its plans and priorities scored 100% from four of the six respondent groups.

Annual Report and Accounts 2017/18 72 ______

PATIENT AND PUBLIC ENGAGEMENT

“This year we have continued putting patients’ views at the heart of our service planning. We improved our children’s and young adults’ mental health services and introduced new facilities, based on evidence which we gained by consulting with young people across the county.

“We also undertook a large-scale listening exercise during the summer, with support from Healthwatch, when we asked all residents to give us their views on some changes which we proposed to prescribing, to providing gluten-free foods, to IVF provision and to supporting people who were smokers, or who were clinically obese to improve their health before undergoing their non-urgent operation. This survey provided us with considerable new information about what local people think about how NHS services are provided. The changes were broadly supported and we will also do some further analysis on what people said to give us further insight into current patient views.

“The CCG has also been proactively seeking views about where and Dianne Desmulie, when people would like extra evening and weekend GP CCG Governing Body appointments to be available in their local area. In 2018 there will Lay Member with be more need for the CCG to engage with patients and carers about responsibility for public primary care services, as we seek to offer additional services in and patient engagement practices and in their localities and neighbourhoods.”

Annual Report and Accounts 2017/18 73 ______

REFRESHING OUR APPROACH TO WORKING WITH THE PUBLIC During the year we have worked with our patient group members to look at a new approach to engaging and involving the public in the CCG’s work. As part of this review, we held two workshops in November 2017 with our members, the chief executive of the National Association for Patient Participation and representatives of the voluntary sector.

We have also been externally audited and assessed by NHS England. The findings and recommended actions of both of these reviews have been fed into a new engagement strategy, an initial version of which was published in March 2018. You can read the new strategy on our website: www.enhertsccg.nhs.uk/get-involved

HIGHLIGHTS OF PUBLIC INVOLVEMENT PROJECTS IN 2017/18 Some examples of how patient engagement and involvement have influenced our commissioning decisions over the course of the year follow below. We have made good progress on the engagement priorities we set last year, including increasing patient involvement in improving cancer diagnosis. You can read more about our patient representative Michael’s work later in this section. Although this part of the Annual Report focuses purely on our engagement work, many other projects mentioned in other sections of the report were also supported by the work of our patient members.

 NHS Let’s Talk – In the summer, a 10-week public consultation considered proposals for changes in several CCG policy areas. As part of the consultation, the CCG briefed key stakeholders, organised a series of public meetings across the area, talked to people at public events, hosted information stalls and gave presentations at community meetings. The analysis and impact of patient feedback on this consultation can be found at: www.healthierfuture.org.uk. During the implementation phase patients have helped us to produce materials explaining the changes in policy.

Annual Report and Accounts 2017/18 74 ______

 Supporting others with diabetes - Patient members from Welwyn Hatfield and Bishop’s Stortford were regional winners of the ‘supporting others’ Diabetes UK award for their work in developing workshops for people living with type 2 diabetes.

 Extended access to primary care – To support GP practices across our localities, we have developed, managed and analysed public responses to surveys about the extension of GP opening hours across east and north Hertfordshire. More than 5,000 people across the area have taken part so far. Results of these surveys can be seen online here: http://www.enhertsccg.nhs.uk/engage-ex-access

 Service design and procurement – patients have been actively involved with and given their views on the procurement of community vasectomy and anti-coagulation services, as well as primary care contracts for The Limes Surgery and Spring House Medical Centre. Patients have been actively involved in setting the CCG’s commissioning framework for GP practices in the area, and have highlighted the need for joint working on cancer awareness between practices and patient groups.

 National and regional consultations - We have shared and promoted both NHS England and local authority consultations with our patient members, supporting them to make their views heard on a range of topics. In February, we held our first Twitter Q&A, during which the CCG’s pharmaceutical advisers answered queries on the prescribing of over the counter medicines.

 Building on the work undertaken during the NHS Let’s Talk consultation, we have created a Sustainability and Transformation Partnership (STP) engagement group, to look at better ways of joint working and ensure that engagement is integrated and embedded into the STP. Find out more on the STP and how you can get involved at: www.healthierfuture.org.uk

 The CCG continued its support of community events and raising awareness of key health campaigns. This year we sponsored the Welwyn and Hatfield Healthfest events, and supported Hertford Community Day. If you would like us to attend a community event in your area then please email: [email protected]

Annual Report and Accounts 2017/18 75 ______

PATIENT EXPERIENCE AND QUALITY IMPROVEMENTS Volunteers took part in 12 ward visits across our area, talking to patients and their friends and families to gather feedback and improve services. The CCG also has a duty to ensure that our providers are consulting and engaging with their service users. Engagement leads from across the STP area meet on a regular basis to discuss current issues.

Patient members continue to contribute to both the cancer steering group and wheelchair service user group on a regular basis and are contributing to a number of key projects.

The CCG also organised a patient leaders workshop for cancer, looking to develop awareness and education materials for the public to achieve increased awareness of prevention, cancer screening and identifying early signs and symptoms. We are continuing to work on this project with Cancer Research UK and our patient members, promoting awareness of cancer screening and the signs and symptoms of cancer.

THE YEAR AHEAD The publication of the new engagement strategy will provide a clear focus for our activity in 2018/19. There are other priorities that we will continue to address with the public. 2018, for example, is the 70th birthday of the NHS and we will use this opportunity to raise awareness of health campaigns and get the public more involved with local health services.

As well as encouraging young people to pursue health and social care careers through our ‘Future Heroes’ careers event, we also hope to do further work with the public on stroke care, supporting carers and addressing health inequalities in Hertfordshire.

We plan to work with the public on the commissioning of GP services, following the CCG’s decision to undertake delegated commissioning.

Annual Report and Accounts 2017/18 76 ______

ENGAGING WITH OUR PATIENTS – IN THEIR OWN WORDS

Some of our committed patient representatives explain how they’ve been involved with our work over the past year. Read more of their stories on our website.

The better care in residential home I joined the CCG’s cancer steering ‘vanguard’ project, has proved to be very group in May. From the start I have been “interesting and rewarding to be involved “made to feel welcome and valued. with. I have been very impressed. “It has been a very interesting period, and “Having experience of residential care as is only to be expected, I have learnt a homes as a carer for members of my own lot about cancer and the way the NHS family, it has been encouraging to see the handles the problems raised by the effort and enthusiasm from both health treatment of cancer. Both I and my other and social care, to make positive patient member feel that our input is both improvements to the existing system of wanted and listened to. care as well as planning to spread this good practice out into the community. “Our suggestions have always been listened to and often incorporated into “They welcomed me as a lay member and regional policy. We are currently being I have been supported and made to feel of supported by the group and the CCG in value to the group. our efforts to produce a questionnaire and a video/presentation to not only introduce the general public to cancer, but to Jenny Young, member” of the vanguard educate them in the advantages of early steering group and Central Surgery diagnosis and treatment. patient participation group. Michael Carn, member of ”the CCG Cancer Steering group and Chair of Ware Road patient participation group

Annual Report and Accounts 2017/18 77 ______

It’s 6.30 in the evening when I step out into the darkness to chair the patient group at the CCG. The meeting discusses the “new extended access to GP services and also the initial plans to develop patient engagement to achieve more effective patient input to the business of commissioning NHS services.

“As I walk back home to a late dinner I reflect on what we have been told. The thought of more input to commissioning is welcome but what might that look like? Jenny Young “In the past year I have been a patient representative on two commissioning teams. One seeking tenders for a new community glaucoma service and another commissioning a vasectomy service. Both of these involved scrutiny of the draft service specification and then evaluation of the tenders from prospective providers against strict criteria. This is exacting work with the added spice that a misjudgement might lead to a legal challenge that would require justification in court of the decisions made. A challenging but rewarding role.

“Patient representatives do much more to support the CCG. There are regular calls for one off contributions to projects and Michael Carn for a patient’s view on some of the many documents and leaflets that are published.

“As I reach home (and dinner) I realise that enhanced patient input to commissioning will be a good thing but it will require an increase in the number of volunteers willing to be patient representatives.

Peter Wilson, chair” of Welwyn Hatfield patient group and Hall Grove Practice Patient Voices.

Peter Wilson

As Peter says, we are always looking for people who want to help us design and monitor services. If you are keen to be involved in the CCG’s work, or help shape services at your GP surgery, visit our website: www.enhertsccg.nhs.uk/get-involved or call us on 01707 685397.

THE WORK OF HERTFORDSHIRE, BEDFORDSHIRE AND LUTON (HBL) ICT SERVICES

Hosted by East and North Hertfordshire CCG, HBL ICT delivers IT services to a number of NHS clients, including the CCG and some of its key provider organisations.

2017/18 has focused on successfully delivering a significant technology transformation programme. This is intrinsic to our digital strategy and that of the HBL Partnership, and will be the foundation of the organisation’s digital innovation.

Due to the prudent financial management of its funds, HBL ICT is successfully delivering these significant technology change programmes on time and within budget, requiring no additional financial contributions from the partnership, which in real terms has resulted in cost efficiencies of more than 4%.

Investment in infrastructure technology – ‘fragile to agile’

In June 2017, two new data centres, in Welwyn Garden City and Farnborough, were brought into operation, enabling the use of a secure HBL private ‘cloud’.

The cloud provides resilience achieved by dual network connectivity via 10gb network links. New data replication software is also being introduced for all of our virtual computer infrastructure, to enable the provision of services at pace and at scale for greater agility. Any failure time at each data centre will be reduced to minutes. This is important as clinicians and their support staff rely on critical data and applications every day to treat patients – there is no opportunity for downtime.

Local Digital Roadmaps and Sustainability and Transformation Plans

HBL ICT is actively involved with, and leads the technology workstreams in both the STPs which cover the partnership’s area. You can read more about this work in Hertfordshire and West Essex and in Bedfordshire, Luton and Milton Keynes.

Annual Report and Accounts 2017/18 79 ______

Governance and ICT Security

Working alongside NHS Digital, HBL ICT is committed to providing a highly secure ICT service to the partnership and proactively provides key components to various Information Governance toolkit submissions throughout the year.

The exponential growth of digital technology within the CCG, GP practices and provider services has enabled more effective delivery of services. However, it has also made the impact much more severe when things go wrong. HBL ICT believe that digital technology should be safe and beneficial and that we have an obligation to ensure that the CCG, GP practices, our partners and the public can trust us to keep the IT systems safe and available, properly protected from cyber threats.

The national cyber-attack ‘Wannacry’ incident in May 2017 did not infect any of the devices within the HBL ICT environment (all pre-2007 devices has already been removed from the open network and critical patches applied). Nevertheless HBL ICT was affected by the attack; teams were on high alert with elevated monitoring and the team dispatched technical resources to other NHS organisations to help them manage the outbreak. At a national scale, Wannacry provided clear evidence that the NHS is not immune from attack, and that cyber risk is a business risk.

Effective cyber management is not limited to technical responses. HBL ICT continues to raise the level of staff awareness of cyber security through regular communications and presentations to staff.

Annual Report and Accounts 2017/18 80 ______

SUSTAINABILITY

INTRODUCTION

As an NHS organisation, and as a spender of public funds, we have an obligation to work in a way that has a positive effect on the communities we serve. Sustainability means spending public money well, the smart and efficient use of natural resources and building healthy, resilient communities. By making the most of social, environmental and economic assets we can improve health both in the immediate and long term even in the context of rising cost of natural resources. Demonstrating that we consider the social and environmental impacts ensures that the legal requirements in the Public Services (Social Value) Act (2012) are met.

To fulfil our responsibilities for the role we play, the CCG has created a sustainable development management plan (SDMP).

Our sustainability mission statement is: The vision for a sustainable health and care system by reducing carbon emissions, protecting natural resources, preparing communities for extreme weather events and promoting healthy lifestyles and environments.

POLICIES

One of the ways in which an organisation can embed sustainability is through the use of an SDMP. The Governing Body approved our SDMP in the last 12 months so our plans for a sustainable future are well known within the organisation and clearly laid out.

Sustainability and social values will be embedded into all procurement specifications, along the lines of guidelines delivered in training by the Sustainable Development Unit.

Climate change brings new challenges to our business both in direct effects to the healthcare estates, but also to patient health. Examples of recent years include the effects of heat waves, extreme temperatures and prolonged periods of cold, floods, droughts etc. Our Governing Body approved plans to address the potential need to adapt the delivery of the organisation's activities and infrastructure to mitigate climate change and adverse weather events.

Annual Report and Accounts 2017/18 81 ______

PARTNERSHIPS

As a commissioning and contracting organisation, we will need effective contract mechanisms to deliver our ambitions for sustainable healthcare delivery. The NHS policy framework already sets the scene for commissioners and providers to operate in a sustainable manner. Crucially for us as a CCG, evidence of this commitment will need to be provided in part through contracting mechanisms.

HEAD OFFICE OCCUPANCY

The CCG occupies a small head office space, which is rented from NHS Property Services who also provide facilities management on behalf of the organisation. The energy rating of the building is ‘D’, which indicates the energy efficiency of the building fabric and the heating, ventilation, cooling and lighting systems.

2017-18

CCG Net Internal Area of Charter House (m2) 1,510 Number of staff (Whole Time Equivalent) 264 Average floor space per staff member (m2) 5.72

HEAD OFFICE LIGHTING UPGRADE

During 2017-18, the organisation upgraded its lighting system from inefficient fluorescent lighting to high efficiency (lower wattage) LED panels. The aim was to reduce energy consumption and carbon emissions, supporting the NHS carbon emission reduction target. This also improved the working environment to support staff health and wellbeing.

TOTAL ENERGY COST (ALL ENERGY SUPPLIES)

NHS East and North Hertfordshire CCG spent £41,523 on energy in 2017-18.

Annual Report and Accounts 2017/18 82 ______

Energy used (consumption in kWh)7

2016-17 2017-18 kg CO2e (17-18) 8 Gas (natural) consumed 623,464 497,344 91590.87 Electricity consumed 575,969 620,989 218314.89

PAPER

The CCG is committed to supporting the movement to a paperless NHS and will begin monitoring performance in this area from a baseline in 2017-18.

Paper consumed

2017-18 kg CO2e (17-18) Paper spend (£) £2,783 Paper products used (metric tonnes) 4,190.95 3,891,716.17

TRAVEL

NHS East and North Hertfordshire CCG spent £129,805 on business travel costs in 2017-18. We can improve local air quality and improve the health of our community by promoting active travel to staff and to the patients and public that use our services. CCG staff can claim cycle mileage for their business travel and the CCG has joined the government’s ‘cycle to work’ scheme. This allows staff to purchase a bike and cycle safety equipment as a tax-free benefit.

7 Please note that East and North Hertfordshire CCG shares a building with other organisations and pays a percentage of the overall cost for utilities. It is not possible to identify consumption by organisation so the figures shown are for the overall building. 8 https://www.gov.uk/government/publications/greenhouse-gas-reporting-conversion-factors-2017

Annual Report and Accounts 2017/18 83 ______

Total kg CO2e Total from Travel Average Average Total Pedal Travel Mileage (cars) Whole Travel Cycle Mileage Mileage Financial Time Mileage claimed as (cars) Estimated using Year Equivalent (cars) per expenses claimed as figures for the (WTE) staff WTE staff (miles) expenses average car of employed employed (miles) unknown fuel type, see here. 2015-16 19 251,159 248 1,013 75,568.64 2016-17 18 269,889 272 992 81,204.34 2017-18 10 221,613 263 842 65,058.93

WASTE DISPOSAL AND RECYCLING NHS East and North Hertfordshire CCG spent £11,615 on waste disposal in 2017-18. This includes confidential waste, general waste and mixed recycling including glass.

WATER AND SEWAGE COST NHS East and North Hertfordshire CCG spent £3,787 on water costs in 2017-18.

KEY INITIATIVES 2017-18 During 2017-18, the organisation upgraded its general waste and indoor recycling bins, and will continue to champion recycling across the organisation throughout the coming year.

Annual Report and Accounts 2017/18 84 ______

REVIEW OF FINANCIAL PERFORMANCE

SUMMARY East and North Hertfordshire CCG’s Annual Accounts are included within this Annual Report. The accounts have been prepared under a Direction issued by NHS England under the National Health Service Act 2006 (as amended by the Health and Social Care Act 2012).

CCGs have a statutory duty to keep their expenditure within the resources available. There are six separate duties with this regard, although there is some overlap between them and some are not relevant to the CCG in 2017/18. The duties, their relevance in 2017/18 and the performance of East and North Hertfordshire CCG in 2017/18 are set out in the following table.

Further details are provided in note 15 of the accounts on page xxx of this Annual Report.

Annual Report and Accounts 2017/18 85 ______

Relevance in Duty [and section of 2012 Act] Achievement 2017/18 Expenditure does not exceed sums allotted to  Underspend Applicable the CCG plus other income received [223H(1)] £4,360k

Capital resource use does not exceed the Applicable  Underspend £7k amount specified in Directions [223I(2)]

Revenue resource use does not exceed the  Underspend Applicable amount specified in Directions [223I(3)] £4,353k Capital resource use on specified matter(s) Not applicable; does not exceed the amount specified in no specified matters in 2017/18 Directions [223J(1)] Revenue resource use on specified matter(s) Not applicable; does not exceed the amount specified in no specified matters in 2017/18 Directions [223J(2)]

Revenue administration resource use does not  Underspend exceed the amount specified in Directions Applicable £1,924k [223J(3)]

FUNDING ALLOCATED TO THE CCG

Firm CCG allocations for the years 2016/17 to 2018/19, along with “indicative” allocations for the following two years, were published following the NHS England Board meeting in December 2015. In calculating these allocations, NHS England took account of individual CCG’s distance from a ‘target’, with the target being their fair share of the total funding being made available to CCGs. The allocations agreed ensured that no CCG would be more than 5% below its fair share from 2016/17 onwards. For the first time, when considering the funding position of individual CCGs, NHS England also considered its own spending on

Annual Report and Accounts 2017/18 86 ______

primary medical care services and specialist services in each CCG area. This created a “place” based target allocation for these three funding streams.

During 2017/18 a further increase in funding to the NHS was agreed for 2018/19 and 2019/20. Following this NHS England announced additional allocations to CCGs for 2018/19 only. This included extra funding for all CCGs and a targeted £400m of commissioner sustainability funding to those CCGs who were in deficit. None of this latter element has been allocated to East and North Hertfordshire CCG, but because of historic underfunding the CCG is receiving higher than average growth over the known period of allocations.

Allocation growth over the last 2 years and the coming 3 years are set out in the table below.

2016/17 2017/18 2018/19 2019/20 2020/21 % increase allocation 6.6% 2.7% 3.7% 2.9% 4.6% % increase per capita 9 5.6% 1.7% 2.7% 2.0% 3.6%

Over the five-year period, funding for the East and North Hertfordshire CCG ‘place’ moves from being 5.5% below target across all three commissioning streams to being 2.1% below target. However for the CCG’s funding alone, the position moves from being 4.4% below to just 0.4% below.

9 i.e. after taking account of estimated population increases

Annual Report and Accounts 2017/18 87 ______

CCG running cost allowances for England as a whole will remain flat to 2020/21, as determined by HM Treasury's Spending Review settlement. Individual CCG allowances have been rebased to adjust for the changing share of population. The figures for East and North Hertfordshire CCG are shown in the following table.

2015/16 2016/17 2017/18 2018/19 2019/20 2020/21 Recurrent Running costs allocation 12,634 12,607 12,637 12,668 12,700 12,733 (£’000) % increase -0.2% 0.2% 0.2% 0.3% 0.3%

During 2015/16 the CCG applied and was selected to become a ‘Vanguard’ site for the new NHS care models programme, one of the first steps towards supporting improvement and integration of services. Over the years 2015/16 to 2017/18 the CCG received an annual non- recurrent funding allocation from NHS England of £1.8m and utilised this to roll out its Enhanced Health in Care Homes project. A number of key achievements were recorded during the period and this model has now received national recognition for providing integrated enhanced care in care homes. Even though the National funding stopped at the end of 2017/18, the CCG has decided to continue commissioning many of the initiatives that started under the Vanguard programme.

Annual Report and Accounts 2017/18 88 ______

FINANCIAL BUSINESS RULES FOR 2017/18

The 2017/18 planning guidance to CCGs sets out the key business rules for commissioners, over and above the statutory duties set out above.

All CCGs were required to sign up to deliver an NHS England set revenue Control Total. For East and North Hertfordshire CCG this allowed a £0.2m release of the CCG’s cumulative underspend from 2016/17. This meant the target position at the end of 2017/18 was a cumulative underspend of £14.498m.

All CCGs were also required to hold back 0.5% of their allocation as a system risk reserve to offset potential overspends in the NHS Provider sector. The sum held in reserve was only to be released on agreement of NHS England and only once NHS England was assured that the NHS Provider Sector was able to achieve its own aggregate Control Total. However, because the NHS Provider Sector came under significant financial pressure, NHS England did not agree to release any of the risk reserve and instead increased each CCG’s revenue Control Total by the amount thus frozen (£3.6m for this CCG).

In addition NHS England decided that CCGs had received an unexpected benefit from a reduction in the cost of some drugs (known as Category M) and during 2017/18 clawed back this saving from CCGs adding it to the national risk reserve. At year-end whilst NHS England released this funding back to CCGs, it also increased their revenue Control Totals by the corresponding amount (£0.8m for this CCG).

Taking the above into account, the CCG’s adjusted revenue Control Total was £18.851m, i.e. cumulative underspend of £14.498m and an in-year underspend of £4.353m. Note 15 in the Accounts and the table above records only the in-year underspend with an added note to explain how the cumulative underspend of £18.851m was arrived at. The CCG met its revised revenue Control Total for 2017-18.

The cumulative underspend of £18.851m will be carried forward into 2018/19 and the CCG’s revenue Control Total for 2018/19 requires the position to be held at that level.

Annual Report and Accounts 2017/18 89 ______

LOCALITY LEVEL PERFORMANCE

The Governing Body has continued to review financial performance at locality level. Funding was retained centrally by the CCG to cover reserves, administration costs and where healthcare costs could not be attributed to a locality, with the balance distributed to localities on a fair share basis using updated practice list sizes. This method of managing performance at locality level allows the CCG to engage effectively with localities who jointly own delivery of the financial duty.

As can be seen from above, East and North Hertfordshire CCG was successful in meeting all of its financial duties and the business rules. Each of the six locality groups also achieved at least breakeven against their agreed budget, as can be seen from the table below.

Variance Locality Budget £'000 Spend £'000 £'000

North Herts £138,905 £138,769 (£135) Lower Lea Valley £92,882 £92,880 (£2) Stevenage £113,548 £113,357 (£191) Welwyn & Hatfield £133,158 £133,148 (£10) Upper Lea Valley £135,692 £135,650 (£42) Stort Valley & Villages £65,619 £65,228 (£391) Central budgets £48,544 £44,962 (£3,582)

Total Surplus (in year) £728 ,347 £723,994 (£4,353) Cumulative Surplus b/f (£14,498) Cumulative Surplus carried forward (£18,851)

This financial performance was achieved despite unplanned overspends on acute hospital services(£5.4m), prescribing (£0.62m) and continuing healthcare (£5.3m). These were offset by the budgeted contingency reserve and underspends on other budgets.

Annual Report and Accounts 2017/18 90 ______

As part of this overall position, the CCG is reporting an underspend of £1.924m against its Administration Cost allocation. The budget set by the CCG was £1.2m lower than the running cost allocation received by the CCG, with this sum being transferred internally to fund additional healthcare services.

MENTAL HEALTH PARITY OF ESTEEM

Another requirement in the 2017/18 planning guidance related to the Mental Health Investment Standard, under which all CCGs were required to increase their spending on mental health services by at least the percentage increase in the CCG’s allocation growth. In 2017/18 this equates to 2.7% for East and North Hertfordshire CCG.

Achievement of the Investment Standard is measured by comparing expenditure in 2017/18 to that in 2016/17, after taking into account any mental health specific allocations received by CCGs in either of these years. This adjustment is made to ensure that changes in spending are not skewed by non-recurrent allocations and are limited to reviewing spending funded from the CCGs’ general allocation. The table below demonstrates that East and North Hertfordshire CCG met the requirements of the Mental Health Investment Standard in 2017/18. The CCG’s budget for 2018/19 has been set to also achieve the standard in 2018/19.

Description £000 unless stated otherwise 2017/18 spending (exc learning disability and dementia) 79,265 Less spending covered by allocations received (1,223) 2017/18 spending funded by general allocation 78,042 2016/17 spending funded by general allocation 75,924 Increase in spending 2,118

Increase in spending (%) 2.789% Increase in allocation (%) 2.696%

Has the Mental Health Investment Standard been met? Yes

Annual Report and Accounts 2017/18 91 ______

FUTURE FINANCIAL STRATEGY

East and North Hertfordshire CCG has a strong underlying financial level of performance and has met its revenue Control Total every year since inception. At the end of 2017/18 the CCG delivered an in-year underspend of £4.353m which is added to the cumulative surplus brought forward resulting in a cumulative underspend of £18.851m, well above the standard national requirement which equates to 1% of its allocation. This additional in-year underspend has been driven by the specific annual requirements of NHS England.

The CCG future Financial Outlook has been updated for the 2017/18 financial position and the impacts on future years to provide assurance on the financial sustainability of the CCG.

The Hertfordshire and West Essex STP has also been working on STP wide financial planning bringing both the commissioners and providers together to identify the system gap (estimated at £550 million a year by 2020/21) and proffer/identify STP wide solutions. As a result, the STP has issued a common planning guideline and assumptions which underpins the update to the Financial Outlook.

Guidance published by NHS England in February 2018, (“Refreshing NHS Plans for 2018/19”) sets out the financial framework for 2018/19. The requirement for CCGs to hold back 0.5% of their allocation, to create a national system risk reserve has been lifted for 2018/19, releasing £3.6m of funding that East and North Hertfordshire CCG can now commit to spending in 2018/19.

Alongside this publication, NHS England has also confirmed that it requires the CCG to breakeven in-year in 2018/19, i.e. it is not allowing the CCG to drawdown any of the £18.851m accumulated underspend. This freezing of the cumulative underspend is likely to continue into the foreseeable future, with the CCG being required to maintain this position although not improve on it any further. It may be possible that in future years the CCG will be able to draw down some of this additional underspend, but that is likely to be possible only if the NHS as a whole improves its financial performance.

When planning for future years CCGs have to take account of changes to the national tariff

Annual Report and Accounts 2017/18 92 ______

(prices charged by providers) and growth in activity and spend compared to changes in funding. Changes to national tariffs are based on guidance issued by NHS England and NHS Improvement, the sector regulators for health services in England.

Growth in activity and spend is estimated based on a number of factors. Firstly, population growth, which is based on the Office of National Statistics estimate of the population increase in the CCG by age-band according to the age of the population using the services we commission. Secondly, non-demographic growth which is based on previous years’ trends in activity and extrapolated assuming the trend continues into future years. Thirdly, there are other inflationary increases in costs, e.g. prescribed drugs. There is also recurrent investment in schemes which may have been previously funded non-recurrently or funded for part of the previous year. Finally a contingency reserve is created to meet unexpected events during the year.

On the funding side, the recurrent increase in the CCG’s programme (healthcare) allocation in 2018/19 is £26.1m (3.68%), but the CCG will no longer receive the non-recurrent Vanguard allocation of £1.8m. The allocation for administration costs is broadly at the same level as in 2017/18 (see table on page 88).

On the expenditure side the CCG needs to recreate the contingency reserve utilised in 2017/18, fund the full year effect of investments made part way through 2017/18 and cover the impact of non-recurrent benefits realised in 2017/18. Together these total about £4.8m. Inflation and other tariff changes have a cost impact of £4.3m and the activity/cost impact of demographic and non-demographic changes add a further £24m. Spending to meet the Mental Health Investment Standard needs to grow by a further £1.5m above this and all other changes and service developments required to deliver the CCG’s ambitions add £8.3m.

Taking account of all the factors described above and without efficiency savings, growth in expenditure would exceed growth in funding in 2018/19 by £13.5m. Projecting further forward into 2019/20 and 2020/21 and a similar picture emerges with projected expenditure growing in each year by £5-6m more than the growth in funding available to the CCG. These gaps will be managed through the development of efficiency (QIPP) schemes. In order to deliver the required financial position, the CCG will need to recurrently deliver QIPP

Annual Report and Accounts 2017/18 93 ______

efficiencies of £13.5m in 2018/19 and a further £5-6m in each of 2019/20 and 2020/21. This compares to an efficiency requirement in 2017/18 of £23m. The CCG has already developed and implemented a number of initiatives with a risk adjusted value in 2018/19 of £13.7m. Some of these schemes are rolled over from 2017/18 with full year effects impacting on 2018/19, some are an expansion of initiatives successfully trialled in 2017/18 and others are new initiatives developed during 2017/18. Further initiatives will be developed during 2018/19 for implementation later in the year or in 2019/20.

Driving the CCG’s financial strategy are our over-arching aims to improve the health of the population, to reduce health need and to find different ways of commissioning high quality services at lower cost. This will include investing in primary and community care services, and together with colleagues in Hertfordshire County Council, into social care services, bearing down on the demand for and expenditure on acute hospital care.

East and North Hertfordshire CCG recognises that the delivery of the financial challenge is closely intertwined with the delivery of the commissioning challenge. Some of the commissioning challenges being addressed by the CCG’s strategic plan include:

 The challenge in efficient use of financial resources, management resources, sound risk management and sound governance arrangements  Inter-practice collaboration working to reduce referrals to secondary services by using expertise currently residing within general practice, community and voluntary services, and specialist services commissioned in a community setting  Working with constituent practices to change health behaviours and so clinical and patient activity to make the best use of available resources.  Involving patients in commissioning decisions affecting their care  Working with Community Services, Local authority, Public Health and other sectors, to identify those at risk of admission to hospital and provide integrated services to meet their needs.  Continuing the strong performance management of commissioned services to ensure that the needs of the population that we serve are met

Annual Report and Accounts 2017/18 94 ______

The CCG continues to support the use of its Primary Care Consolidated Funding Framework as a mechanism to invest in additional capacity and transformation of services in primary care and so improve population health and reduce avoidable pressure on hospitals. Investment will continue to be made into services focussing on long term conditions and our ageing population and we will work with our partner organisations and patients to reduce avoidable hospital admissions and improve the safety and patient experience wherever care is delivered.

In 2018/19 the CCG will take on delegated primary care commissioning responsibilities and this is both an opportunity and a challenge. Taking on these functions will enable the CCG to combine them with its own previous commissioning of primary care to make a more coherent whole. However, the administrative resources newly available to the CCG to carry out these new functions are insufficient and the CCG’s financial plan has set aside £0.5m to increase managerial capacity. Even with this increase in running costs, the CCG still plans to spend less than the running cost allocation it receives.

On 22nd March 2018 the Governing Body of the CCG agreed a balanced in-year budget for 2018/19, which meets the planning requirements and delivers the required cumulative underspend of £18.851m.

REVIEW OF STATUTORY DUTIES

East and North Hertfordshire CCG has reviewed all of the statutory duties and powers conferred on us by the National Health Service Act 2006 (as amended) and other associated legislative and regulations. We are clear about the legislative requirements associated with each of the statutory functions for which we are responsible, including any restrictions on delegation of those functions.

Annual Report and Accounts 2017/18 95 ______

…………………………………………………… ………………………….. signed date Beverley Flowers, Chief Executive

…………………………………………………… ………………………….. signed ACCOUNTABILITY date Beverley Flowers, Chief Executive

xxxxxxxxxxxxxxxx …………………………………. ………………………….. signed REPORT date

Beverley Flowers, Chief Executive ______

[Insert signature] Beverley Flowers, Accountable Officer

May / June 2018

This Accountability Report is subject to audit opinion.

Annual Report and Accounts 2017/18 96 ______

PART ONE: CORPORATE GOVERNANCE REPORT

Members’ report The membership body of the CCG is formed of 57 member practices:

Lower Lea Valley locality North Hertfordshire locality

• Abbey Road • Ashwell Surgery • Cromwell and Wormley Medical • The Baldock Surgery Centres • Birchwood Surgery • Cuffley and Goffs Oak Medical Centre • Courtenay House Surgery • High Street Surgery • The Garden City Surgery • The Maples • Knebworth and Marymead Surgery • Stanhope Surgery • Nevells Road Surgery • Stockwell Lodge Medical Centre • Orford Lodge Surgery • Warden Lodge Medical Practice • The Portmill Surgery • Regal Chambers Surgery • The Sollershott Surgery • Whitwell Surgery

Stevenage locality Stort Valley and Villages locality

• Bedwell Medical Centre • Central Surgery • Chells Way Surgery • Church Street Partnership • King George Surgery • Much Hadham Health Centre • Manor House Surgery • Parsonage Surgery • Shephall Way Surgery • Sawbridgeworth Medical Services • Stanmore Medical Group • South Street Surgery • Symonds Green Health Centre

Annual Report and Accounts 2017/18 97 ______

Upper Lea Valley locality Welwyn and Hatfield locality

• Amwell Street Surgery • Bridge Cottage Surgery • Buntingford Medical Centre • Burvill House Surgery • Castlegate Surgery • The Garden City Practice • Church Street Surgery • Hall Grove Surgery • Dolphin House Surgery • Lister House Surgery • Hailey View Surgery • Peartree Lane Surgery • Haileybury College • Potterells Medical Centre • Hanscombe House Surgery • Spring House Medical Centre • The Limes Surgery • Wrafton House Surgery • Orchard Surgery • Park Lane Surgery • Puckeridge Surgery • Wallace House Surgery • Ware Road Surgery • Watton Place Surgery

Annual Report and Accounts 2017/18 98 ______

Composition of Governing Body

Throughout 2017-18 the Chair of the CCG was Dr Hari Pathmanathan and the Chief Executive was Beverley Flowers. From April 2017 to the time of writing this report, the Governing Body was composed of the following members:

Role Name Chair Dr Hari Pathmanathan Deputy Clinical Chair Dr Nicky Williams Chief Executive (Accountable) Officer Beverley Flowers Director of Commissioning Harper Brown Director of Operations Sharn Elton Medical Director Dr Rachel Joyce (permanent from 1 Jan 2018) Chief Finance Officer Alan Pond Director of Nursing and Quality Sheilagh Reavey Director of Strategic Partnerships Vacant Lay Member Dianne Desmulie Lay Member and Deputy Chair Linda Farrant Lay Member Yvette Twumasi-Ankrah (until 22 March 2018) GP Member Dr Mark Andrews GP Member Dr Tara Belcher (from 1 July 2017) GP Member Dr Haydar Bolat (from 5 May 2017) GP Member Dr Sachin Gupta GP Member Dr Russell Hall GP Member Dr Alison Jackson GP Member Dr Deborah Kearns (until 5 Feb 2018) GP Member Dr Prag Moodley GP Member Dr Ashish Shah GP Member Dr Nabeil Shukur GP Member Vacant Secondary Care Specialist Doctor Dr Dermot O’Riordan

Annual Report and Accounts 2017/18 99 ______

THE CCG GOVERNING BODY AS AT 31 MARCH 2018

Dr Hari Pathmanathan, CCG Chair Hari took up the role of CCG Chair on 1 September 2014. Hari has been a GP at Bridge Cottage Surgery for over 18 years and has held various roles in locality commissioning.

Dr Nicky Williams, CCG Deputy Clinical Chair and GP Governing Body Member, Upper Lea Valley Nicky has been a GP partner for 20 years at Church Street Surgery in Ware. Her lead roles on the CCG board include Patient and Public Engagement, Carers and Provider Integration. She was also Clinical Lead for the National project for Enhanced Health in Care Homes Vanguard until 2018 and will now be taking forward a role as Clinical Lead for Primary Care.

Beverley Flowers, Chief Executive/Accountable Officer Beverley joined the CCG in April 2014 from NHS England. Previous to this she held a range of commissioning, partnership and contracting roles across health and social care organisations in London and the East of England. Beverley became Chief Executive of East and North Hertfordshire CCG in December 2015.

Annual Report and Accounts 2017/18 100 ______

Harper Brown, Director of Commissioning After a five-year spell in the army, Harper studied international relations and teaching before working for VSO and Oxfam in Nigeria and Uganda. He then spent time working in general management positions within the NHS, with over 15 years at director level and three years as a chief executive. Harper moved back to Africa to take on the role of first chief executive of Sentebale, a charity in Lesotho, South Africa, founded to help vulnerable child victims of poverty and HIV/Aids. Back in the UK, Harper re-joined the health service in 2010 and held various management roles, coming to East and North Hertfordshire CCG on an interim basis in 2014 to set up the operations directorate before taking up the position of Director of Commissioning.

Sharn Elton, Director of Operations Sharn originally trained as a nurse at Bedford hospital and moved to the Lister hospital in Stevenage as a matron in 2001. Sharn moved into general management in 2003 and worked in a variety of hospital services across surgery, medicine, women’s and children’s specialities. Through developing her networks beyond the hospital Sharn became interested in the broader aspects of health and subsequently moved to work for NHS England across Hertfordshire and the South Midlands in 2013. Sharn was delighted to be appointed as the Director of Operations at the CCG in 2015 when the post became available.

Annual Report and Accounts 2017/18 101 ______

Dr Rachel Joyce, Medical Director (permanent from 1 January 2018) Rachel is a medical doctor, who is both a GP and a public health consultant by background. In the past she has worked as a Director of Public Health and a Medical Director in Bedfordshire, and has been working in the Hertfordshire health system for over 10 years. Rachel has particular expertise in clinical effectiveness (ensuring health services are as safe and effective as possible), the redesign of services from a clinical perspective, including the development of pathways and the prioritisation of scarce resources, wellbeing and the prevention and early identification of illness.

Alan Pond, Chief Finance Officer (Senior Information Risk Owner) Alan has been a Finance Director/Chief Finance Officer for 17 years. During this time he has worked for numerous NHS commissioning organisations. He has over 30 years’ experience in the NHS in both provider and commissioner organisations and 2 years at the Department of Health. He has a broad range of experience within the finance function and also other areas, having been involved in strategy development and implementation and with direct operational responsibility for financial management, costing and pricing, contract negotiation, contract management and business case preparation.

Sheilagh Reavey, Director of Nursing & Quality (Caldicott Guardian) Sheilagh has trained as a nurse, midwife and health visitor and has worked at a senior level in the NHS for a number of years. She has both operational service delivery and commissioning experience and has significant experience in relation to quality and safeguarding issues.

Annual Report and Accounts 2017/18 102 ______

Dianne Desmulie, Lay Member – Public and Patient Engagement Dianne has a career background in local government and the NHS. She has experience within the Department of Health and Adult Social Care in the Eastern region, promoting Dignity in Care and working closely with carers’ organisations. Dianne was a local councillor in East Herts for 8 years and in 2001 was Mayor of Hertford, where she has lived since 1982. She is a member of Hanscombe House Surgery Patient Participation Group and volunteers for Carers in Hertfordshire as a Hub Lead in Hoddesdon.

Linda Farrant, Deputy Chair, Lay Member – Audit A qualified accountant, Linda spent much of her career in local government working on finance, regeneration policy and practice and developing devolved public sector services. She has undertaken various non-executive director roles in the voluntary and public sectors and became the Lay Member for Governance and Audit at the CCG in April 2013.

Yvette Twumasi-Ankrah MBE, Chair, Joint Co-Commissioning Committee (until 22 March 2018) Yvette has a career background in marketing and business development and currently runs her own consultancy. She has previously held a Non-Executive Director role in a Primary Care Trust and was a government approved Business Adviser with Enterprise London. At present she is a board member at Creative Works, a co- working space, and was awarded an MBE in 2017 for her work supporting women in business. She has currently submitted a Ph.D. in Sociology and is a tutor with The Brilliant Club, working with pupils from under-represented backgrounds to progress to highly- selective universities.

Annual Report and Accounts 2017/18 103 ______

Dr Mark Andrews, GP Governing Body Member, Upper Lea Valley Mark has worked at the Limes Surgery in Hoddesdon since 1989. He has been engaged with commissioning in Hertfordshire continuously since 1995 and as an East and North Herts CCG governing body member since 2013. He has been co-lead of the Upper Lea Valley Locality throughout that time. In addition he has been the CCG's clinical lead for cancer and end of life care.

Dr Tara Belcher, GP Governing Body Member, North Herts (from 1 July 2017) Tara is a GP Partner at The Portmill Surgery in Hitchin, where she has worked since 2003. She is also a GP trainer and appraiser.

Dr Haydar Bolat, GP Governing Body Member, Lower Lea Valley (from 5 May 2017) Haydar is a highly motivated, dedicated and competent newly qualified GP who has been working full time in Stanhope Surgery for 9 months. He joined the CCG in May 2017 as a Governing Body member and is the co-chair for Lower Lea Valley locality working alongside Alison.

Dr Sachin Gupta, GP Governing Body Member, Welwyn Hatfield Sachin is a GP at Garden City Practice in Welwyn Garden City. He has previously worked as non-executive director and Medical Director at Herts Urgent Care, MacMillan GP and Royal College of General Practitioners Clinical Lead.

Annual Report and Accounts 2017/18 104 ______

Dr Russell Hall, GP Governing Body Member, Stevenage Russell has worked as a full time GP in Stevenage since 1999. Before joining the CCG Governing Body, he was the prescribing lead for Stevenage. He is the CCG’s Urgent Care lead.

Dr Alison Jackson, GP Governing Body Member, Lower Lea Valley Alison is a GP based in Cheshunt with over 18 years’ experience. She is the co-chair of the Lower Lea Valley locality and works closely with other local GP practices and local organisations within the Lower Lea Valley locality. Alison’s lead area of work for the CCG includes Long Term Conditions.

Dr Deborah Kearns, GP Governing Body Member, Stort Valley and Villages (until 5 February 2018) Deborah has been a GP in Hertfordshire for over 25 years.

Dr Prag Moodley, GP Governing Body Member, Stevenage Prag has been a GP for over 20 years and is the CCG’s mental health lead. His lead area of work is Mental Health and Learning Disabilities. Prag has been a GP in Stevenage since 2004.

Annual Report and Accounts 2017/18 105 ______

Dr Ashish Shah, GP Governing Body Member, Welwyn and Hatfield Ashish has been GP principal at Wrafton House surgery, Hatfield since 2009. He is qualified as a GP trainer and has a special interest in cardiology and respiratory medicine. He is currently the prescribing lead for the CCG.

Dr Nabeil Shukur, GP Governing Body Member, Stort Valley and Villages Nabeil is a GP at South Street Surgery in Bishop’s Stortford. He has several years’ experience on the locality commissioning board. He is the CCG quality lead for the Princess Alexandra Hospital contract.

Dr Dermot O’Riordan, Secondary Care Specialist Doctor Dermot is a Consultant General Surgeon at West Suffolk NHS Foundation Trust and previously was Medical Director for 5 years and interim-Chief Executive Officer. Dermot is also Chief Clinical Information Officer.

Annual Report and Accounts 2017/18 106 ______

Members of the Governance and Audit Committee throughout the year and up to the signing of the Annual Report and Accounts and unless otherwise stated: • Dianne Desmulie – Lay member (patient and public engagement) • Linda Farrant – Lay member (governance and audit), Deputy Chair of the Governing Body and Chair of the Governance and Audit Committee. • Dr Nicky Williams – Governing Body Deputy Clinical Chair

The Remuneration Report starting on page 142 provides details of the membership of the Remuneration Committee.

The Governance Statement, from page 112 provides details of the attendance of the Governing Body and its Committee members at their respective meetings, namely:

• Governing Body in Public • Governing Body in Private • Governing Body Workshops • Governance and Audit Committee • Quality Committee • Remuneration Committee • ICT Stakeholder Board • Locality Committees x 6 • Joint Co-commissioning Committee

The Governing Body maintains an up-to-date Register of Interests, which formally records the declarations of interests made by its employees and members and is available on the Clinical Commissioning Group’s website. Any interest that arises during the course of a meeting is declared immediately and recorded in the minutes of the meeting. This ensures

Annual Report and Accounts 2017/18 107 ______

that the Governing Body acts in the best interests of the organisation and avoids situations where there may be a potential conflict of interest. To view details of the Register of Interests please visit our website: www.enhertsccg.nhs.uk/declarations-interest

Personal data related incidents

The organisation has not reported any Information Governance Serious Untoward Incidents to the Information Commissioner’s Office in 2017-18.

Statement of Disclosure to Auditors

Each individual who is a member of the CCG at the time the Members’ Report is approved confirms:

• so far as the member is aware, there is no relevant audit information of which the clinical commissioning group’s auditor is unaware that would be relevant for the purposes of their audit report

• the member has taken all the steps that they ought to have taken in order to make him or herself aware of any relevant audit information and to establish that the clinical commissioning group’s auditor is aware of it.

Modern Slavery Act

NHS East and North Hertfordshire Clinical Commissioning Group fully supports the Government’s objectives to eradicate modern slavery and human trafficking, but does not meet the requirements for producing an annual Slavery and Human Trafficking Statement, as set out in the Modern Slavery Act 2015.

Annual Report and Accounts 2017/18 108 ______

STATEMENT OF ACCOUNTABLE OFFICER’S RESPONSIBILITIES

The National Health Service Act 2006 (as amended) states that each Clinical Commissioning Group shall have an Accountable Officer and that Officer shall be appointed by the NHS Commissioning Board (NHS England). NHS England has appointed the Chief Executive to be the Accountable Officer of the NHS East and North Hertfordshire Clinical Commissioning Group.

The responsibilities of an Accountable Officer are set out under the National Health Service Act 2006 (as amended), Managing Public Money and in the Clinical Commissioning Group Accountable Officer Appointment Letter. They include responsibilities for:

• The propriety and regularity of the public finances for which the Accountable Officer is answerable,

• For keeping proper accounting records (which disclose with reasonable accuracy at any time the financial position of the Clinical Commissioning Group and enable them to ensure that the accounts comply with the requirements of the Accounts Direction),

• For safeguarding the Clinical Commissioning Group’s assets (and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities).

• The relevant responsibilities of accounting officers under Managing Public Money,

• Ensuring the CCG exercises its functions effectively, efficiently and economically (in accordance with Section 14Q of the National Health Service Act 2006 (as amended)) and with a view to securing continuous improvement in the quality of services (in accordance with Section14R of the National Health Service Act 2006 (as amended)),

Annual Report and Accounts 2017/18 109 ______

• Ensuring that the CCG complies with its financial duties under Sections 223H to 223J of the National Health Service Act 2006 (as amended).

Under the National Health Service Act 2006 (as amended), NHS England has directed each Clinical Commissioning Group to prepare for each financial year financial statements in the form and on the basis set out in the Accounts Direction. The financial statements are prepared on an accruals basis and must give a true and fair view of the state of affairs of the Clinical Commissioning Group and of its net expenditure, changes in taxpayers’ equity and cash flows for the financial year.

In preparing the financial statements, the Accountable Officer is required to comply with the requirements of the Group Accounting Manual issued by the Department of Health and Social Care and in particular to:

• Observe the Accounts Direction issued by NHS England, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis,

• Make judgements and estimates on a reasonable basis,

• State whether applicable accounting standards as set out in the Group Accounting Manual issued by the Department of Health and Social Care have been followed, and disclose and explain any material departures in the financial statements; and,

• Prepare the financial statements on a going concern basis.

To the best of my knowledge and belief, I have properly discharged the responsibilities set out under the National Health Service Act 2006 (as amended), Managing Public Money and in my Clinical Commissioning Group Accountable Officer Appointment Letter.

Annual Report and Accounts 2017/18 110 ______

I also confirm that:

• as far as I am aware, there is no relevant audit information of which the CCG’s auditors are unaware, and that as Accountable Officer, I have taken all the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that the CCG’s auditors are aware of that information,

• that the annual report and accounts as a whole is fair, balanced and understandable and that I take personal responsibility for the annual report and accounts and the judgements required for determining that it is fair, balanced and understandable.

[Insert Signature] May 2018

…………………………………. ………………………….. signed date

Beverley Flowers, Chief Executive

Annual Report and Accounts 2017/18 111 ______

GOVERNANCE STATEMENT

Introduction and Context

NHS East and North Hertfordshire Clinical Commissioning Group (CCG) is a body corporate established by NHS England on 1 April 2013 under the National Health Service Act 2006 (as amended).

The clinical commissioning group’s statutory functions are set out under the National Health Service Act 2006 (as amended). The CCG’s general function is arranging the provision of services for persons for the purposes of the health service in England. The CCG is, in particular, required to arrange for the provision of certain health services to such extent as it considers necessary to meet the reasonable requirements of its local population.

As at 1 April 2017, the clinical commissioning group is not subject to any directions from NHS England issued under Section 14Z21 of the National Health Service Act 2006.

Scope of responsibility

As Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the clinical commissioning group’s policies, aims and objectives, whilst safeguarding the public funds and assets for which I am personally responsible, in accordance with the responsibilities assigned to me in ‘Managing Public Money’. I also acknowledge my responsibilities as set out under the National Health Service Act 2006 (as amended) and in my Clinical Commissioning Group Accountable Officer Appointment Letter.

Annual Report and Accounts 2017/18 112 ______

I am responsible for ensuring that the clinical commissioning group is administered prudently and economically and that resources are applied efficiently and effectively, safeguarding financial propriety and regularity. I also have responsibility for reviewing the effectiveness of the system of internal control within the clinical commissioning group as set out in this governance statement.

UK Corporate Governance Code

NHS Bodies are not required to comply with the UK Code of Corporate Governance. However the CCG follows the principles in the code that are most relevant to it given its size and nature, but does not comply with the code as a whole. The following section discusses the most relevant parts of the code where the CCG has complied:

GOVERNANCE ARRANGEMENTS AND EFFECTIVENESS

Council of Members

NHS East and North Hertfordshire Clinical Commissioning Group is a membership organisation currently made up of 57 GP member practices. The main function of the Council of Members is to provide clinical leadership across east and north Hertfordshire. All of the GP practices are members and a representative from each practice make up the full council.

Governing Body

The main function of the Governing Body is to ensure that the group has made appropriate arrangements for ensuring that it exercises its functions effectively, efficiently and economically and complies with such generally accepted principles of good governance as are relevant to it.

Annual Report and Accounts 2017/18 113 ______

Governance Structure

The Governing Body has created the statutorily-required Audit Committee and Remuneration Committee. Additionally the Governing Body has established a Quality Committee, an Information Communication Technology Stakeholder Board and six Locality Committees. On 1st April 2015 the CCG also created a Joint Committee with NHS England with responsibility for primary care co-commissioning.

Figure 1: Governance Structure

Annual Report and Accounts 2017/18 114 ______

Council of Members

The Council of Members met on four occasions throughout the year and discussed various themes relating to primary care, for example, the General Practice Forward View, primary care workforce and primary and community care transformation. The membership received a presentation from the Local Medical Committee on improving practice resilience, and also deliberated the opportunity to move to ‘delegated commissioning’ and agreed to commission primary medical services on behalf of NHS England from 1 April 2018.

Governance and Audit Committee

The Governance and Audit Committee is a committee of the Governing Body. It provides assurance to the Governing Body that the organisation’s overall internal control and governance system operates in an adequate and effective way. The committee’s work focuses on the adequacy of the controls on finance, risk management and clinical quality. It does this by reviewing the assurance framework, strategic and operational risk and obtaining independent assurance on controls. It also oversees internal and external audit arrangements, for both financial and non-financial systems. As part of its role the committee reviews audit reports and monitors implementation of recommendations. Members also assess the Risk Management Framework and undertakes in-depth analysis of specific risks.

During its work, activities and areas of review throughout the year, the committee ensured that any areas of particular concern were brought to the Governing Body's attention through the Governance Report.

Annual Report and Accounts 2017/18 115 ______

Remuneration Committee

The Remuneration Committee is a committee of the Governing Body. It reports its decisions to the Governing Body on determinations about pay and remuneration for all ‘Very Senior Managers’, Governing Body members, including GPs and Lay Members of the Clinical Commissioning Group. A Very Senior Manager typically has Governing Body level responsibility and reports directly to the Chief Executive. During the year, the committee ensured appropriate ‘off-payroll’ working rules were put in place to ensure that individuals who are not employees but provide services to the CCG, pay broadly the same tax and National Insurance contributions as an employee would. This was done by deducting the contributions from individuals and paying and reporting those to HM Revenue and Customs.

Quality Committee

The Quality Committee is a committee of the Governing Body. It works to ensure that commissioned services are being delivered in a high quality and safe manner, ensuring that quality sits at the heart of everything the organisation does. It is responsible for providing assurance and information on quality to enable the Governing Body to fulfil its role and responsibilities in relation to quality. It also reports on quality related risks to the Governance and Audit Committee. The committee takes on overall responsibility for leading the Clinical Commissioning Group’s patient care, quality and safety agenda and reports directly to the Governing Body on these matters. To support it in this role the committee involves a Patient Network Quality Group to provide an invaluable patient perspective.

Annual Report and Accounts 2017/18 116 ______

Joint Co-Commissioning Committee

The role of the Joint Co-Commissioning Committee is to carry out the functions relating to the commissioning of primary medical services provided under General Practice Contract arrangements, for example, General Medical Services and Alternative Provider Medical Services contracts. This is with the exception of those functions relating to individual GP performance management, which have been reserved to NHS England. A minimum of four scheduled meetings take place per year, and where required, additional meetings are arranged.

The remit of the committee has covered premises, supporting resilience in general practice, technological developments, workforce, education and training, new care models and mergers, monitoring quality and improving standards. The committee has also been involved in ensuring the smooth handover as the CCG moves into a delegated role.

Annual Report and Accounts 2017/18 117 ______

Governing Body and Committee Attendance for 2017-18

Members’ attendance records are detailed in the following table:

Public Private Workshops

Number of meetings held during 2017-18 6 5 16 Name: Title/Locality: Attendance: Dr M Andrews Upper Lea Valley 5/6 4/5 12/16 Dr T Belcher 10 North Herts 5/5 4/4 11/12 Dr H Bolat 11 Lower Lea Valley 4/6 4/5 12/14 H Brown Director of Commissioning 5/6 4/5 16/16 D Desmulie Lay Member - Public and Patient Engagement 4/6 4/5 15/16 S Elton Director of Operations 6/6 5/5 13/16 L Farrant Lay Member – Governance and Audit, Deputy Chair 6/6 5/5 15/16 B Flowers Chief Executive 6/6 5/5 15/16 Dr S Gupta Welwyn and Hatfield 6/6 5/5 12/16 Dr R Hall Stevenage 5/6 5/5 13/16 Dr A Jackson 12 Lower Lea Valley 1/2 1/2 6/7 Dr R Joyce Medical Director 6/6 5/5 15/16 Dr D Kearns 13 Stort Valley and Villages 2/2 2/2 7/7 Dr P Moodley Stevenage 6/6 5/5 13/16 Dr D O'Riordan 14 Secondary Care Specialist Doctor 5/6 4/5 N/A Dr H Pathmanathan Chair 6/6 5/5 12/16 A Pond Chief Finance Officer 5/6 4/5 14/16 S Reavey Director of Nursing and Quality 6/6 5/5 13/16 Dr A Shah Welwyn and Hatfield 3/6 2/5 13/16 Dr N Shukur Stort Valley & Villages 5/6 5/5 14/16 Y Twumasi-Ankrah MBE Lay Member – Co-Commissioning 3/6 2/5 13/16 Dr N Williams Deputy Chair – Clinical 5/6 5/5 13/16

10 Dr T Belcher joined the CCG in July 2017 11 Dr H Bolat joined the CCG in May 2017 12 From September 2017, GP GB role (Dr A Jackson) was allocated to work with the locality 13 From September 2017, GP GB role (Dr D Kearns) was allocated to work with the locality 14 The Secondary Care Specialist Doctor is not required to attend Governing Body workshops

Annual Report and Accounts 2017/18 118 ______

Committee Attendance for 2017-18 All members have good attendance records – these are detailed in the following tables. During September 2017, the Governing Body agreed that Dr D Kearns and Dr A Jackson could pilot new models of working in their localities, and this is why their attendance records are less than the other GP leads. The pilots will inform the locality strategy for 2018-19.

Governance and Audit Committee

Number of meetings held during 2017-18 5 Name: Title: Attendance: D Desmulie Lay Member – Public and Patient Engagement 5/5 L Farrant * Lay Member – Governance and Audit 5/5 Dr N Williams Deputy Chair – Clinical 4/5

* Chair of Governance and Audit Committee

Quality Committee

Number of meetings held during 2017-18 4 Name: Title/Locality: Attendance: D Desmulie Lay Member – Public and Patient Engagement 4/4 L Farrant* Lay Member – Governance and Audit 4/4 J Jewitt or Nominated Deputy Patient Network Quality 4/4 Dr R Joyce Medical Advisor 4/4 S Reavey Director of Nursing and Quality 4/4 Dr N Shukur Stort Valley and Villages 3/4 C Slater Associate Director of Quality and Patient Experience 2/4

* Chair of Quality Committee

Annual Report and Accounts 2017/18 119 ______

Remuneration Committee

Number of meetings held during 2017-18 3 Name: Title/Locality: Attendance: L Farrant* Lay Member – Governance and Audit 3/3 Dr D O’Riordan Secondary Care Specialist Doctor 3/3 Dr N Williams Deputy Chair – Clinical 3/3

* Chair of Remuneration Committee

Annual Report and Accounts 2017/18 120 ______

Joint Co-Commissioning Committee

Public Private

Number of meetings held during 2017-18 4 7 Name Title/Locality Attendance CCG Membership: Dr H Bolat 15 GP Lead, Lower Lea Valley 2/2 3/4 H Brown * Director of Commissioning or Nominated Deputy 4/4 7/7 Lay Member, Patient and Public Engagement D Desmulie 4/4 7/7 (Vice Chair of JCC from October 2016) S Elton * Director of Operations 3/4 5/7 Lay Member, Governance and Audit L Farrant 3/4 6/7 (Vice Chair of JCC up until October 2016) Dr A Jackson 16 GP Lead, Lower Lea Valley 1/2 2/3 Dr D Kearns 17 GP Lead, Stort Valley and Villages 2/2 1/3 Alan Pond * Chief Finance Officer 3/4 5/7 S Reavey * Director of Nursing and Quality or Nominated Deputy 4/4 7/7 Dr N Shukur 18 GP Lead, Stort Valley and Villages 2/2 4/4 Y Twumasi-Ankrah MBE ** JCC Chair, Lay Member, Co-Commissioning 3/4 5/7 Dr N Williams Deputy Chair of Governing Body / GP Lead, Upper Lea Valley 3/4 4/7 NHS England Membership: D Cox * Locality Director 4/4 7/7 M Derby * Director of Nursing or Nominated Deputy 2/4 4/7 A Rashid * Medical Director or Nominated Deputy 2/4 4/7

** Chair of Joint Co-Commissioning Committee

* The Terms of Reference allow members indicated to nominate an appropriate deputy to attend in their place. 15 Dr H Bolat became a member of JCC in October 2017 16 Dr A Jackson was a member of the JCC until September 2017 17 Dr D Kearns was a member of the JCC until September 2017 18 Dr N Shukur became a member of JCC in October 2017

Annual Report and Accounts 2017/18 121 ______

Information Communication Technology Stakeholder Board

The Information Communication Technology Stakeholder Board is a committee of the Governing Body. This committee brings together the stakeholders of the ICT Shared Service and its role is to ensure focus on strategy, policy and the overall operational performance of information and communications technology. Attendance at meetings of the committee is recorded in the table below.

Member Organisations: Out of total of 6 meetings Bedfordshire Clinical Commissioning Group 3/6 East and North Hertfordshire Clinical Commissioning Group 6/6 Hertfordshire Community NHS Trust 5/6 Hertfordshire Partnership University NHS Foundation Trust 6/6 Herts Valleys Clinical Commissioning Group 4/6 Luton Clinical Commissioning Group 5/6

Locality Committees

There are six Locality Committees of the Governing Body, which are responsible for ensuring the Governing Body is informed by the members of the Clinical Commissioning Group and that local knowledge is fed into the decision making process. The committees are responsible for ensuring that members have the opportunity to contribute to the development of policy and commissioning strategy.

Annual Report and Accounts 2017/18 122 ______

Attendance records for each of the committees are detailed in the following table:

Lower Lea Valley: Out of total of 2 meetings * Abbey Road, Waltham Cross 2 Cromwell and Wormley Medical Centre, Cheshunt 2 Cuffley and Goffs Oak Medical Centre, Cuffley 2 High Street Surgery, Cheshunt 2 The Maples Health Centre, Broxbourne 2 Stanhope Surgery, Waltham Cross 2 Stockwell Lodge Medical Centre, Cheshunt 2 Warden Lodge, Cheshunt 2 North Herts: Out of total of 9 meetings Ashwell Surgery, Ashwell 9 The Baldock Surgery 8 Birchwood Surgery, Letchworth 9 Courtenay House Surgery, Hitchin 9 Garden City Surgery, Letchworth 8 Knebworth & Marymead Surgery, Knebworth 9 Nevells Road Surgery, Letchworth 8 Orford Lodge Surgery, Hitchin 9 Portmill Surgery, Hitchin 7 Regal Chambers Surgery, Hitchin 9 Sollershott Surgery, Letchworth 19 5 Whitwell Surgery, Whitwell 8 Stevenage: Out of total of 10 meetings Bedwell Medical Centre, Stevenage 8 Chells Way Surgery, Stevenage 10 King George Surgery, Stevenage 9 Manor House Surgery, Stevenage 10 Shephall Way Surgery, Stevenage 10 Stanmore Medical Group, Stevenage 20 9 Symonds Green Health Centre, Stevenage 6

* The table shows that this locality has a low number of recorded locality meetings. Additional meetings have been held, but these have been in a different format and therefore are not listed here.

19 Agreement was made with Sollershott Surgery, the locality and the CCG that due to the exceptional circumstances with the practice’s caretaker contract being introduced, that the practice could be represented at meetings by the practice manager only during Q1 20 Canterbury Way Surgery, Stevenage and St Nicholas Health Centre, Stevenage have merged with Stanmore Medical Group Stevenage

Annual Report and Accounts 2017/18 123 ______

Stort Valley and Villages: Out of total of 1 meeting * Central Surgery, Sawbridgeworth 1 Church Street Partnership, Bishop’s Stortford 1 The Health Centre, Much Hadham 0 Parsonage Surgery, Bishop’s Stortford 0 Sawbridgeworth Medical Services, Sawbridgeworth 21 1 South Street Surgery, Bishop’s Stortford 1 Upper Lea Valley: Out of total of 6 meetings Amwell Street Surgery, Hoddesdon 4 Buntingford Medical Centre, Buntingford 6 Castlegate Surgery, Hertford 6 Church Street Surgery, Ware 6 Dolphin House Surgery, Ware 6 Hailey View Surgery, Hoddesdon 6 Haileybury College, Hertford Heath ** 0 Hanscombe House Surgery, Hertford 6 The Limes Surgery, Hoddesdon 5 Orchard Surgery, Buntingford 6 Park Lane Surgery, Broxbourne 22 6 Puckeridge Surgery, Puckeridge 6 Wallace House Surgery, Hertford23 6 Ware Road Surgery, Hertford 5 Watton Place Surgery, Watton at Stone 24 6 Welwyn and Hatfield: Out of total of 6 meetings Bridge Cottage Surgery, Welwyn 6 Burvill House Surgery, Hatfield 6 The Garden City Surgery, Welwyn Garden City 6 Hall Grove Surgery, Welwyn Garden City 6 Lister House Surgery, Hatfield 6 Peartree Lane Surgery, Welwyn Garden City 6 Potterells Medical Centre, Hatfield 6 Spring House Surgery, Welwyn Garden City 6 Wrafton House Surgery, Hatfield 6

21 These GP practices provide services to a limited cohort of patients (boarding school and care home) and are therefore not required to attend meetings. 22 Park Lane surgery was given attendance credits in October 2017 as their GP representative was representing the Locality Commissioning Board at the Launch of the 100 Challenge Project for ULV. 23 Wallace House surgery was given attendance credits in October 2017 as their GP representative was representing the Locality Commissioning Board at the Launch of the 100 Challenge Project for ULV. 24 Watton Place Clinic was granted attendance credit at three locality meetings (October, November 2017 and January 2018) due to extenuating circumstances within the practice.

Annual Report and Accounts 2017/18 124 ______

Committee effectiveness Governing Body members have undertaken mandatory training throughout the year, which included Anti-Fraud and Bribery (Managing Conflicts of Interest and Standards of Business Conduct), Health and Safety including Wellbeing and Resilience, Information Governance, Safeguarding Children and Safeguarding Adults including Prevent. Annual mandatory training enables the members to regularly keep their knowledge and skills up-to-date. In addition, each member is allocated sufficient time to discharge their respective duties and responsibilities effectively.

The Governing Body made two new appointments throughout the year to ensure progressive refreshing of the membership. The election process is formally overseen by Bedfordshire and Hertfordshire Local Medical Committee for openness and transparency. New members are subject to a probationary period and to re-election after 4 years.

The Governance and Audit Committee and Quality Committee undertake self-assessments of their effectiveness on an annual basis. The Chairman and Chief Executive undertake performance evaluations through regular 1:1 and appraisals of the members.

Discharge of Statutory Functions

The Clinical Commissioning Group has reviewed all of the statutory duties and powers conferred on it by the National Health Service Act 2006 (as amended) and other associated legislative and regulations. As a result, I can confirm that the Clinical Commissioning Group is clear about the legislative requirements associated with each of the statutory functions for which it is responsible, including any restrictions on delegation of those functions. Responsibility for each duty and power has been clearly allocated to a lead Executive Director. Directorates have confirmed that their structures provide the necessary capability and capacity to undertake all of the Clinical Commissioning Group’s statutory duties.

Annual Report and Accounts 2017/18 125 ______

Risk management arrangements and effectiveness

The CCG undertakes proactive holistic identification of risks utilising a top down and bottom up approach to ensure a robust process is in place. These risks are managed using tiered risk registers, which include:-

 Strategic Risk Register: Register of the key strategic risks faced by the CCG. Risks are owned by Executive team members.

 Corporate Risk Register: Risk Control and Assurance Dashboard. Risks are owned by Associate/Assistant Directors and Managers across the CCG with an assigned Director responsible for oversight.

 Directorate and Project Risk Registers: Project risk registers are maintained for projects. Directorate risk registers are not mandatory but their use is encouraged.

The Clinical Commissioning Group’s Risk Management Framework sets out the strategic aim, commitment to and objectives of the risk management process. It also identifies the leadership and responsibilities for risk management throughout the organisation. Roles and responsibilities are based around the Three Lines of Defence model (Please see diagram on the following page).

Annual Report and Accounts 2017/18 126 ______

First Line of Defence – Management and Staff

Each department and employee is responsible for implementing the requirements of the Risk Management Framework. All line managers have a responsibility for identifying, assessing, managing and reporting risk within their area of responsibility, which could affect achievement of any of the organisation’s objectives. They are also responsible for putting actions into place to mitigate these risks and for reporting activities or circumstance that may give risk to new or changed risk.

Annual Report and Accounts 2017/18 127 ______

Second Line of Defence – Specialist Support Functions

The second line of defence is made up of the functions that specialise in risk management or compliance. The Corporate Governance Manager is responsible for facilitating risk management activity across the CCG. This includes providing training and advice to staff in the management of risk, embedding best practise risk management, co-ordinating and reporting risk information to the Governing Body and its committees. In addition, this role is also responsible for ensuring that the Risk Management Framework and Procedure guidance are kept relevant and in line with current best practise.

Third Line of Defence

The third line of defence relates to functions that provide independent assurance which includes Internal Audit.

Executive Team

The Executive Directors are responsible for overseeing the implementation of the Risk Management Framework, including defining; supporting and challenging key risks and risk management activity.

Governing Body

The Governing Body is ultimately responsible for risk management and is supported in discharging its responsibilities by the Governance and Audit and Quality Committees.

Annual Report and Accounts 2017/18 128 ______

Capacity to Handle Risk

The Chief Executive has overall responsibility for risk management within the organisation. The Director of Nursing and Quality has delegated responsibility for clinical risk and the Chief Finance Officer has delegated responsibility for financial risk and information risk.

The amount and type of risk that the Clinical Commissioning Group is willing to take on in pursuit of its strategic objectives is determined by the Governing Body in their determination of the organisation’s Risk Appetite. This appetite is influenced by a number of key factors including (but not limited to) the overall level of risk, as well as the economic, regulatory and operational landscape.

Strategic risks are identified by the Executive team based on the Strategic Objectives and informed by other sources. The Clinical Commissioning Group is an active member of the Health and Wellbeing Board and regularly participates in scrutiny meetings led by Hertfordshire County Council to discuss local health issues. This level of joint activity enables stakeholders to work with the organisation to understand and manage any risks that may impact on them. The Strategic Risk Register and highest scoring risks are published for Governing Body Meetings, in which they are reviewed three times a year, providing a further opportunity for public engagement with stakeholders in risks that impact on them.

All Executive Directors are responsible for ensuring that key and emerging strategic risks are identified, assessed and managed. They also monitor the effectiveness of risk assessment, mitigating actions and assurances in place. The Directorate teams are responsible for reviewing their work areas to identify risks to the achievement of objectives and to put in place actions to mitigate these.

Members of the Governing Body have attended specific training in risk management. Risk management training is also mandatory for all managers and staff. At 31 March 2018, 94% of staff had completed risk management training.

Annual Report and Accounts 2017/18 129 ______

Risk Assessment

The risk management process starts with the organisation setting its objectives and identifying possible risks to their achievement. The controls in place to mitigate the risks are assessed together with the assurance in place on those controls. Gaps in controls and assurance are evaluated and further actions identified and implemented. If the residual risk is not acceptable further actions are identified, assigned to named individuals and timescales for implementation agreed.

In support of the Risk Management Framework, the organisation has Risk Management Procedure Guidance, which is used by all levels of staff. It contains the risk scoring matrix and descriptors, which enables staff to ensure that risks are scored consistently so that priority can be given to the risks that could hinder the achievement of objectives. It also details the process by which risks are managed and escalated to the Strategic Risk Register.

The Strategic Risk Register details the risks that, at a strategic level, could have an impact on achieving the organisation’s objectives. Updates to the Strategic Risk Register take into consideration the risks on the Risk Controls and Assurance Dashboard. The Strategic Risk Register and the Risk Controls and Assurance Dashboard are updated three times a year. This update is facilitated by the Corporate Governance Manager and occurs via meetings held with the individual risk owners. These update meetings include a review of the nature of the risk, the risk description including causes and impact, risk scoring, discussion and challenge of the controls and identification of further actions required to mitigate the risk.

The following table details the Strategic Risks of the Clinical Commissioning Group. These are continuously reviewed by the Executive Team and reflect both the ‘in-year’ and ‘future’ risks faced by the organisation:

Annual Report and Accounts 2017/18 130 ______

Risk Mitigation  Robust programme of quality monitoring and Failure of the Clinical Commissioning assurance visits together resulting in actions Group to ensure delivery of safe,  Quarterly Quality Committee meeting where risks Strategic high quality and effective services are discussed and assurance for mitigation Risk 1: from appropriately commissioned reviewed providers  Quality review meetings with providers, including review of CQC action plans

 Development of Locality Commissioning Committee and Locality Commissioning Plans as Failure to establish an adequate and of 01 April 2018 Strategic appropriate commissioning plan  Named GP Lead (Governing Body member) for Risk 2: that is informed by member each locality who will be responsible for the practices oversight and leadership of the localities, including performance and quality of primary care delivery

If we fail to fulfil our responsibility  STP Steering Group with nine core work streams to proactively engage with other identified STP stakeholders and to influence  Review of CCG internal processes to fit STP work the STP appropriately there is a risk Strategic streams and reporting to Governing Body to be that we will not deliver a Risk 3: established sustainable local health and social  Baseline view of STP Progress Assessment for care system potentially resulting in Hertfordshire and west Essex as ‘Category 3 – judicial review, financial failure and Making Progress’ (July 2017) detrimental effects on patients.

 Financial reporting to the Executive Team, Governance and Audit Committee, Governing Failure of the Clinical Commissioning Body and NHS England Strategic Group to manage the financial  Detailed Financial Policies in place Risk 4: budget and meet its financial target  Financial position for 2017-18 is in line with plan  Financial plans for 2018-19 in development, QIPP challenge has significantly reduced from 2017-18

Annual Report and Accounts 2017/18 131 ______

Risk Mitigation • Delivery of Operational Plan reviewed, process Failure to implement key work underway for 2018-19 Operational Plan with Strategic streams to ensure delivery of the focus on most challenged areas Risk 5: Clinical Commissioning Group’s • Review of CCG internal monitoring and assurance strategic plan process to reflect new operating model and national STP requirements

• Identification of additional schemes for cost reduction, targeting areas where the Trust is running with excessive costs Strategic Financial Sustainability of Providers • Trust control totals are challenging, planning in Risk 6: in the Health Economy progress for 2018-19 • STP Partnership governance structure pulls together STP wide performance and QIPP challenge

As a result of a shortage of • Strategic Primary Care Workforce work stream is appropriately skilled staff there is a in place with the STP, with a plan for the next risk that the Clinical Commissioning three years Group will not be able to effectively • GP locality leads appointed to support education Strategic commission new services or and retention activities, and Local Workforce Risk 7: provide existing services which Education Board established could result in diminished services • Working with district Council to encourage and poor outcomes for patients and increased level of key worker housing and failure to deliver core services. engagement via STP Workforce stream

Annual Report and Accounts 2017/18 132 ______

Other sources of assurance

Internal Control Framework

A system of internal control is the set of processes and procedures in place in the Clinical Commissioning Group to ensure it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.

The system of internal control allows risk to be managed to a reasonable level rather than eliminating all risk; it can therefore only provide reasonable and not absolute assurance of effectiveness.

Internal Audit

The organisation uses an internal audit function to monitor the internal controls in operation to try to identify and correct any weaknesses identified. The system is embedded in the activity of the organisation through an annual Internal Audit Work Plan. The Internal Audit services for the organisation are currently provided by RSM. The Head of Internal Audit reports independently to the Chair of the Governance and Audit Committee and provides objectivity and independent assurance on the effectiveness of its system of internal control, including the application of the Risk Management Framework. The annual Head of Internal Audit Opinion (see page 140) provides independent overarching assurance to the organisation.

Annual Audit of Conflicts of Interest Management

The revised statutory guidance on managing conflicts of interest for Clinical Commissioning Groups (published June 2016) requires Clinical Commissioning Groups to undertake an annual internal audit of conflicts of interest management. To support Clinical Commissioning Groups to undertake this task, NHS England has published a template audit framework.

Annual Report and Accounts 2017/18 133 ______

The organisation received positive assurance for this audit and is currently in the process of implementing the one medium and four low recommendations agreed with the auditors to make sure the identified risk continues to be managed effectively. The area found to be partially compliant related to how declared conflicts were recorded in meeting minutes, and in particular how meeting secretariats record the Chair’s decision making in the Minutes. Additional training and meeting templates have been provided to secretariats across the organisation to address this concern.

Data Quality

The CCG undertakes monthly validation of all ‘Secondary Uses Service’ data for all contracted providers against a comprehensive list of validation rules. There is also a monthly Organisational Performance and Delivery Day held with Governing Body members to discuss and resolve a range of issues associated with the organisation’s main providers, including data quality and validation issues. Commissioning Information Groups are held monthly with all the main acute and community providers to discuss and agree improvements in performance and data quality issues. Data Quality Improvement Plans have been agreed with all the main providers and monitored at the Commissioning Information Data Groups on a monthly or quarterly basis.

The CCG has access to the national Hospital Episode Statistics data, through Mede/Analytics, to undertake bespoke comparative data analysis to be compared alongside any national benchmarking reports such as Right Care.

Annual Report and Accounts 2017/18 134 ______

Information Governance

The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by an Information Governance Toolkit and the annual submission process provides assurances to the CCG, other organisations and to individuals that personal information is dealt with legally, securely, efficiently and effectively. Risks to data security are managed through a series of management, technical, operational and privacy controls.

Information Governance Toolkit v14.1

The CCG has undertaken an assessment of its position against the Information Governance Toolkit v14.1 and has submitted a 66% level of compliance, which evaluated that the organisation achieved level 2 or above on all requirements. Policies and processes for the management of information have been agreed at the Information Governance Forum and ratified by the Governance and Audit Committee.

We place high importance on ensuring there are robust information governance systems and processes in place to help protect patient confidentiality and corporate information. We have established an Information Governance Management Framework and have developed information governance processes and procedures in line with the Information Governance Toolkit. We have ensured that all staff members undertake information governance training annually, which is mandatory and ensures they are aware of their roles and responsibilities.

An internal sub-group has also been established to oversee the implementation of the General Data Protection Regulations (GDPR) by 25 May 2018. This group is meeting on a fortnightly basis and is reviewing progress against an agreed action plan.

There are processes in place for incident reporting and investigation of serious incidents. We have appointed a Senior Information Risk Owner who is the Chief Finance Officer and continue to embed an information risk culture throughout the organisation.

Annual Report and Accounts 2017/18 135 ______

Business Critical Models

The CCG uses activity models that are based on official Government produced information; for example, population demographics, provided by the Office for National Statistics. It is assumed that the Office for National Statistics, as a nationally recognised body will have undertaken quality assurance processes with regard to construction of these models.

The CCG currently uses a local risk stratification model that was jointly developed between health and social care and is made available through Mede/Analytics. This model is used to identify a discrete group of patients who are at risk of being admitted to hospital as an emergency, who may be better looked after through local community services such as ‘Home First’. The patients identified by this model are followed up by a multi-disciplinary team of clinicians from primary care, community health, mental health, and social workers as part of a clinical review process to provide assurance only patients suitable for the schemes developed are followed up. The CCG is currently developing a model to calculate the elderly frailty index (EFI) using primary care data. This will be made available during April 2018.

The organisation does not use any other sophisticated models beyond those described above, but is currently undertaking further analysis to develop new risk stratification models using the wider range of data that is now available through the data integration and pseudonymisation at source project.

Third Party Assurances

The CCG has a contract with Mede/Analytics to provide Business Intelligence support as a Data Processor. As a third party supplier assurance is provided by satisfactory completion of version 14.1 of the IG Toolkit with an overall score of 100% and they are entered on the Data Protection Register with the Information Commissioners Office (ICO.) In addition there is a confidentiality clause in the contract between the CCG and Mede/Analytics and they have been audited by NHS Digital with an assessment of minimal risk of inappropriate exposure and/or access to data provided by NHS Digital, and were highlighted with a number of areas of good practice.

Annual Report and Accounts 2017/18 136 ______

The CCG also has a contract with North East London Commissioning Support Unit (NELCSU) to provide Data Services for Commissioning (DSCRO) services. As a third party supplier assurance is provided by satisfactory completion of version 14.1 of the IG Toolkit with an overall score of 100% and they are entered on the Data Protection Register with the ICO. Further assurance is provided by the inclusion of a confidentiality clause in the contract between the CCG and NELCSU.

The organisation does not have any other contracts with third party suppliers who have access to and process patient identifiable data. All other third party contractors are assessed on an annual basis and contract clauses included where appropriate.

Control Issues

The Head of Internal Audit has concluded that there are no significant control issues currently facing the organisation.

Annual Report and Accounts 2017/18 137 ______

Review of economy, efficiency and effectiveness of the use of resources

To ensure the Clinical Commissioning Group resources are used economically, efficiently and effectively the organisation has implemented processes, which are described below:

 the CCG has agreed its prime and detailed financial policies, which set out the systems to be adhered to in order to ensure that resources are used efficiently.  developed and implemented strategic and operational plans, which include an agreed annual budget approved by the Governing Body.  contracts with providers that use the national standard NHS contract and include detailed finance, activity and quality schedules. The contracts require providers to innovate to improve quality and efficiency.  comprehensive programme of contract monitoring, covering all aspects of performance, quality, activity and finance against agreed plans.  corporate wide process for the development and review of business cases for investment. Processes include assessment of value for money and contribution to the achievement of CCG objectives.  reports on finance and quality presented on a monthly basis to the Governing Body, with actions identified when performance is off track.  report on identified key financial risks to regular meetings of the Governance and Audit Committee.  implementation of an internal audit programme that is targeted at the strategic risks and key financial control processes.  annual fraud risk assessment undertaken by an independent party, providing recommendations for key actions.  comprehensive suite of Fraud and Bribery policies agreed and in place with local counter fraud specialist delivering an agreed work plan.  requirement as part of mandatory training that all staff undertake counter fraud and bribery training.  training for staff on how to raise concerns under the whistleblowing policy – with the mechanisms being used appropriately  the NHS ‘Atlas of Variation’ allows the organisation to compare the amount we spend, the health services we commission and the health of our population against that of other

Annual Report and Accounts 2017/18 138 ______

areas in England. These comparisons help the CCG to identify whether our population is receiving high quality, efficient and effective health services.

Delegation of functions

Not applicable as during 2017/18 the CCG jointly commissioned services with NHS England.

Counter Fraud Arrangements

The Clinical Commissioning Group contracts RSM to provide the counter fraud provision by way of a nominated lead local counter fraud specialist (LCFS). The LCFS is accredited by the NHS Counter Fraud Authority and qualified to undertake the duties of that role.

RSM provides the Clinical Commissioning Group with a LCFS Annual Report, which details all work undertaken in respect of counter fraud activities for the reporting year and measures each task as specified in the NHS Counter Fraud Authority Standards for Commissioners. The LCFS Workplan is designed to meet the requirements set out in the NHS Counter Fraud Authority Standards for Commissioners and each task is designed to provide compliance with each of the standards described. The LCFS Workplan is designed to address the locally and nationally identified fraud risk areas in conjunction with the Chief Finance Officer.

The Chief Finance Officer holds responsibility for the delivery of the LCFS work and provides the support to the LCFS in achieving this. The LCFS works with the Chief Finance Officer in submitting the annual NHS Counter Fraud Authority Self-Review Tool. An action plan is produced on the findings of this tool which is monitored at the Governance and Audit Committee for any areas not deemed as fully compliant with the standards.

Please see page 165 of this report for the CCG’s ‘whistleblowing’ procedures.

Annual Report and Accounts 2017/18 139 ______

HEAD OF INTERNAL AUDIT OPINION

Following completion of the planned audit work for the financial year for the Clinical Commissioning Group, the Head of Internal Audit issued an independent and objective opinion on the adequacy and effectiveness of the Clinical Commissioning Group’s system of risk management, governance and internal control. For the 12 months ended 31 March 2018, the head of internal audit opinion for NHS East and North Hertfordshire CCG is as follows:

The organisation has an adequate and effective framework for risk management, governance and internal control. However our work has identified further enhancements to the framework of risk management, governance and internal control to ensure that it remains adequate and effective.

During the year, Internal Audit issued the following audit reports:

Area of Audit Level of Assurance Given Business continuity Substantial Conflicts of Interest Reasonable Effectiveness of Continuing Healthcare Arrangements Advisory – no opinion provided Delivery of Improving Access to Psychological Therapies Substantial Delivery of the Financial Plan [including Quality, Substantial Innovation, Productivity and Prevention (QIPP)] Delivery of the Integrated Urgent Care Service Reasonable General Data Protection Regulations Compliance Advisory – no opinion provided Key Financial Controls Substantial Prescribing – Delivery of QIPP Schemes Substantial QIPP and Financial Planning Reasonable Risk Management and Assurance Substantial Follow-up Good Progress

Annual Report and Accounts 2017/18 140 ______

Review of the effectiveness of governance, risk management and internal control

My review of the effectiveness of the system of internal control is informed by the work of the Internal Auditors, the Executive Directors and senior management within the Clinical Commissioning Group who have responsibility for the development and maintenance of the internal control framework. I have drawn on performance information available to me. My review is also informed by comments made by the External Auditors in their annual audit letter and other reports.

Our assurance framework provides me with evidence that the effectiveness of controls that manage risks to the Clinical Commissioning Group achieving its principal objectives have been reviewed.

I have been advised on the implications of the result of this review by the:

 Governing Body  Governance and Audit Committee  Quality Committee  Internal Audit  External Audit

Conclusion

As Accountable Officer, and based on the review processes outlined above, I can confirm that the Governance Statement is a balanced reflection of the actual controls position and there are no significant internal control issues identified for the Clinical Commissioning Group.

Annual Report and Accounts 2017/18 141 ______

PART TWO: REMUNERATION REPORT AND STAFF REPORT

REMUNERATION REPORT The information on pages 142 and 143 is not subject to audit.

REMUNERATION COMMITTEE The members of the Remuneration Committee for the year were as follows. The committee met three times during 2017/18 and all members were in attendance.

 Linda Farrant – Lay member (Governance and Audit), Chair of the Remuneration Committee  Dr Nicky Williams – Deputy Clinical Chair  Dr Dermot O’ Riordan – Secondary Care Specialist Doctor

POLICY ON REMUNERATION OF SENIOR MANAGERS (not subject to audit)

The Clinical Commissioning Group’s Remuneration Committee used the remuneration guidance provided by NHS England to inform its decisions regarding the pay of all very senior managers. We can confirm that the pay of all our very senior managers is within the pay ranges identified in the guidance. Additional payments have been agreed on a post-by-post basis for additional responsibilities and complexity, as assessed by the Remuneration Committee.

Annual Report and Accounts 2017/18 142 ______

SENIOR MANAGERS PERFORMANCE RELATED PAY (not subject to audit) The Remuneration Committee has agreed that there will be no performance related pay for senior managers.

POLICY ON SENIOR MANAGERS’ CONTRACTS

As at 31 March 2018 there were six permanent executive team managers and one vacant position. GPs on the Governing Body are employed on fixed term contracts:

 Dr Pathmanathan (4 year fixed term from 1 September 2014 to 31 August 2018)  Drs Hall and Williams (4 year fixed term from 1 April 2017 to 31 March 2021)  Drs Andrews, Jackson and Moodley (4 year fixed term from 1 April 2015 to 31 March 2019)  Dr Shukur (3 year fixed term from 16 February 2017 to 29 February 2020)  Dr Shah (4 year fixed term from 1 November 2014 to 31 October 2018)  Dr Gupta (4 year fixed term from 1 November 2015 to 31 October 2019)  Dr Bolat (4 year fixed term from 5 May 2017 to 30 April 2021)  Dr Belcher (4 year fixed term from 1 July 2017 to 30 June 2021)

Lay members are also employed on fixed term contracts:

 Linda Farrant (1 April 2013 to 31 March 2022)  Dianne Desmulie (27 November 2014 to 26 November 2022)  Yvette Twumasi-Ankrah (3 year fixed term from 4 August 2015. Yvette resigned her post in March 2018)

SENIOR MANAGER SERVICE CONTRACTS (not subject to audit) We do not have any senior manager service contracts.

PAYMENTS TO PAST SENIOR MANAGERS (not subject to audit) There have been no payments to past senior managers.

Annual Report and Accounts 2017/18 143 ______

SALARIES AND ALLOWANCES (AUDITED SECTION)

The salary and pension entitlements of East and North Hertfordshire CCG’s senior managers are disclosed in the following two tables. The definition of a senior manager is a person in a senior position having authority or responsibility for directing or controlling the major activities of the clinical commissioning group. This means those who influence the decisions of the clinical commissioning group as a whole rather than the decisions of individual directorates or departments, people including advisory and lay members. The Chief Executive confirms that this definition covers members of the Governing Body only.

SALARIES AND ALLOWANCES IN 2017/18

Long term All pension Expense performance Salary Performance pay related TOTAL payments pay and Name and Title (bands of and bonuses benefits (bands of (taxable) to bonuses £5,000) (bands of £5,000) (bands of £5,000) nearest £100 (bands of £2,500) £5,000) £000 £ £000 £000 £000 £000 Beverley Flowers - Accountable Officer 130-135 0 0 0 30-32.5 165-170 Alan Pond - Chief Finance Officer 125-130 200 0 0 22.5-25 150-155 Sheilagh Reavey - Director of Nursing & Quality 110-115 0 0 0 15-17.5 125-130 Sharn Elton - Director of Operations 110-115 0 0 0 25-27.5 135-140 Harper Brown - Director of Commissioning 110-115 0 0 0 15-17.5 125-130 Rachel Joyce - Medical Director 120-125 0 0 0 115-117.5 235-240 Denise Boardman - Programme Director (from 1 Apr 2017) 95-100 100 0 0 12.5-15 110-115 Hari Pathmanathan - GP Board Member and CCG Chair - Note 1 & 2 105-110 0 0 0 £NIL 105-110 Nicky Williams - GP Board Member and CCG Vice Chair - Note 2 100-105 0 0 0 £NIL 100-105 Mark Andrews - GP Board Member - Note 2 50-55 0 0 0 £NIL 50-55 Alison Jackson - GP Board Member - Note 2 55-60 0 0 0 £NIL 55-60

144

Prag Moodley - GP Board Member - Note 2 55-60 0 0 0 £NIL 55-60 Russell Hall - GP Board Member - Note 2 50-55 0 0 0 £NIL 50-55 Deborah Kearns - GP Board Member (1 Apr 2017 to 5 Feb 2018) - Note 2 50-55 0 0 0 £NIL 50-55 Nabeil Shukur - GP Board Member - Note 2 50-55 0 0 0 £NIL 50-55 Fiona Sinclair - GP Board Member (1 Apr 2017 to 30 June 2017) - Note 2 5-10 0 0 0 £NIL 5-10 Ashish Shah - GP Board Member - Note 2 55-60 0 0 0 £NIL 55-60 Sachin Gupta - GP Board Member - Note 2 55-60 0 0 0 £NIL 55-60 Tara Belcher - GP Board Member (from 1 Jul 2017)- Note 2 30-35 0 0 0 £NIL 30-35 Haydar Bolat - GP Board Member (from 1 Apr 2017) - Note 2 40-45 0 0 0 £NIL 40-45 Dianne Desmulie - Lay Member 10-15 0 0 0 0 10-15 Yvette Twumasi - Ankrah - Lay Member (1 Apr to 22 March 2018 ) 5-10 100 0 0 0 5-10 Linda Farrant - Lay Member 15-20 200 0 0 0 15-20 Dermot O'Riordan - Secondary Care Specialist Doctor 10-15 0 0 0 0 10-15

Notes

The taxable benefits referred to in the table above relate to the re-imbursement of mileage undertaken on official duties. The benefit arises from the mileage allowance payments made to all staff, to reimburse them for expenses related to the use of their own vehicle for business travel. East and North Hertfordshire CCG pays the rate per mile set out in Agenda for Change, which exceeds the HMRC "approved mileage allowance payments" rate in 2017-18 of 45p a mile. The excess amount is taxable and is disclosed above.

The "All pension related benefits" in the table above shows the real terms increase in pension benefits over the course of the past year, i.e. the additional money (lump sum and annual pension) that would be payable to the individual if they had become entitled to it on 31 March 2018 compared to their entitlements as at 31 March 2017. These benefits are funded by East and North Hertfordshire CCG and are calculated on the assumption that the annual pension will be paid for 20 years after the date of retirement.

Annual Report and Accounts 2017/18 145 ______

Note 1 - In additional to his remuneration as a GP Board Member and CCG Chair above, Hari Pathmanathan also received £8,854 in salary which is recharged to Hertfordshire Partnership Foundation NHS Trust for his role as the clinical lead in the Hertfordshire and West Essex Sustainability and Transformation Plan.

Note 2 - Where a GP Board member is working under a "contract for services" and the GP is set up on the payroll system to satisfy HMRC rulings, the position is pensionable under the "Practioner Pension Scheme". The CCG must make the post non pensionable on the payroll and submit a GP Solo form with the employer's pension contribution of 14.3% plus an administration levy of 0.08% to the NHS Pension Authority. The salary banding above comprises of gross payment plus employer pension contribution, where relevant.

PAY MULTIPLES (AUDITED ELEMENT OF REMUNERATION REPORT)

Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director/member in the organisation and the median remuneration of the CCG's workforce, as at the reporting date (31 March 2018).

The banded remuneration of the highest paid director/member in East and North Hertfordshire CCG at the reporting date was £130,000- £135,000 (2016-17: £130,000-£135,000). This was 3.59 times (2016-17: 3.59) the median remuneration of the workforce, which was £37,259 (2016-17: £36,890).

In 2017-18 and 2016-17, at the reporting date, no employee received remuneration in excess of the highest paid director/member of the CCG's Governing Body. The lowest paid member of staff received £14,680 (2016-17: £16,212).

Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind, but not severance payments. It does not include employer pension contributions (with the exception of those GPs see Note 2 above, where employer pension contributions are included in accordance with guidance) and the cash equivalent transfer value of pensions.

Annual Report and Accounts 2017/18 146 ______

SALARIES AND ALLOWANCES IN 2016/17 (AUDITED SECTION) Restated in respect of Chief Finance Officer and GP Governing Body Members *

Taxable Annual Long Term All Salary Benefits Performance Performance Pension Total and Fees (rounded Related Related Related Name and Title (bands of (bands of to the Bonuses Bonuses Benefits £5,000) £5,000) nearest (bands of (bands of (bands of £100) £5,000) £5,000) £2,500) £000 £ £000 £000 £000 £000 Beverley Flowers - Accountable Officer 130-135 0 0 0 135-137.5 265-270 Alan Pond - Chief Finance Officer 125-130 200 0 0 30-32.5 155-160 Sheilagh Reavey - Director of Nursing & Quality 110-115 100 0 0 22.5-25 135-140 Sharn Elton - Director of Operations 110-115 0 0 0 35-37.5 135-140 Harper Brown - Director of Commissioning 110-115 0 0 0 0 110-115 Hari Pathmanathan - GP Board Member and CCG Chair - Note 1 110-115 0 0 0 £NIL 110-115 Nicky Williams - GP Board Member and CCG Vice Chair 105-110 0 0 0 £NIL 105-110 Robert Graham - GP Board Member ( 1st April 2016 - 31st December 2016) 40-45 0 0 0 £NIL 40-45 Stephen Kite - GP Board Member ( 1st April 2016 - 24th November 2016) 35-40 0 0 0 £NIL 35-40 Mark Andrews - GP Board Member 50-55 0 0 0 £NIL 50-55 Alison Jackson - GP Board Member 55-60 0 0 0 £NIL 55-60 Ed Bosonnet - GP Board Member (1st April 2016 - 30th September 2016) 25-30 0 0 0 £NIL 25-30 Prag Moodley - GP Board Member 55-60 0 0 0 £NIL 55-60 Russell Hall - GP Board Member 50-55 0 0 0 £NIL 50-55 Deborah Kearns - GP Board Member 55-60 0 0 0 £NIL 55-60 Nabeil Shukur - GP Board Member 55-60 0 0 0 £NIL 55-60 Fiona Sinclair - GP Board Member 55-60 0 0 0 £NIL 55-60 Ashish Shah - GP Board Member 55-60 0 0 0 £NIL 55-60 Sachin Gupta - GP Board Member (Commenced 1st November 2015) 55-60 0 0 0 £NIL 55-60 Dianne Desmulie - Lay Member 10-15 0 0 0 0 10-15 Yvette Twumasi - Ankrah - Lay Member (Commenced 3rd August 2015) 10-15 200 0 0 0 10-15 Linda Farrant - Lay Member 15-20 200 0 0 0 10-15 Rachel Joyce - Medical Director (1st December 2016 - 31st March 2017) 20-25 0 0 0 27.5-30 50-55

Annual Report and Accounts 2017/18 147 ______

* The 2016-17 Remuneration report has been restated to reflect: i) revised figures for the Chief Finance Officer as recalculated by Pensions Agency ii) the contract for services that GP Board Members have with the CCG. The GP is set up on the payroll system to satisfy HMRC rulings and the position is pensionable under the "Practitioner Pension Scheme". The must make the post non pensionable on the payroll and submit GP SOLO forms with the employers pension contribution of 14.3% plus 0.08% administration levy to the NHS Pension Authority. The salary figure shown above in respect of these Board Members is based on gross pay and employer pension contributions.

Note 1

The taxable benefits referred to in the table above relate to the re-imbursement of mileage undertaken on official duties. The benefit arises from the mileage allowance payments made to all staff, to re-imburse them for expenses related to the use of their own vehicle for business travel. East and North Hertfordshire CCG pays the rate per mile set out in Agenda for Change, which exceeds the HMRC "approved mileage allowance payments" rate in 2016/17 of 45p a mile. The excess amount is taxable and is disclosed above.

The all pension related benefits in the table above shows the real terms increase in pension benefits over the course of the past year, i.e. the additional money (lump sum and annual pension) that would be payable to the individual if they had become entitled to it on 31 March 2017 compared to their entitlements as at 31 March 2016. These benefits are funded by the CCG and are calculated on the assumption that the annual pension will be paid for 20 years after the date of retirement.

Annual Report and Accounts 2017/18 148 ______

PENSIONS BENEFITS 2017/18 (SUBJECT TO AUDIT)

Name and title

£2,500) £5,000)

April 2017 April

Employer's

March 2018

Lumpsum at

Totalaccrued

accruedpension

age age (bandsof

at at pension age TransferValue

2018 (bands 2018 of

contributionto

CashEquivalent

Real increase Real in increase Real in increase Real in

CashEquivalent CashEquivalent

age at age 31 March

(bandsof £2,500) at March 31 2018 (bandsof £5,000)

pensionlump sum

TransferValue at 1

pensionat pension pensionat pension to

pension age related

TransferValue at 31 stakeholderpension Relating to the period 1 April 2017 to 31st March 2018 £000 £000 £000 £000 £000 £000 £000 £000 Beverley Flowers - Accountable Officer 2.5-5.0 0 35-40 95-100 603 32 674 0 Alan Pond - Chief Finance Officer - see Note 1 0-2.5 0 55-60 95-100 836 16 877 0 Sheilagh Reavey - Director of Nursing & Quality 0-2.5 2.5-5.0 40-45 120-125 792 36 873 0 Sharn Elton - Director of Operations 0-2.5 0 45-50 115-120 666 33 739 0 Harper Brown - Director of Commissioning - Note 2 0-2.5 2.5-5.0 30-35 100-105 0 0 0 0 Rachel Joyce - Medical Director 5.0-7.5 17.5-20.0 30-35 100-105 539 67 679 0 Denise Boardman - Programme Director 0-2.5 2.5-5.0 40-45 120-125 781 24 835 0 Hari Pathmanathan - GP Board Member and CCG Chair - Note 4 £NIL £NIL £NIL £NIL £NIL £NIL £NIL £NIL Alison Jackson - GP Board Member - Note 4 £NIL £NIL £NIL £NIL £NIL £NIL £NIL £NIL Prag Moodley - GP Board Member - Note 4 £NIL £NIL £NIL £NIL £NIL £NIL £NIL £NIL Deborah Kearns - GP Board Member (1 April 2017 - 5 February 2018) - Note 4 £NIL £NIL £NIL £NIL £NIL £NIL £NIL £NIL Sachin Gupta - GP Board Member - Note 4 £NIL £NIL £NIL £NIL £NIL £NIL £NIL £NIL Fiona Sinclair - GP Board Member (1 April 2017 - 30 June 2017) - Note 4 £NIL £NIL £NIL £NIL £NIL £NIL £NIL £NIL Ashish Shah - GP Board Member - Note 4 £NIL £NIL £NIL £NIL £NIL £NIL £NIL £NIL Tara Belcher - GP Board Member (from 1st July 2017) - Note 4 £NIL £NIL £NIL £NIL £NIL £NIL £NIL £NIL Haydar Bolat - GP Board Member (from 1 April 2017) - Note 4 £NIL £NIL £NIL £NIL £NIL £NIL £NIL £NIL Linda Farrant - Lay Member - Note3 0 0 0 0 0 0 0 0 Dianne Desmulie - Lay Member - Note 3 0 0 0 0 0 0 0 0 Dermot O'Riordan - Lay Member - Note 3 0 0 0 0 0 0 0 0 Yvette Twumasi - Ankrah - Lay Member (1 April 2017-22 March 2018)- Note 3 0 0 0 0 0 0 0 0

Annual Report and Accounts 2017/18 149 ______

Notes

1. 2016/17 figures have been recalculated by the Pensions Agency and restated as above.

2. The officer has no CETV at 31st March 2018 as at that date they were past the normal retirement age meaning that their pensions cannot be transferred.

3. As Lay Members do not receive pensionable remuneration, there will be no entries in respect of pensions for Lay Members.

4. Where a GP Board member is working under a "contract for services" and the GP is set up on the payroll system to satisfy HMRC rulings, the position is pensionable under the "Practitioner Pension Scheme". The CCG must make the post non-pensionable on the payroll and submit GP SOLO forms with the employer’s pension contribution of 14.3% plus 0.08% administration levy to the NHS Pensions Authority.

5. NHS employees contribute towards their pension benefits. In 2017/18 contribution rates were 14.5% of salary where the individual earned in excess of £111,377 and 13.5% where the individual earned between £70,631 and £111,377.

6. Cash Equivalent Transfer Values A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particularly point in time. The benefits valued are the member's accrued benefits and any contingent spouse's pension payable from the scheme. A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme.

The pension figures shown relate to the benefits that the individual has accrued as a consequence of their membership of the pension scheme. This may be more than just their service in a senior capacity to which disclosure applies.

The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries.

7. Real Increase in CETV The real increase in CETV reflects the increase in CETV that is funded by the employer. It does not include the increase in accrued pension due to inflation or contributions paid by the employee (including the value of any benefits transferred from another pension scheme or arrangement).

…………………………………………… Finance Signing Officer ………………………………………………. Date

Annual Report and Accounts 2017/18 150 ______

Table 1: Off-payroll engagements longer than 6 months (not subject to audit)

For all off-payroll engagements as of 31 March 2018, for more than £245 per day and that last longer than six months.

Number of existing engagements as of 31 March 2018 10 Of which… Number that have existed for less than one year at time of reporting 9 Number that have existed for between one and two years at time of reporting 1 Number that have existed for between two and three years at time of reporting 0 Number that have existed for between three and four years at time of reporting 0 Number that have existed for four or more years at time of reporting 0

Table 2: For all new off-payroll engagements, or those that reached six months in duration, between 1 April 2017 and 31 March 2018, for more than £245 per day and that last longer than six months.

Number of new engagements, or those that reached six months in duration, 11 between 1 April 2017 and 31 March 2018 Of which… Number assessed as caught by IR35 11 Number assessed as not caught by IR35 0

Number engaged directly (via PSC contracted to department) and are on the 5 departmental payroll Number of engagements re-assessed for consistency / assurance purposes 0 during the year Number of engagements that saw a change to IR35 0

151

Table 3: Off-payroll board member/senior official engagements

For any off-payroll engagements of board members, and/or senior officials with significant financial responsibility, between 1 April 2017 and 31 March 2018.

Number of off-payroll engagements of board members, and/or senior officials 0 with significant financial responsibility, during the financial year Number of individuals that have been deemed ‘board members, and/or senior officials with significant responsibility’ during the financial year. This figure 24 should include both off-payroll and on-payroll engagements

EXIT PACKAGES AGREED IN THE FINANCIAL YEAR (SUBJECT TO AUDIT)

There were no exit packages paid during the year. Three exit packages were paid in 2016/17 totalling £69,791).

TRADE UNION FACILITY TIME (NOT SUBJECT TO AUDIT)

Union representatives have a statutory right to reasonable paid time off from employment to carry out trade union duties and to undertake trade union training. Union duties must relate to matters covered by collective bargaining agreements between employers and trade unions and relate to the union representative’s own employer, unless agreed otherwise in circumstances of multi-employer bargaining, and not, for example, to any associated employer.

Union representatives and members also have a statutory right to reasonable unpaid time off when taking part in trade union activities. Employers can also consider offering paid time off.

Annual Report and Accounts 2017/18 152 ______

Activities can be, for example, taking part in:

 branch, area or regional meetings of the union where the business of the union is under discussion  meetings of official policy making bodies such as the executive committee or annual conference  meetings with full time officers to discuss issues relevant to the workplace.

The Trade Union (Facility Time Publication Requirements) Regulations 2017 came into force on 1st April 2017 and put in place the provisions in the Trade Union Act 2016 requiring relevant public sector employers to publish specified information related to facility time provided to trade union officials.

The specified information is provided in Tables 1-4 below.

Table 1: Relevant union officials

Number of employees who were relevant Full-time equivalent union officials during 2017/18 employee number

3 3.00

Table 2: Percentage of time spent on facility time

Percentage of time Number of employees

0% 0

1-50% 3

51%-99% 0

100% 0

Annual Report and Accounts 2017/18 153 ______

Table 3: Percentage of pay bill spent on facility time

Description Figures

Total cost of facility time £10,228

Total pay bill £13,867,000

Percentage of the total pay bill spent on facility time 0.07%

Table 4: Paid trade union activities

Time spent on paid trade union activities as a 90.60% percentage of total paid facility time hours

…………………………………………… ……………………………… Date Beverley Flowers, Chief Executive

Annual Report and Accounts 2017/18 154 ______

STAFF REPORT

As at 31 March 2018, East and North Hertfordshire CCG employed a total of 322 staff (263.29 full time equivalents). These figures include all governing body members and five staff on external secondment to partnership organisations.

The table below details how many senior managers are employed by the CCG by banding (as at 31 March 2018).

Band Number of Staff 8a 30 8b 27 8c 15 8d 12 9 1 VSM 6

Equality and Diversity (not subject to audit) The Equality Act 2010: The Public Sector Equality Duty

Section 149 of the Equality Act 2010 states that a public authority must have due regard to the need to:

 eliminate discrimination, harassment, victimisation and any o0ther conduct that is prohibited by or under this Act;  advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it;  foster good relations between persons who share a relevant protected characteristic and persons who do not share it.

Annual Report and Accounts 2017/18 155 ______

Throughout 2017/18, East and North Hertfordshire CCG’s engagement approach was fully cognisant of this duty and it will continue to promote equality of opportunity for the population of East and North Hertfordshire in the context of all its commissioning engagement activities in the future.

The CCG met statutory responsibilities around data publication and will meet the NHS requirements in using the NHS Equality Delivery System (EDS2) and the Workforce Race Equality Standard (WRES) as tools to enable us to review our equality and diversity work and identify where improvements can be made.

NHS Workforce Race Equality Standards (WRES) The CCG is required to have ‘due regard’ to the WRES in respect of its own workforce. It is recognised that the small size of many CCGs means that a literal application and interpretation of the indicators should be approached with caution. CCGs should pay due regard to the WRES both as an indication they are complying with their Public Sector Equality Duty and in order to demonstrate that as commissioners they also take the intent of the WRES seriously.

Annual Report and Accounts 2017/18 156 ______

The CCG’s profile for staff-declared ethnicity appears in the table below (at 31 March 2018).

Ethnic Origin Headcount% A White – British 65.41% B White – Irish 3.14% C White - Any other White background 3.46% D Mixed - White & Black Caribbean 1.57% E Mixed - White & Black African 0.31% F Mixed - White & Asian 0.63% G Mixed - Any other mixed background 0.31% H Asian or Asian British – Indian 7.86% J Asian or Asian British – Pakistani 1.57% K Asian or Asian British - Bangladeshi 1.26% L Asian or Asian British - Any other Asian background 1.26% LE Asian Sri Lankan 0.31% M Black or Black British - Caribbean 1.26% N Black or Black British – African 5.35% P Black or Black British - Any other Black background 0.31% R Chinese 0.31% S Any Other Ethnic Group 1.57% Z Not Stated 4.09%

Annual Report and Accounts 2017/18 157 ______

Equality and Diversity Action Planning and the NHS Equality Delivery System (EDS2) The CCG is required to implement EDS2. Our last assessment took place a number of years ago as part of a Hertfordshire-wide assessment and was graded as ‘Developing’ (on a scale of Undeveloped, Developing, Achieving and Excelling). A review of the CCG is underway and the findings will be used to refresh our equality and diversity strategy and action plan. Equality and diversity support is delivered to the CCG, via a shared service resource alongside Herts Valleys CCG and Bedfordshire CCG. This model enables best practice and expertise to be shared amongst the three organisations.

Disability

The CCG previously held the Positive About Disabled People (PADP) award presented by Jobcentre Plus to those employers who demonstrated a commitment to recruiting disabled employees and developing their skills and prospects. This award was also known as the ‘Two Ticks’ award because of the design of logo looked like two ticks.

The PADP award was replaced by the Disability Confident award. This has been awarded to the CCG for two years from June 2017, recognising our commitment to recruiting and developing disabled employees.

At 31 March 2018, 89.3% of staff have declared they have no disability, with 3.5% declaring a disability and the remaining 7.2% declaring they do not wish to disclose.

Gender Profile (not subject to audit) Gender Profile – overall workforce (at 31 March 2018)

Gender % Female 61.54 Male 38.46

Annual Report and Accounts 2017/18 158 ______

% gender by pay band (at 31 March 2018)

Pay Band 2017 Agenda for Change (AfC) Male (%) Female (%) Band 3 0.80 2.50 Band 4 13.60 14.00 Band 5 13.60 10.00 Band 6 17.60 15.00 Band 7 14.40 22.00 Band 8A 6.40 11.00 Band 8B 9.60 7.50 Band 8C 4.80 4.50 Band 8D 3.20 4.00 Band 9 0.80 - Very Senior Managers (VSM) 1.60 2.00

Non-AfC 25 13.60 7.50

Gender breakdown (as at 31 March 2018)

Governing Body members (covers VSM pay framework grades) Male Female Headcount % Headcount % 11 52.38 10 47.62 Senior Managers – Band 8a and above Male Female Headcount % Headcount % 31 36.47 54 63.53 All other bands (band 7 and below) Male Female Headcount % Headcount % 83 37.90 136 62.10

25 Increase in non-AfC payments in 2017/18 due to introduction of IR35 regulations

Annual Report and Accounts 2017/18 159 ______

Gender pay gap reporting regulations

From 31 March 2017, all public sector organisations in England employing 250 or more staff have been required to publish gender pay gap information annually, both on their website and on the designated government website at www.gov.uk/genderpaygap. The results for the CCG published on 31 March 2018 can be found here.

East and North Hertfordshire is one of the few CCGs nationally which is required to publish this information, as most CCGs employ fewer than 250 members of staff.

Gender pay reporting is different to equal pay. Equal pay deals with the pay differences between men and women who carry out the same jobs, similar jobs or work of equal value. It is unlawful to pay people unequally because they are a man or a woman.

The gender pay gap shows the difference in the average pay (both mean and median) between all men and women in our workforce. Calculations are based on the hourly rate of ordinary salary paid to each employee on a snapshot date in the financial year. This includes staff employed under Agenda for Change terms and conditions, clinical advisers and very senior managers.

East and North Hertfordshire CCG employs more women than men, with women making up approximately 60% of the workforce.

The percentage of women employed in the top 25% of all roles ranked according to their hourly salaries is 59%, which closely mirrors the percentage of women in the organisation altogether. Men are statistically slightly over-represented in the lowest paid roles – where they make up 43% of the workforce.

The median gender pay gap is 0%. This means that the mid-point for pay for men and women in the CCG is the same.

Annual Report and Accounts 2017/18 160 ______

The average (mean) gender pay gap calculation for East and North Hertfordshire CCG shows that men are paid on average 10.7% more than women, based on the average hourly rate earned. This is probably due to the disproportionate number of male employees paid at the highest hourly rates. As more data becomes available, the CCG will be able to note any trends and develop an action plan to address areas of concern.

Religion and beliefs The declared religion or belief of CCG staff at 31 March 2018 appears in the table below:

Religious Belief Headcount % Atheism 11.95% Buddhism 0.94% Christianity 35.85% Hinduism 3.46% I do not wish to disclose my religion/belief 28.93% Islam 2.52% Jainism 0.31% Judaism 0.31% Other 5.97% Sikhism 0.94% Not stated 8.81%

The declared sexual orientation for the CGG at 31 March 2018 appears in the table below:

Sexual Orientation Headcount % Bisexual 0.63% Gay 0.31% Heterosexual 66.04% I do not wish to disclose my sexual orientation 24.21% Lesbian 0.31% Not stated 8.49%

Annual Report and Accounts 2017/18 161 ______

Sickness Absence Data Sickness absence data relating to 2017 (1 January – 31 December) is as follows:

Total days lost: 2,213 days (source: NHS Digital, FTE days lost to sickness)

Average absence per 5.0 days (average of total days lost by CCG headcount: employee: which was 271.4 FTE for the calendar year 2017)

Of total days lost, 10 (taken from ESR) long term absence episodes:

Long term days total: 802 days (taken from ESR; included in total days lost)

The CCG’s sickness absence rate for 2017 was 2.23% 26 (3.01% in 2016). The rate is below the 2017 national CCG average of 2.80%.

26 365 days x 271.4 FTE staff = 99,061 / 2,213 FTE days lost to sickness = 2.23%

Annual Report and Accounts 2017/18 162 ______

EMPLOYEE BENEFITS AND STAFF NUMBERS (SUBJECT TO AUDIT)

Employee benefits 2017-18 Total Admin Programme Permanent Permanent Permanent Total Employees Other Total Employees Other Total Employees Other £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Employee Benefits Salaries and wages 12,366 11,083 1,283 10,455 9,663 792 1,910 1,420 491 Social security costs 1,279 1,272 7 1,168 1,168 0 111 104 7 Employer Contributions to NHS Pension scheme 1,511 1,511 0 1,367 1,367 0 144 144 0 Other pension costs 1 1 0 1 1 0 0 0 0 Apprenticeship Levy 46 46 0 41 41 0 5 5 0 Termination benefits 0 0 0 0 0 0 0 0 0 Gross employee benefits expenditure 15,203 13,913 1,290 13,032 12,240 792 2,171 1,673 498

Less: Employee costs capitalised 0 0 0 0 0 0 0 0 0

Net employee benefits excluding capitalised costs 15,203 13,913 1,290 13,032 12,240 792 2,171 1,673 498 Employee benefits 2016-17 Total Admin Programme

Permanent Permanent Permanent Total Employees Other Total Employees Other Total Employees Other £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Employee Benefits Salaries and wages 13,464 11,347 2,117 10,833 9,426 1,407 2,631 1,921 710 Social security costs 1,264 1,264 0 1,106 1,106 0 158 158 0 Employer Contributions to NHS Pension scheme 1,491 1,491 0 1,279 1,279 0 212 212 0 Other pension costs 0 0 0 0 0 0 0 0 0 Apprenticeship Levy 0 0 0 0 0 0 0 0 0 Termination benefits 70 70 0 66 66 0 4 4 0 Gross employee benefits expenditure 16,289 14,172 2,117 13,284 11,875 1,407 3,005 2,295 710

Less: Employee costs capitalised 0 0 0 0 0 0 0 0 0

Net employee benefits excluding capitalised costs 16,289 14,172 2,117 13,284 11,875 1,407 3,005 2,295 710

4.2 Average number of people employed 2017-18 2016-17 (subject to audit) Permanently Permanently Total employed Other Total employed Other (no.) (no.) (no.) (no.) (no) (no.)

Total 281.7 262.4 19.3 308.8 272.2 36.6

163

HR shared service model

In order to continue to respond to the developing needs of the CCG, the Human Resources provision continues to be delivered via a shared service, hosted by Herts Valleys CCG. The service also provides support to Bedfordshire and Luton CCGs. As part of a shared service, the CCG benefits from economies of scale, an enhanced knowledge base and a wider pool of HR and organisational skills and expertise, as well as access to a dedicated Director of Workforce, who is representing the CCG in aspects of the STP workforce agenda across both Hertfordshire and West Essex.

Staff Policies

The HR Shared Service has developed a policy forum that spans across four CCGs. The policy forum has HR, management and staff representatives from each CCG and works together to adopt best practice in people management policy across the organisations. Through this group, 25 policies were amended and implemented during 2017/18:

• Agency and Interim Use Policy • Flexible Working Policy • Agile Working Policy • Grievance Policy • Alcohol, Drug and Substance Misuse Policy • Maternity, Maternity Support (Paternity), • Annual Leave Policy Adoption/Fostering Parental Leave Policy • Appraisal and Performance Review Policy • Organisational Change Policy • Apprenticeship Policy • Overtime, On-Call and Working Time Policy • Attendance and Wellbeing Policy • Probation and Induction Policy • Bullying and Harassment Policy • Raising Concerns (Whistleblowing) Policy • Capability Policy • Recruitment and Selection Policy • Disciplinary Policy • Secondment Policy • Education, Training and Development Policy • Special Leave Policy • Employment Break Policy • Verification of Professional Registration Policy • Equality and Diversity Policy • Volunteer Policy

Support for staff

The CCG is fully committed to the health and positive wellbeing of its employees and understands that a healthy and happy workforce is crucial to delivering improvements in patient care.

164

The CCG offers an Employee Assistance Programme (EAP), accessed through a free and confidential helpline. The EAP provides information, advice and counselling covering a range of personal, family and workplace issues. The CCG also has access to Occupational Health services, to support staff with health concerns.

Whistleblowing

The CCG has in place a ‘Raising Concerns at Work’ policy which provides staff with information and reassurance regarding their rights and responsibilities in reporting concerns. It sets out clearly how staff can report in confidence, good faith and without fear of retribution. As part of this policy, the CCG has nominated a lay member- Dianne Desmulie - to oversee the effectiveness of this process. During 2017/18, Dianne has held staff sessions to help staff understand the process which has led to a number of contacts from staff wishing to raise concerns.

Appraisals

The CCG requires line managers to complete staff appraisals between April and June each year. For the year 2017/18, 83.96% of staff working in HBL ICT had an appraisal and 85.21% of staff in the rest of the CCG had an appraisal.

Health and safety

The CCG is fully committed to protecting the health, safety and welfare of all its staff and providing a secure and healthy environment in which to work.

The CCG recognises its legal obligations under the Health and Safety at Work etc. Act (HASAWA) 1974, to ensure the health, safety and welfare of its staff, so far as is reasonably practicable. The CCG also accepts such responsibility for other persons who may be affected by its activities.

Annual Report and Accounts 2017/18 165 ______

During 2017/18, the CCG obtained professional health and safety guidance through SERCO ASP’s Health and Safety Advisor who also delivered face-to-face mandatory fire training for CCG staff.

Training

In 2017/18, 92.17% of CCG staff completed mandatory training - an improvement on the previous year’s results. The high compliance rate has been achieved by regular reports being circulated, so staff and managers are aware when they need to complete a course. The CCG also offers protected time each Friday in order for staff to complete training or personal development. For 2018/19 a new mandatory training programme has been introduced which is delivered by combination of online and face-to-face participation. The new system is directly linked to the electronic staff record.

Employee consultation and communications

The Joint Partnership Forum meets regularly and is a chance for staff and union representatives to discuss key issues affecting their working lives with executive members and make plans for improvements.

During 2017/18, CCG staff quickly adapted to the new hot-desking system, enabling the CCG to reduce the space it occupied and its estates costs by 20%. Engagement with staff took place throughout the planning, implementation and evaluation stages, with staff ideas being incorporated where possible. Some of the savings created from not leasing an additional building were reinvested in improving the office space using suggestions made by staff, with the balance contributing towards the CCG’s efficiency target of £23m. The new office environment and move to ‘agile working’ has been welcomed by staff who have found it helpful in balancing the demands of home and work, as well as improved opportunities for cross-team collaboration.

Annual Report and Accounts 2017/18 166 ______

Internal communications

We have a range of internal communication channels for all our staff including our magazine ‘Charter Chat’, our intranet site, team meetings and a weekly all staff email which contains a round-up of local and national health news, HR and staff information. Results from the staff survey, carried out in the autumn, identified some areas where the CCG could improve, including ensuring communication between senior management and staff is effective which the CCG will be addressing in the coming year.

The ‘learning and development hour’ continues to be popular on a Friday, where staff can hear updates from other teams on their key projects and talks from external organisations. Topics covered this year included delegated commissioning, GDPR, cyber resilience and the role of the primary care workforce and education network.

Staff health and wellbeing

The NHS Five Year Forward View encourages employers to introduce a range of initiatives including promoting physical activity, reducing stress, and providing health checks for staff. The CCG is committed to supporting its staff to live as healthily as possible both physically and mentally and has a range of health and wellbeing initiatives in place.

The staff wellbeing group organises team and individual activities throughout the year. Lunchtime walks and healthy lunches were held regularly and teams of staff took part in charity challenges.

Other initiatives to help staff keep fit and healthy include the cycle-to-work scheme which allows staff to buy a bike at a reduced cost and pay for it monthly through tax efficient salary deductions.

Annual Report and Accounts 2017/18 167 ______

PART THREE: PARLIAMENTARY ACCOUNTABILITY AND AUDIT

REPORT

East and North Hertfordshire CCG is not required to produce a Parliamentary Accountability and Audit Report but has opted to include disclosures on remote contingent liabilities, losses and special payments, gifts, and fees and charges are included in the Financial Statements of this report at page xx. An audit certificate and report is also included in this Annual Report at page xx.

Annual Report and Accounts 2017/18 168 ______

EXTERNAL AUDIT OPINION

To follow

THE ACCOUNTS To follow

Annual Report and Accounts 2017/18 169 ______

If you would like this information in another language or format, please contact us on 01707 685397.

You can also read a summary of this

Annual Report on our website www.enhertsccg.nhs.uk/annualreport

Annual Report and Accounts 2017/18 170 ______NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

Statement of Comprehensive Net Expenditure for the year ended 31 March 2018 2017-18 2016-17 Note £'000 £'000

Income from sale of goods and services 2 (11,504) (9,876) Other operating income 2 (361) (471) Total operating income (11,865) (10,347)

Staff costs 3 15,203 16,289 Purchase of goods and services 4 719,480 701,572 Depreciation 4 569 393 Provision expense 4 98 0 Other Operating Expenditure 4 509 513 Total operating expenditure 735,859 718,766

Net Operating Expenditure 723,994 708,419

Comprehensive Expenditure for the year ended 31 March 2018 723,994 708,419

The notes on pages xx to xx form part of this statement.

1 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

Statement of Financial Position as at 31 March 2018 31 March 2018 31 March 2017 Note £'000 £'000 Non-current assets: Property, plant and equipment 6 3,400 2,855 Trade and other receivables 7 278 0 Total non-current assets 3,678 2,855 Current assets: Trade and other receivables 7 9,066 5,826 Cash and cash equivalents 8 169 298 Total current assets 9,235 6,124

Total assets 12,913 8,979

Current liabilities Trade and other payables 9 (48,083) (46,833) Provisions (98) (275) Total current liabilities (48,181) (47,109)

Non-Current Assets less Net Current Liabilities (35,268) (38,130)

Assets less Liabilities (35,268) (38,130)

Financed by Taxpayers’ Equity General fund (35,268) (38,130) Total taxpayers' equity: (35,268) (38,130)

The notes on pages xx to xx form part of this statement.

The financial statements on pages xx to xx were approved by the Governing Body on and signed on its behalf by:

Chief Accountable Officer Beverley Flowers

2 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

Statement of Changes In Taxpayers' Equity for the year ended 31 March 2018

General Fund £'000 Changes in taxpayers’ equity for 2017-18

Balance at 1 April 2017 (38,130)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2017-18 Net operating expenditure for the financial year (723,994)

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year including balance brought forward from previous year (762,124) Net funding 726,856 Balance at 31 March 2018 (35,268)

General Fund £'000 Changes in taxpayers’ equity for 2016-17

Balance at 1 April 2016 (39,508)

Changes in NHS Clinical Commissioning Group taxpayers’ equity for 2016-17 Net operating costs for the financial year (708,419)

Net Recognised NHS Clinical Commissioning Group Expenditure for the Financial Year including balance brought forward from previous year (747,927) Net funding 709,797 Balance at 31 March 2017 (38,130)

The notes on pages xx to xx form part of this statement.

3 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

Statement of Cash Flows for the year ended 31 March 2018 2017-18 2016-17 Note £'000 £'000 Cash Flows from Operating Activities Net operating expenditure for the financial year (723,994) (708,419) Depreciation and amortisation 4 569 393 (Increase) / Decrease in trade & other receivables 7 (3,518) 311 (Decrease) / Increase in trade & other payables 9 918 324 Provisions utilised (275) (562) Increase in provisions 98 0 Net Cash Outflow from Operating Activities (726,202) (707,953)

Cash Flows from Investing Activities Payments for property, plant and equipment (782) (1,805)

Net Cash Outflow from Investing Activities (782) (1,805)

Net Cash Outflow before Financing (726,984) (709,758)

Cash Flows from Financing Activities Grant in Aid Funding Received 726,855 709,797

Net Cash Inflow from Financing Activities 726,855 709,797

Net (Decrease) / Increase in Cash & Cash Equivalents 8 (129) 39

Cash & Cash Equivalents at the Beginning of the Financial Year 298 259

Cash & Cash Equivalents at the End of the Financial Year 169 298

The notes on pages xx to xx form part of this statement.

4 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

Notes to the financial statements

1 Accounting Policies

NHS England has directed that the financial statements of clinical commissioning groups shall meet the accounting requirements of the Group Accounting Manual issued by the Department of Health and Social Care. Consequently, the following financial statements have been prepared in accordance with the Group Accounting Manual 2017-18 issued by the Department of Health. The accounting policies contained in the Group Accounting Manual follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to clinical commissioning groups, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the Group Accounting Manual permits a choice of accounting policy, the accounting policy which is judged to be most appropriate to the particular circumstances of the clinical commissioning group for the purpose of giving a true and fair view has been selected. The particular policies adopted by the clinical commissioning group are described below. They have been applied consistently in dealing with items considered material in relation to the accounts. 1.1 Going Concern

These accounts have been prepared on the going concern basis. Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents. Where a clinical commissioning group ceases to exist, it considers whether or not its services will continue to be provided (using the same assets, by another public sector entity) in determining whether to use the concept of going concern for the final set of Financial Statements. If services will continue to be provided the financial statements are prepared on the going concern basis.

1.2 Accounting Convention

These accounts have been prepared under the historical cost convention.

1.3 Pooled Budgets Where the clinical commissioning group has entered into a pooled budget arrangement under Section 75 of the National Health Service Act 2006 the clinical commissioning group accounts for its share of the assets, liabilities, income and expenditure arising from the activities of the pooled budget, identified in accordance with the pooled budget agreement. If the clinical commissioning group is in a joint operation, the clinical commissioning group recognises: · The assets the clinical commissioning group controls; · The liabilities the clinical commissioning group incurs; · The expenses the clinical commissioning group incurs; and, · The clinical commissioning group’s share of the income from the pooled budget activities. If the clinical commissioning group is involved in a joint venture, in addition to the above, the clinical commissioning group recognises: · The clinical commissioning group’s share of the jointly controlled assets (classified according to the nature of the assets); · The clinical commissioning group’s share of any liabilities incurred jointly; and, · The clinical commissioning group’s share of the expenses jointly incurred.

The CCG has entered into a partnership agreement and a pooled budget with Hertfordshire County Council (HCC) in respect of the Better Care Fund. This is a national policy initiative and the funds involved are material in the CCG accounts. Having reviewed the terms of the partnership agreement, the Department of Health and Social Care Group Accounting Manual and the appropriate financial reporting standards, the CCG has determined that there are three elements to the Better Care Fund and they are accounted for as follows:

(1) the major part is controlled by HCC which commissions services from various non-NHS providers. Whilst the services are determined in partnership, the risks and rewards of the contracts remain wholly with HCC. The CCG accounts for this on a lead commissioner basis as healthcare expenditure with the local authority. (2) The second part is controlled by the CCG which commissions various services from NHS and non-NHS providers. The risks and rewards of these contracts are the responsibility of the CCG, which considers itself to be acting as a lead commissioner for those services on behalf of the partnership. The CCG accounts for these costs as healthcare purchased from NHS and non-NHS providers.

(3) The final part are services which are jointly commissioned by the CCG and HCC, including mental health services, equipment services, intermediate care services and protection of social care services. HCC acts as the host body for these services which are provided by a third party. Each partner is however wholly responsible for their own share of the expenditure and this is accounted for as a joint operation.

1.4 Critical Accounting Judgements & Key Sources of Estimation Uncertainty In the application of the clinical commissioning group’s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period or in the period of the revision and future periods if the revision affects both current and future periods.

1.4.1 Key Sources of Estimation Uncertainty The following are the key estimations that management has made in the process of applying the clinical commissioning group’s accounting policies that have the most significant effect on the amounts recognised in the financial statements:

Prescription Services

The CCG receives financial information from NHS Business Services Authority relating to the cost of drugs prescribed by independent GPs, CCG run practices and other CCG services. The total expenditure for the year includes estimates for February and March, based on the estimated profile of spend. The estimate for February and March 2017-18 is £13.971m (2016-17 £13.972m).

5 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

Notes to the financial statements

Secondary Healthcare Secondary activity reports are received from providers monthly, but activity information for the final month of the year is not available in time for the accounts, so estimates are made in agreement with providers. A full reconciliation is undertaken once actual activity is agreed which is at the end of the first quarter of the following year. Any increase or decrease in activity (if any) becomes a charge or credit in the next financial year. Historically, when these estimates have been compared to the subsequent actual data, they have not been materially different. Estimation techniques are used to ensure that the correct levels of income and expenditure due relating to the current year are included through the inclusion of accruals based on known commitments and local knowledge.

1.5 Revenue Revenue in respect of services provided is recognised when, and to the extent that, performance occurs, and is measured at the fair value of the consideration receivable.

Where income is received for a specific activity that is to be delivered in the following year, that income is deferred.

1.6 Employee Benefits 1.6.1 Short-term Employee Benefits Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees.

1.6.2 Retirement Benefit Costs

Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, General Practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the clinical commissioning group of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period.

For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to expenditure at the time the clinical commissioning group commits itself to the retirement, regardless of the method of payment.

1.7 Other Expenses

Other operating expenses are recognised when, and to the extent that, the goods or services have been received. They are measured at the fair value of the consideration payable.

1.8 Property, Plant & Equipment 1.8.1 Recognition Property, plant and equipment is capitalised if: · It is held for use in delivering services or for administrative purposes; · It is probable that future economic benefits will flow to, or service potential will be supplied to the clinical commissioning group; · It is expected to be used for more than one financial year; · T he cost of the item can be measured reliably; and, · The item has a cost of at least £5,000; or, · Collectively, a number of items have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or, · Items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost. Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives.

1.8.2 Valuation All property, plant and equipment are measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. All assets are measured subsequently at valuation.

Fixtures and equipment are carried at depreciated historic cost as this is not considered to be materially different from current value in existing use.

1.8.3 Subsequent Expenditure

Where subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is capitalised. Where subsequent expenditure restores the asset to its original specification, the expenditure is capitalised and any existing carrying value of the item replaced is written- out and charged to operating expenses.

6 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

Notes to the financial statements

1.9 Depreciation, Amortisation & Impairments

Depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible non-current assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an asset is the period over which the clinical commissioning group expects to obtain economic benefits or service potential from the asset. This is specific to the clinical commissioning group and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis.

At each reporting period end, the clinical commissioning group checks whether there is any indication that any of its tangible non-current assets have suffered an impairment loss. If there is indication of an impairment loss, the recoverable amount of the asset is estimated to determine whether there has been a loss and, if so, its amount. A revaluation decrease that does not result from a loss of economic value or service potential is recognised as an impairment charged to the revaluation reserve to the extent that there is a balance on the reserve for the asset and, thereafter, to expenditure. Impairment losses that arise from a clear consumption of economic benefit are taken to expenditure. Where an impairment loss subsequently reverses, the carrying amount of the asset is increased to the revised estimate of the recoverable amount but capped at the amount that would have been determined had there been no initial impairment loss. The reversal of the impairment loss is credited to expenditure to the extent of the decrease previously charged there and thereafter to the revaluation reserve. 1.10 Leases Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases. 1.10.1 The Clinical Commissioning Group as Lessee Property, plant and equipment held under finance leases are initially recognised, at the inception of the lease, at fair value or, if lower, at the present value of the minimum lease payments, with a matching liability for the lease obligation to the lessor. Lease payments are apportioned between finance charges and reduction of the lease obligation so as to achieve a constant rate on interest on the remaining balance of the liability. Finance charges are recognised in calculating the clinical commissioning group’s surplus/deficit. Operating lease payments are recognised as an expense on a straight-line basis over the lease term. Lease incentives are recognised initially as a liability and subsequently as a reduction of rentals on a straight-line basis over the lease term. Contingent rentals are recognised as an expense in the period in which they are incurred. Where a lease is for land and buildings, the land and building components are separated and individually assessed as to whether they are operating or finance leases.

1.11 Cash & Cash Equivalents Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value.

1.12 Provisions Provisions are recognised when the clinical commissioning group has a present legal or constructive obligation as a result of a past event, it is probable that the clinical commissioning group will be required to settle the obligation, and a reliable estimate can be made of the amount of the obligation. The amount recognised as a provision is the best estimate of the expenditure required to settle the obligation at the end of the reporting period, taking into account the risks and uncertainties.

1.13 Clinical Negligence Costs

The NHS Resolution operates a risk pooling scheme under which the clinical commissioning group pays an annual contribution to the NHS Resolution which in return settles all clinical negligence claims. The contribution is charged to expenditure. Although the NHS Resolution is administratively responsible for all clinical negligence cases the legal liability remains with the clinical commissioning group.

1.14 Non-clinical Risk Pooling The clinical commissioning group participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the clinical commissioning group pays an annual contribution to the NHS Resolution and, in return, receives assistance with the costs of claims arising. The annual membership contributions, and any excesses payable in respect of particular claims are charged to operating expenses as and when they become due.

1.15 Financial Assets Financial assets are recognised when the clinical commissioning group becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are derecognised when the contractual rights have expired or the asset has been transferred. Financial assets are classified into the following categories: · Financial assets at fair value through profit and loss; · Held to maturity investments; · Available for sale financial assets; and, · Loans and receivables. The classification depends on the nature and purpose of the financial assets and is determined at the time of initial recognition.

7 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

Notes to the financial statements

1.16 Financial Liabilities

Financial liabilities are recognised on the statement of financial position when the clinical commissioning group becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are derecognised when the liability has been discharged, that is, the liability has been paid or has expired.

1.17 Value Added Tax Most of the activities of the clinical commissioning group are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.

1.18 Accounting Standards That Have Been Issued But Have Not Yet Been Adopted

The Department of Health and Social Care (DHSC) Group Accounting Manual does not require the following standards and interpretations to be applied in 2017-18. HM Treasury has adopted IFRS 9 and IFRS 15 into the Financial Reporting Manual (FReM) for 2018-19 and is expected to adopt IFRS 16 in the FReM for 2019-20. The standards will become effective for future financial reporting periods and have not been adopted in these financial statements. · IFRS 9: Financial Instruments (application from 1 January 2018) · IFRS 15: Revenue for Contract with Customers (application from 1 January 2018) · IFRS 16: Leases (expected application from 1 January 2019)

The application of IFRS 9 and IFRS 15 as revised would not have a material impact on the accounts for 2017-18, were they applied in that year. We do not yet know how IFRS 16 will impact on the CCG once it is applied, as we have not yet assessed the impact.

8 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

2 Other Operating Revenue 2017-18 2016-17 Total Total £'000 £'000

Education, training and research 180 38 Non-patient care services to other bodies 11,324 9,838 Other revenue 361 471 Total other operating revenue 11,865 10,347

Other operating revenue is derived from the rendering of services.

3. Employee benefits and staff numbers

3.1 Employee benefits 2017-18 2016-17

Total Total £'000 £'000 Employee Benefits Salaries and wages 12,366 13,464 Social security costs 1,279 1,264 Employer Contributions to NHS Pension scheme 1,511 1,491 Other pension costs 1 0 Apprenticeship Levy 46 0 Termination benefits 0 70 Gross employee benefits expenditure 15,203 16,289

3.2 Ill health retirements

There were no ill health retirements in 2017-18 (nil 2016-17).

9 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

3.3 Pension costs Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the benefits payable and rules of the Schemes can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions.

Both are unfunded defined benefit schemes that cover NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State in England and Wales. They are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities.

Therefore, each scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS body of participating in each scheme is taken as equal to the contributions payable to that scheme for the accounting period.

In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that “the period between formal valuations shall be four years, with approximate assessments in intervening years”. An outline of a) Accounting valuation A valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary’s Department) as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and is accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2018, is based on valuation data as 31 March 2017, updated to 31 March 2018 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM

The latest assessment of the liabilities of the scheme is contained in the report of the scheme actuary, which forms part of the annual NHS Pension Scheme Accounts. These accounts can be viewed on the NHS Pensions website and are published annually. Copies can also be obtained from The Stationery Office. b) Full actuarial (funding) valuation

The purpose of this valuation is to assess the level of liability in respect of the benefits due under the schemes (taking into account recent demographic experience), and to recommend contribution rates payable by employees The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2012. The Scheme Regulations allow for the level of contribution rates to be changed by the Secretary of State for Health, with the consent of HM Treasury, and consideration of the advice of the Scheme Actuary and employee and employer representatives as deemed appropriate.

The next actuarial valuation is to be carried out as at 31 March 2018 and is currently being prepared. The direction assumptions are published by HM Treasury which are used to complete the valuation calculations, from which the final valuation report can be signed off by the scheme actuary. This will set the employer contribution rate payable from April 2019 and will consider the cost of the Scheme relative to the employer cost cap. There are provisions in the Public Service Pension Act 2013 to adjust member benefits or contribution rates if the cost of the Scheme changes by more than 2% of pay. Subject to this ‘employer cost cap’ assessment, any required revisions to member benefits or contribution rates will be determined by the Secretary of State for Health after consultation with the For 2017-18, employers’ contributions of £1,514k were payable to the NHS Pensions Scheme (2016-17: £1,495k) at the rate of 14.38% of pensionable pay. The scheme’s actuary reviews employer contributions, usually every four years and now based on HMT Valuation Directions, following a full scheme valuation. The latest review used data from 31 March 2012 and was published on the Government website on 9 June 2012. These costs are included in the NHS pension line of note 3.

10 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

4. Operating expenses 2017-18 2016-17 Total Total £'000 £'000 Gross employee benefits Employee benefits excluding governing body members 13,460 14,586 Executive governing body members 1,743 1,703 Total gross employee benefits 15,203 16,289

Other costs Services from other CCGs and NHS England 932 991 Services from foundation trusts 65,092 62,443 Services from other NHS trusts 367,522 360,778 Services from other WGA bodies 0 1 Purchase of healthcare from non-NHS bodies 169,747 162,373 Purchase of social care 13,647 17,904 Chair and Non Executive Members 170 178 Supplies and services – clinical 13 0 Supplies and services – general 1,290 1,184 Consultancy services 170 94 Establishment 5,624 5,694 Transport (Note 1) 1,611 0 Premises 1,249 1,043 Depreciation 569 393 Audit fees (Note 2 and 3) 54 86 Prescribing costs 83,009 82,359 GPMS/APMS and PCTMS 8,850 4,913 Other professional fees (Note 3) 103 249 Legal Fees 213 244 Grants to Other bodies 109 0 Education and training 354 149 Provisions 98 0 CHC Risk Pool contributions 0 1,066 Other expenditure 230 335 Total other costs 720,656 702,477

Total operating expenses 735,859 718,766

Notes 1. For part of the year, patient transport service of £1,610k was commissioned from non-NHS providers and shown under Transport in accordance with NHS England guidance. For the remainder of the year, this service was provided by a NHS Trust and disclosed in services from other NHS Trusts. In 2016-17, patient transport service of £2,727k was commissioned from a non-NHS provider but this was shown under purchase of healthcare from non-NHS bodies.

2. Audit fees above is shown inclusive of VAT. The amount excluding VAT is £45k (2016-17 £71k).

3. Limitation on auditor’s liability for external audit work carried out for the financial year 2017-18 is £1million or, if greater, 10 times the total of fees invoiced under the Engagement Letter.

4. Other professional fees includes the sum of £41k for Internal Audit Fees (2016-17 £34k)

11 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

5 Better Payment Practice Code

Measure of compliance 2017-18 2017-18 2016-17 2016-17 Number £'000 Number £'000 Non-NHS Payables Total Non-NHS Trade invoices paid in the Year 18,793 215,472 19,422 222,371 Total Non-NHS Trade Invoices paid within target 18,525 213,779 19,075 212,084 Percentage of Non-NHS Trade invoices paid within target 98.57% 99.21% 98.21% 95.37%

NHS Payables Total NHS Trade Invoices Paid in the Year 3,640 464,284 3,544 450,654 Total NHS Trade Invoices Paid within target 3,544 460,601 3,349 447,125 Percentage of NHS Trade Invoices paid within target 97.36% 99.21% 94.50% 99.22%

The Better Payment Practice Code requires the CCG to aim to pay all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later.

6 Property, plant and equipment Information Furniture & 2017-18 technology fittings Total £'000 £'000 £'000 Cost or valuation at 1 April 2017 3,625 542 4,167

Additions purchased 1,059 55 1,114 Disposals other than by sale (729) 0 (729)

Cost/Valuation at 31 March 2018 3,955 597 4,552

Depreciation 1 April 2017 1,296 16 1,312

Disposals other than by sale (729) 0 (729) Charged during the year 507 62 569

Depreciation at 31 March 2018 1,074 78 1,152

Net Book Value at 31 March 2018 2,881 519 3,400

Purchased 2,881 519 3,400 Total at 31 March 2018 2,881 519 3,400

Asset financing:

Owned 2,881 519 3,400

Total at 31 March 2018 2,881 519 3,400

The clinical commissioning group did not hold any revaluation reserve balance for property, plant & equipment in 2017-18 and 2016-17.

6.1 Economic lives Minimum Maximum Life (years) Life Information technology 1 19 Furniture & fittings 7 10

12 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

7 Trade and other receivables Current Non-current Current Non-current 31 March 2018 31 March 2018 31 March 2017 31 March 2017 £'000 £'000 £'000 £'000 NHS receivables: Revenue 4,845 0 1,267 0 NHS prepayments 2,994 0 3,284 0 NHS accrued income 71 0 56 0 Non-NHS and Other WGA receivables: Revenue 340 0 249 0 Non-NHS and Other WGA prepayments 562 278 849 0 Non-NHS and Other WGA accrued income 79 0 0 0 VAT 174 0 110 0 Other receivables and accruals 1 0 11 0 Total Trade & other receivables 9,066 278 5,826 0

Total current and non current 9,344 5,826

There were no prepaid pensions contributions included above.

The great majority of trade is within the NHS group. As the NHS is funded by Government, no credit scoring is considered necessary.

8 Cash and cash equivalents 2017-18 2016-17 £'000 £'000 Balance at 1 April 298 259 Net change in year (129) 39 Balance at 31 March 169 298

Made up of: Cash with the Government Banking Service 168 297 Cash in hand 1 1 Cash and cash equivalents as in statement of financial position 169 298

Balance at 31 March 169 298

There were no patients' monies held by the clinical commissioning group in 2017-18 and 2016-17.

9 Trade and other payables Current Current 31 March 2018 31 March 2017 £'000 £'000

NHS payables: revenue 7,389 5,148 NHS accruals 3,795 12,576 NHS deferred income 101 7 Non-NHS and Other WGA payables: Revenue 6,167 3,755 Non-NHS and Other WGA payables: Capital 352 20 Non-NHS and Other WGA accruals 24,235 23,165 Non-NHS and Other WGA deferred income 2 2 Social security costs 189 180 Tax 164 153 Other payables and accruals 5,689 1,827 Total Trade & Other Payables 48,083 46,833

Total current and non-current 48,083 46,833

Other payables include £221k outstanding pension contributions at 31 March 2018 (£218k - 31 March 2017).

13 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

10 Financial instruments

10.1 Financial risk management

International Financial Reporting Standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities.

Because the clinical commissioning group is financed through parliamentary funding, it is not exposed to the degree of financial risk faced by business entities. Also, financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The clinical commissioning group has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the clinical commissioning group in undertaking its activities.

Treasury management operations are carried out by the finance department, within parameters defined formally within the clinical commissioning group standing financial instructions and policies agreed by the Governing Body. Treasury activity is subject to review by the clinical commissioning group and internal auditors.

10.1.1 Credit risk

Because the majority of the clinical commissioning group and revenue comes from parliamentary funding, the clinical commissioning group has low exposure to credit risk. The maximum exposures as at the end of the financial year are in receivables from customers, as disclosed in the trade and other receivables note.

10.1.2 Liquidity risk The clinical commissioning group is required to operate within revenue and capital resource limits, which are financed from resources voted annually by Parliament. The clinical commissioning group draws down cash to cover expenditure, as the need arises. The clinical commissioning group is not, therefore, exposed to significant liquidity risks.

10.2 Financial assets Loans and Loans and 2017-18 2016-17 £'000 £'000 Receivables: · NHS 4,916 1,323 · Non-NHS 419 249 Cash at bank and in hand 169 298 Other financial assets 1 11 Total at 31 March 5,505 1,881

10.3 Financial liabilities Other Other 2017-18 2016-17 £'000 £'000 Payables: · NHS 11,184 17,724 · Non-NHS 36,443 28,767 Total at 31 March 47,627 46,491

14 NHS East and North Hertfordshire CCG - Annual Accounts 2016-17

11 Operating segments

Healthcare costs are attributed to localities as shown below. Transformation schemes, running costs and other costs which cannot be attributed directly to localities are charged centrally.

2017-18 2016-17 Net Net expenditure expenditure £'000 £'000 North Hertfordshire locality 138,769 134,523 Lower Lea Valley locality 92,880 90,119 Stevenage locality 113,357 109,543 Welhat locality 133,148 128,730 Upper Lea Valley locality 135,650 132,052 Stort Valley & Villages locality 65,228 63,323 Total 679,032 658,290

11.1 Reconciliation between Operating Segments and SoCNE 2017-18 2016-17 £'000 £'000 Total net expenditure reported for operating segments 679,032 658,290 Reconciling items - Central Budgets 44,962 50,129 Total net expenditure per the Statement of Comprehensive Net Expenditure 723,994 708,419

15 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

12 Pooled budgets

The clinical commissioning group has entered into a pooled budget with Hertfordshire County Council, Herts Valleys Clinical Commissioning Group, and Cambridgeshire and Peterborough Clinical Commissioning Group. The pool is hosted by Hertfordshire County Council.

Under the arrangement funds are pooled under Section 75 of the NHS Act 2006 for the commissioning of services as follows: mental health, learning disabilities, child and adolescent mental health, integrated health and social care community equipment service, residential and nursing care in a number of care homes, social care services complementary to the NHS. The pooled budget only includes that expenditure over which the partners have joint control.

The clinical commissioning group's share of the income and expenditure handled by the pooled budget in the financial year were:

Mental Health, Learning Protection of Social Care Disabilities & CAMHS Equipment Service Intermediate Care Services Total CCG Total Pooled- CCG Total Pooled- CCG Total Pooled- CCG Total Pooled- CCG Contribution Budget Budget Budget Budget 2017-18 2017-18 2017-18 2017-18 2017-18 2017-18 2017-18 2017-18 2017-18 2017-18 £000 £000 £000 £000 £000 £000 £000 £000 £000 Original Contribution 336,582 73,900 5,745 1,395 6,225 2,934 17,904 13,980 92,209 Expenditure and revised contribution 336,528 73,851 5,074 1,232 4,923 2,069 17,904 13,648 90,800 54 49 671 163 1,302 865 0 332 1,409

Original Contribution 323,022 71,528 6,745 1,643 6,409 3,042 17,904 17,904 94,117 Expenditure and revised contribution 322,836 71,442 5,646 1,376 6,533 3,033 17,904 17,904 93,755 186 86 1,099 267 (124) 9 0 0 362

16 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

13 Related party transactions

Details of related party transactions with individuals are as follows:

During the year, other than that declared below, none of the Department of Health and Social Care Ministers, clinical commissioning group Governing Body members or members of the key management staff, or parties related to any of them, has undertaken any material transactions with the clinical commissioning group.

A number of local GPs were members of the CCG's Governing Body. Details of payments made by the CCG to their practices and related parties disclosed by the GPs and other Governing Body members were as follows:

Receipts Amounts Payments to from owed to Amounts due Related Related Related from Related Party Party Party Party £'000 £'000 £'000 £'000

Regal Chambers Surgery - Dr. F Sinclair 109 0 0 0 Church Street Surgery - Dr. N Williams 142 0 10 0 The Limes Surgery - Dr. M Andrews 88 0 12 0 The Maples Surgery - Dr. A Jackson 122 0 3 0 Bridge Cottage Surgery - Dr. H Pathmanathan 199 0 31 0 Garden City Practice - Dr S Gupta 114 0 7 0 Stanmore Medical Group - Dr. P Moodley 532 0 11 0 Chells Surgery - Dr. R Hall 193 0 10 0 Central Surgery - Dr. D Kearns 223 0 0 0 South Street Surgery - Dr. N Shukur 277 0 31 0 Wrafton House Surgery - Dr. A Shah 131 0 20 0 Stanhope Surgery - Dr. H Bolat 65 0 5 0 Portmill Surgery - Dr. T Belcher 87 0 17 0

The following payments were made to the organisation below where the spouse of a GP Governing Body Member is a Partner in that organisation:

Mills & Reeves 35 0 1 0

The following are payments for services procured from GP Federations of which GPs were shareholders.

Ephedra Healthcare Limited 355 0 53 0 Generating Health Limited 450 0 121 0 12 Point Care 245 0 24 0 Lea Valley Health 324 0 0 6 Stort Valley Health Care Ltd 166 0 19 0

These payments were made in the normal course of business and Governing Body members had no direct control over them.

The Department of Health and Social Care is regarded as a related party. During the year the clinical commissioning group has had a significant number of material transactions with entities for which the Department is regarded as the parent organisation. The clinical commissioning group has adopted a disclosure level of £5million in 2017-18 and these entities are listed below. In addition, the clinical commissioning group had a number of material transactions with other government departments and other central government bodies. Where appropriate, these entities have also been reflected in the list below:

East & North Hertfordshire NHS Trust East of England Ambulance Service NHS Trust Hertfordshire Community NHS Trust North Middlesex University Hospital NHS Trust The Princess Alexandra Hospital NHS Trust Cambridge University Hospitals NHS Foundation Trust Royal Free London NHS Foundation Trust University College London Hospitals NHS Foundation Trust Hertfordshire County Council

Comparators for 2016-17 are shown on the following page.

17 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

13a Related party transactions (2016-17)

Details of related party transactions with individuals are as follows:

Amounts Amounts Payments to Receipts owed to due from Related from Related Related Related Party Party Party Party £000 £000 £000 £000

Birchwood Surgery - Dr. R Graham 164 0 2 0 Regal Chambers Surgery - Dr. F Sinclair 138 0 3 0 Church Street Surgery - Dr. N Williams 151 0 0 0 The Maltings Surgery - Dr. S Kite 13 0 0 0 The Limes Surgery - Dr. M Andrews 57 0 0 0 The Maples Surgery - Dr. A Jackson 57 0 11 0 Bridge Cottage Surgery - Dr. H Pathmanathan 100 0 1 0 Garden City Practice - Dr S Gupta 54 0 1 0 Stanmore Medical Group - Dr. P Moodley 125 0 0 0 Chells Surgery - Dr. R Hall 114 0 0 0 Central Surgery - Dr. D Kearns 125 0 8 0 South Street Surgery - Dr. N Shukur 162 0 6 0 Wrafton House Surgery - Dr. A Shah 78 0 0 0 Warden Lodge Surgery - Dr. E Bosonnet 67 0 0 0

The following are payments for services procured from GP Federations of which GPs were shareholders.

Ephedra Healthcare Limited 331 0 0 0 Generating Health Limited 407 0 0 0 12 Point Care 306 0 28 0 Lea Valley Health 353 0 43 0 Stort Valley Health Care Ltd 204 0 46 0

These payments were made in the normal course of business and Governing Body members had no direct control over them.

The Department of Health and Social Care is regarded as a related party. During the year the clinical commissioning group has had a significant number of material transactions with entities for which the Department is regarded as the parent organisation. The clinical commissioning group has adopted a disclosure level of £5million in 2016-17 and these entities are listed below. In addition, the clinical commissioning group had a number of material transactions with other government departments and other central government bodies. Where appropriate, these entities have also been reflected in the list below:

18 NHS East and North Hertfordshire CCG - Annual Accounts 2017-18

14 Events after the end of the reporting period

This clinical commissioning group has been approved under delegated commissioning arrangements which mean that it will assume full responsibility from 1 April 2018, for decisions relating to the commissioning, procurement and management of Primary Medical Services contracts such as enhanced services and local incentive schemes. The new primary care co-commissioning arrangements are part of a series of changes set out in the NHS Five Year Forward View.

15 Financial performance targets

The clinical commissioning group has a number of financial duties under the NHS Act 2006 (as amended). The clinical commissioning group performance against those duties was as follows:

2017-18 2017-18 2016-17 2016-17 Target Performance Target Performance £'000 £'000 £'000 £'000

Expenditure not to exceed income (Note 1) 741,333 736,973 735,291 720,592 Capital resource use does not exceed the amount specified in Directions 1,121 1,114 1,827 1,826 Revenue resource use does not exceed the amount specified in Directions (Note 1) 728,347 723,994 723,117 708,419 Capital resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 0 0 Revenue resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 0 0

Revenue administration resource use does not exceed the amount specified in Directions 12,709 10,785 12,648 11,015

Note 1

In prior years the Revenue Resource Limit was calculated as a cumulative amount. This meant that any underspend from one year was carried forward and included in the limit for the following year. From 2017-18, NHS England amended the way in which the limit is determined such that it now excludes any prior year underspends. Had the resource limit been calculated on a consistent basis to the prior year, the target for Income and Expenditure and Revenue Resource use would have been £14.498m higher, with the underspend increasing by a corresponding amount.

The clinical commissioning group's cummulative underspend and resources available in the future are £18.851m made up of the following: £m 2016-17 brought forward underspend not released for spending 14.498 In-year underspend 4.353 Total cummulative underspend 18.851

19 Agenda Item No: 9

Date of Meeting: 24th May 2018

Governing Body Meeting in Public

Paper Title: Governance and Audit Committee Annual Report 2017-18

Decision or Approval Discussion Information

Report author: Linda Farrant, Chair Governance and Audit Committee

Report signed off by: Governance and Audit Committee

Executive Summary: The Audit Committee has prepared an annual report which includes information provided by Internal Audit, External Audit and other assurance providers, advising the Governing Body on the adequacy and effectiveness of the CCG’s systems of internal control and its arrangements for risk management, control and governance processes. The attached Annual Report of the Governance and Audit Committee was approved at the meeting on 16 May 2018.

Recommendations . To note the annual report to the members:

Conflicts of Interest . There are none identified. involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Page | 1 East and North Hertfordshire Clinical Commissioning Group Governance and Audit Committee Annual Report 2017/18

1. Introduction

The Committee’s principal function is to advise the Governing Body on the adequacy and effectiveness of the CCG’s systems of internal control and its arrangements for risk management, control and governance processes.

In order to fulfil this function, the Audit Committee prepares an annual report for the Governing Body and Accountable Officer. This report includes information provided by Internal Audit, External Audit and other assurance providers.

2. Audit Committee’s Opinion

The opinion of the Audit Committee, based on the issues set out later in this report, is that adequate assurance can be given to the Governing Body on the effectiveness of the risk management and control processes in place during 2017/18.

3. Information Supporting Opinion

3.1 Internal Audit

Internal Audit services are provided by RSM. The Internal Audit Programme for 2017/18 focused on the CCG’s major risks and was drawn up in consultation with the Audit Committee and Executive Team. At each meeting the Committee considers progress against the audit plan and the level of assurance that has been provided by each review. The completion of the internal audit programme enables the Head of Internal Audit to provide an annual, independent opinion on the adequacy and effectiveness of the systems over governance, risk and control. The annual opinion of the Internal Auditor was presented to the Audit Committee on 16 May. It stated that:

“Based on the work undertaken in 2017/18, the organisation has an adequate and effective framework for risk management, governance and internal control. However, our work has identified further enhancements to the framework of risk management, governance and internal control to ensure it remains adequate and effective.”

A summary of the audits and opinions given is shown in Appendix A and as you can see, there were no negative assurances given during the year.

It is encouraging to note that all the audits received a positive assurance level again this year. There were several Reasonable Assurance levels. Of note are the two audits on financial planning and delivery including QIPP: the first audit on financial planning received a Reasonable Assurance rating whilst the second audit, undertaken later in the year, on financial plan delivery, received a Substantial Assurance rating reflecting the largely successful delivery of the QIPP programme. Given the level of risks involved in the delivery of the QIPP target of £23m, the Committee undertook a further Deep Dive into the progress and monitoring arrangements for the programme. Both the Committee and the Auditors were assured about the systems and the proactive approach taken, which resulted in a 96% achievement of the target.

Despite Continuing Healthcare (CHC) having been audited in previous years, the Committee asked for a further Advisory audit in light of the continuing overspend and demands on the

Page | 2 service. A number of opportunities for improvements have emerged from the audit which, once implemented, should improve both the value for money and delivery of the CHC service.

As required by NHS England, the Internal Auditors again audited Conflicts of Interest this year. Whilst this only achieved a Reasonable level of assurance, it is fair to say that improvements continue to be made in both the CCG’s approach and management of Conflicts of Interest.

The Committee will continue to monitor the implementation of the recommendations from these audits as it does for all audits, via its Tracker report to ensure that weaknesses are addressed. The Internal Auditors follow up medium and high actions in the following year to ensure recommendations have been implemented.

The Committee undertook another assessment of the effectiveness of Internal Audit. Overall, the outcome was positive with improvements demonstrated from last year’s review.

3.2 External Audit

BDO are the newly appointed External Auditors for the CCG following a competitive procurement process last year. They have been planning the audit of the 2017/18 Annual Report and Accounts, including an interim audit in January where no issues were identified. On 16 May 2018, the Committee reviewed the Annual Report and final Accounts including the Governance Statement and recommends them to the Governing Body for approval. The Committee also reviewed the audit progress report on the Annual Report and Accounts from BDO who identified no significant issues to date. A final report will be issued prior to the Governing Body meeting on 24 May 2018 when a verbal update will be provided.

3.3 Financial Reporting

Given that the Governing Body regularly reviews the management accounts, the Committee focuses on a review of finance risks at each of its meetings. This continues to provide a useful analysis for the Committee during the year.

3.4 Quality Committee

The Quality Committee provides an assurance report to the Audit Committee setting out areas of concern, emerging risks and actions to address them in relation to clinical governance. The Committee continues to find this a valuable assurance report.

3.5 Strategic Risks

The Committee has regularly reviewed the Strategic Risk Report and principal operational risks and supported the development of a new Assurance Framework and Corporate Risk Register to be implemented during 2018/19.

Given the WannaCry cyber security attack affecting the NHS earlier in the year, the Committee undertook a Deep Dive into HBLICT’s data security arrangements especially as the CCG is the host provider of ICT services for Hertfordshire, Bedfordshire and Luton. We discussed with the Chief Finance Officer and Director of HBLICT the approach and steps taken to manage the cyber security threat, challenging them on compliance with the outcomes of the National Audit office report on the WannaCry attack. The Committee noted that there was minimal impact on our ICT services from the attack because of HBLICT’s robust systems and processes.

Page | 3 3.6 Local Counter Fraud Service (LCFS)

The LCFS is also provided by RSM and they have reported regularly on progress against the workplan for 2017/18. Regular profile-raising of fraud and presentations to staff continue to take place.

4 The Role and Operation of the Audit Committee

4.1 Membership of the Committee.

The members of the Committee have remained stable. Attendances during 2017/18:

Linda Farrant 5/5 Nicky Williams 4/5 Dianne Desmulie 5/5

The Committee is supported by the Governance Team. It is also attended by the Chief Finance Officer, Board Secretary, Corporate Governance Manager, Internal Audit and External Audit. Other Directors and staff attend to present reports, as necessary.

4.2 Operation of the Committee

The Committee has met 5 times during the year and has followed an agreed business cycle. As well as regularly reviewing Finance and Strategic Risks, the Committee receives regular reports from Internal and External Audit, LCFS, Quality Committee, policies for approval, and reports relating to other legal and governance matters including the Declarations of Interest Register. It has also reviewed and scrutinised the Annual Report and Accounts for 2017/18.

The Committee has again undertaken a self-assessment of its effectiveness. Committee members and the Auditors continue to feel that the Committee is performing well, with robust debates and challenges of risk and internal control issues. In light of this, the Committee has agreed, with the support of the Auditors, to reduce the number of meetings to four during 2018/19 as agreed with the Governing Body as part of the recently revised governance arrangements for the CCG.

5 Conclusions

The Committee has successfully discharged its functions throughout the year and in so doing can confirm that in its opinion adequate assurance can be given to the Governing Body on the effectiveness of the risk management and control processes for 2017/8.

6 Recommendations

The Board is asked to note this report.

Linda Farrant Chair, Governance and Audit Committee

Page | 4 Appendix A

Summary of Internal Audit Reports and their opinions for 2017/18

Subject of Completed Audits Assurance Level Conflicts of Interest Reasonable Delivery of the Integrated Urgent Care service Reasonable QIPP and Financial Planning Reasonable Delivery of Financial Plan (including QIPP) Substantial Risk Management and Assurance Substantial Key Financial Controls Substantial Delivery of IAPT Substantial Business Continuity Planning (including HBLICT) Substantial Prescribing – Delivery of QIPP schemes Substantial GDPR Compliance Advisory Effectiveness of Continuing Healthcare arrangements Advisory

The Internal Audit definitions of the Assurances are:

Substantial Taking account of the issues identified, the Board can take substantial assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and operating effectively.

Reasonable Taking account of the issues identified, the Board can take reasonable assurance that the controls to manage this risk are suitably designed and consistently applied. However, we have identified issues that need to be addressed in order to ensure that the control framework is effective in managing the identified risk.

Partial Taking account of the issues identified, the Board can take partial assurance that the controls to manage this risk are suitably designed and consistently applied. Action is needed to strengthen the control framework to manage the identified risk.

None Taking account of the issues identified, the Board cannot take assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied or effective. Urgent action is needed to strengthen the control framework to manage the identified risk.

Page | 5 Agenda Item No: 10 Date of Meeting: 24th May 2018

Governing Body Meeting in Public

Paper Title: Locality Committee Annual Report 2017-18

Decision or Approval Discussion Information

Report author: Alison Ryan, Head of Locality Commissioning and Service Integration Report signed off Harper Brown – Director of Commissioning by:

Executive This paper describes the progress on locality commissioning Summary: & development over the last 12 months. There have been developments in integrated working and taking forward locality priorities which are summarised for each locality, as well as the broader STP Place Based Care work under the E & N Herts Delivery Board. Some of the achievements and new initiatives achieved by localities are also summarised within this paper as well as the issues and challenges. Finally an overview of the financial and quality position of each locality is provided, as well as a series of recommendations.

Recommendations to the members: The governing body are asked to note this progress and support the recommendations.

Conflicts of Interest There is a potential indirect financial interest to governing involved: body members and practice partners who chair or sit on locality committees as these committees can influence commissioning decisions.

Page | 1 Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Direct (or personal) A direct financial interest is one where there is or appears to financial interest be opportunity for personal financial gain or financial gain to close family members, close friends and associates, and business partners (dependent on the circumstances and the nature of such relationships). Indirect (or non- An indirect financial interest involves payment or other benefit personal) financial to a department or organisation in which the individual is interest employed or otherwise engaged but which is not received personally. Non-financial A non-financial interest is one where there is or appears to be interests an opportunity for non-financial gain (e.g. status), or where an individual’s decision making is or could be compromised for example due to a conflict of loyalty.

1. Background Governing Body received the last report on 20 July 2017. At that time, for some localities the development of the Integrated (Provider) Care Delivery Boards were just developing, with first meetings being planned. For other localities, new governance structures had been agreed and significant progress made in locality working.

There have not been significant changes over the past 12 months on the structural front in localities. The Governing Body carried out a review in November 2017 and set up two Task & Finish Groups which made recommendations that are now being implemented from April 2018. A major change for the 2018-19 period is that the CCG formally moved to delegated commissioning of Primary Care. The Constitution of the CCG was revised in line with this development, and the Terms of Reference for the Locality Commissioning Committees (LCC) were revised as part of that formal process. An independent Primary Care Committee has also been established.

The role of GP Leads was reviewed by the Governing Body and re-developed such that each locality now has a Locality (Clinical) Lead GP who holds responsibility for the oversight and leadership of localities as well as the performance and quality of primary care in the localities. The development of sustainable and integrated primary & community services are seen as a key element of the work of the localities, and related to this, the delivery of sustainable primary care services, all key elements of the CCG objectives.

Page | 2 Within the STP structure, the East and North Herts Delivery Board has continued throughout the year, reporting in to the Place Based Care STP Work Stream. This group has responsibility to unblock inter-organisational problems to ensure integrated working across organisations is supported as a system. Operational issues are unblocked where possible and sharing of good practice takes place in the Operational Delivery Group meeting.

As part of the Place Based STP Work Stream, the STP commissioned an Independent Consultant, Joe Gannon to review the localities working across all three CCGs. The report found that there were many examples of excellent work taking place within localities and in East and North Herts he observed that in general localities were struggling with implementation due to capacity constraints and expressing associated frustration.

There was significant work still to do in relation to a number of key elements of localities across the STP. These included leadership, organisational development, workforce, system levers (with IM&T described as a significant block and with limited progress perceived at a locality level), and little evidence of a move to delegated resource. While common populations were generally clear there was limited understanding of populations at neighbourhood level. The report also summarised locality working and place based care across Herts Valleys and West Essex with similar themes being found across the STP footprint. While the STP response to this document is not yet clear, it is nonetheless a useful summary for the CCG in working with stakeholders across localities, and taking forward clear plans to support the localities in making progress.

The Terms of Reference of the Locality Commissioning Committee (LCC) in the CCG Constitution make reference to a Memorandum of Understanding (MOU) which is being developed as a framework for localities working. The purpose of the MOU is firstly to work alongside the Terms of Reference of the CCG Constitution and to describe in detail the duties of the Locality Commissioning Committee, across the broad areas of commissioning, primary care, integrated working and enablers. More broadly the MOU has the goal of providing a framework for the locality to support place based care, and integrated working.

The MOU proposes that the Integrated Care Delivery Board (ICDB) is a sub- committee of the LCC, reporting in to the LCC. It is proposed that the delivery of integrated working is delegated to the ICDB. As the ICDB develops in maturity it is anticipated that more of the duties of the LCC, are as appropriate, delegated to the ICDB.

Page | 3 The MOU also proposes a solution to the lack of administrative, project management and transformation management resource which localities are experiencing as a block to more rapid progress. A resource allocation equally split by providers is proposed to address this gap. The MOU is in the final stages of collaborative development and will then be submitted for internal CCG approval and also system wide approval by all CEOs and AOs.

The minutes of each meeting across each locality and the associated governance processes related to formal approval of the minutes are summarised in Table 1.

Table 1 2017-18 Minutes Locality Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Notes No Comm sent No Comm No Comm Council of No Comm No Comm Council of No Comm No Comm Council of Sent Meeting 16.05.18 LLV Meeting Meeting members Meeting Meeting Members Meeting Meeting Members 18.04.18 (TARGET) Sent Sent Sent Sent No Comm Sent Sent Sent Sent Sent Sent Sent Stevenage 15.12.17 15.12.17 15.12.17 15.12.17 Meeting 15.12.17 15.12.17 15.12.17 14.05.18 14.05.18 08.05.18 14.05.18 Sent Sent Council of Sent No Comm Council of No Comm Sent to Gov Council of Sent No Comm Council of 4 LCC and 4 18.05.17 13.07.17 Members & 09.11.17 Meeting. Members Meeting Team Members 08.05.18 Meeting Members CoM held. TARGET (TARGET) 07.03.18 (TARGET) Provider ULV Board No Comm No Comm Council of No Comm No Comm Council of No Comm No Comm Sent No Comm No Comm Council of One meeting Meeting. Meeting. Members Meeting Meeting. Members Meeting. Meeting 08.05.18 Meeting. Meeting Members & monthly - Provider Provider (TARGET) Provider Provider (TARGET) Provider (TARGET) Provider Provider Board only Board only Board only Board only Board only Board Board meetings were held SVV on the Sent Sent Council of Sent Sent Council of Sent Sent Council of Sent Awaiting Council of North Herts 01.09.17 23.10.17 members 23.10.17 27.11.17 Members 27.11.17 15.03.18 Members 15.03.18 Approval Members Sent No Comm Council of Sent No Comm Sent Sent No Comm Council of Awaiting Awaiting Council of WelHat 23.10.17 Meeting members 23.10.17 Meeting 27.11.17 15.03.18 Meeting Members Approval Approval Members

No Commissioning Meeting took place Written, but waiting approval at the next meeting Written and approved, waiting for Governace team to request them Sent to Governance Team Council of Members Commissioning Meetings

This summary table illustrates the variability across localities during the past 12 months in the degree to which formal Locality Commissioning Meetings took place and in some localities it was provider boards that met.

The revised and now formally approved Terms of Reference for these two new meetings provides clarity on the expectations of localities in relation to formal meetings, and the governance process. The MOU adds further detail in terms of the framework within which localities need to operate.

Page | 4 2. Locality Update: A summary of the key achievements and issues experienced by each locality over the last 12 months is provided below.

2.1 Upper Lea Valley

In terms of locality specific areas of priority, Upper Lea Valley have been focusing throughout the year on a number of locality priorities, including care homes working and community frailty. Care homes and the growth of new housing are a significant challenge for the locality. They have used locality funds to employ a GP working in their local frailty services, which has been in place since October 2017. An enhanced primary mental health pilot is also being trialled within this locality, evaluating the impact of placing secondary care mental health staff in primary care, to support more rapid and effective triage.

The use of social prescribing across this locality has been well embedded. A number of ‘quick wins’ in relation to care home working have been implemented, and the locality is exploring options around developing a wrap around team to support resident of care homes in a more integrated and proactive approach.

Two parts of the locality have been involved in a successful 100 day challenge during the year. This is an approach working on the ground with staff and teams which has been used successfully elsewhere in the country. The goal has been that of culture change and fostering integrated and different ways of working across organisations that support the needs of elderly patients with complex social & clinical needs in the locality.

Feedback from the teams involved was extremely positive for this approach as a form of culture change for staff on the ground. Integrated multi-disciplinary team working, across provider organisations was embedded and found to be valuable. The work of this locality and particularly the use of the 100 day challenge as a vehicle has shown the benefits of empowering and supporting integrated working across organisational boundaries. The learning in relation to the 100 day challenge is being reviewed, in terms of what can be taken forward across this and other localities. The areas of learning appear to be in relation not only to culture change, but also to integrated care planning, promoting the use of personal health budgets, sharing of professionals’ directories and health care records, and triage processes.

The CFF for 2017-18 supported this approach and ULV locality completed 2,337 new care plans with 911 for severe EFI, 1,108 moderate and 318 mild.

2.2 Welwyn and Hatfield

Welwyn and Hatfield have had a number of commissioning and some provider meetings throughout the year attended by all practice representatives, with the aim

Page | 5 of building engagement and support for the concept of integrated locality working. Agreement was reached during the year amongst primary care staff that their voice would be represented by two GPs and one practice manager colleague at the Integrated Care Delivery Board. The focus of the locality at these meetings has thus far been on the community frailty services. The locality has been hindered by having no dedicated project or transformation support, no administrative support and no involvement by the nominated provider senior manager role.

More recently there has been agreement for some project management input, and a data drill down is being undertaken to identify a key focus to support collaborative working.

At primary care level, a working group has been developed working alongside Ephedra for the locality Federation, to plan and provide the Extended Access Service for Welwyn and Hatfield. The take up and impact is being measured as part of the project. This is serving not only as a valuable part of extending the access to primary care, but also as a combined project for the locality to work on jointly, with good engagement from all practices.

WelHat locality completed 2,191 care plans as part of the CFF 2017-18, 1,066 severe patients, 650 moderate patients and 475 mild patients.

2.3 Lower Lea Valley

Given the four way patient flows to Acute Care in this locality, the importance of continuity in patients care as well as fostering different and integrated ways of working in the community to support place based care has particular significance.

The locality has good links with Broxbourne Borough Council and is one of the advanced localities holding joint Health and Wellbeing Board meetings in the locality. This is particularly important as tackling childhood obesity is one of their key priority areas.

The locality has been focused on building a different way of working with dementia, and testing an enhanced primary care model for dementia care, alongside Healthy Memory Cafés, located in the local Tesco, and with the third sector and providers working together. These are being launched in May 2018, after considerable planning and will be evaluated in terms of impact.

The locality has also been scoping an integrated diabetes pathway, working with all partners and aiming to build a holistic and integrated dementia pathway. They have also trialled a whole system single care plan, called My Plan and following this trial will be taking forward the second stage which is a system wide single care plan for those who are frail and complex with multiple co-morbidities.

Page | 6 A significant challenge for this locality has been the lack of administrative and project management support to be able to take forward their plans. The locality has over the past 12 months been focused more on the development of integrated working and locality pathways. However the locality has now re-developed their locality commissioning committee meetings as well as continuing their integrated provider working.

The locality completed 2,156 new care plans as part of the 2017-18 CFF, 357 severe, 817 moderate and 988 mild patients.

2.4 Stevenage

Stevenage have undertaken a number of integrated pathways as a locality over the past 12 months that have made a positive difference to patients and activity reduction in A&E.

Following an analysis of COPD admissions, primary, secondary and acute care staff worked together to review the patients, provide self-management plans and use GSF meetings to discuss more complex patients. A new integrated pathway was developed. The project was positive evaluated and COPD emergency admissions declined by 12%. There are future plans in place for the locality regarding COPD and this work has built the working relationships and confidence of the locality to make positive changes.

Other work in the locality has taken place in relation to UTIs. The locality is also in the midst of trialling a primary mental health model, with rapid primary based care triage, brief intervention and signposting taking place with mental health staff being based in primary care. The results thus far are suggesting positive patient experiences, with rapid and responsive services, and ensuring that the right people are being seen within the secondary mental health services.

One of the challenges for the locality has been the support needed to drive forward some of these changes, with resourcing issues in the CCG locality management team, and limited support roles provided across providers.

Stevenage locality completed 1,849 new care plans for EFI patients, 818 severe, 753 moderate and 278 mild. They believe this contributed to the reduction in A&E attendances and Non –Elective emergency admission reductions in 2017-18.

2.5 Stort Valley and Villages

Stort Valley and Villages have recently recruited a new Locality (Clinical) Lead GP and are in the process of recruiting other locality lead posts for particular clinical areas. Their meeting structures have been re-shaped and are now comprising two

Page | 7 meetings – the Locality Commissioning Committee meetings, and the Integrated Provider Delivery Boards.

The locality has been focused on promoting culture change and building relationships and engagement across all providers. An example of the impact of this engagement has been the significant improvement in the financial performance of the locality with a very significant decline in the acute overspend. This has been achieved by all practices actively working together and a fully joined up approach in working with their rapid response team.

A further example of the engagement within the locality has been the role of a senior manager in HCT who has been working to support staff across HPFT and HCT. This has facilitated positive changes, e.g. the development of multi-disciplinary teams across organisations. It has also highlighted some of the practical difficulties in moving forward at pace with these changes in the current landscape of governance and individual accountability of provider organisations.

One of the key challenges for the locality is the very significant expansion in the locality population, with phase 1 in progress of what will ultimately be close to 3000 new houses. NHSE have been delayed in giving formal confirmation to the locality of the full funding of the Herts and Essex Hospital co-location plans. This creates challenges in implementing these plans within the required time frame. Given the size of the increase, the practices within the locality have also raised the need for a broader premises plan with expansion of the north and south branches to meet the needs. This is an issue for the locality both in terms of meeting the needs of the growing population, but also maintaining the engagement with the locality.

SVV locality completed 1,395 new care plans as part of the 2017-18 CFF, 490 severe, 483 moderate and 422 mild.

2.6 North Herts

This locality has had some GP leadership changes during the past 12 months and has maintained momentum and energy with some significant achievements. The Locality Commissioning Meetings have been taking place, and the ICDB has been in place since December 2017.

The locality has been reviewing the new community frailty model and is currently exploring options for multi-disciplinary falls and frailty services. The Hospice has employed two Frailty Nursing Posts, funded by GPFV and working closely with HCPA, HCT, HPFT, Care Home pharmacists and dieticians.

The local federation won the tender to run The Sollershott surgery, which had documented quality concerns. Within Hitchin, Orford Lodge and Courtenay House surgeries have merged, with a view for the other two practices to join later. One of

Page | 8 the challenges for the locality remains that of IT - not all practices use SystmOne, and many of the plans for integrated working require as a cornerstone IT systems that are interoperable.

The progress of the locality has also been impacted upon by the capacity of the CCG Locality Management Team to meet its needs, in addition to challenges in provider based capacity around project management and administrative capacity. Practices have engaged well with the medicine optimisation leads and have welcomed the support and help of in-practice and care home pharmacists to implement initiatives.

North Herts locality completed 1,748 new care plans as part of the 2017-18 CFF with 1,129 severe, 515 moderate and 104 mild.

3. Finance

Table 2 summarises the overall financial position of each locality. A major achievement of this year is that all localities achieved financial balance for the financial year 2017-2108.

Although each locality remained overspent on acute spend, there were significant decreases in the amount of overspend across localities, with a notable reductions in acute activity and improvement in acute underspend achieved by Stort Valley and Villages. The CCG utilised some of the centrally held underspends to support the localities in achieving financial balance. The financial balance was also supported by some community services underspent.

Table 2

East & North HertsCCG Overall Financial Position by Locality 2017-18 £'000 North Lower Lea Stevenage WelHat var Upper Lea SVV Var Centrally Total Var Service Area Herts Var Valley Var Var Valley Var Held Var Acute 1,383 464 1,023 1,812 1,375 292 (935) 5,414 Non-Acute 488 221 353 (142) 183 35 (342) 797 Primary Care (392) 391 (261) (145) (42) 47 (1,393) (1,795) Management Costs (23) (14) (14) (14) (1) (12) (801) (879) Redistribution of Non Acute & primary Care Budget from unattributable (854) (571) (698) (818) (834) (403) 4,178 0 Contingency (738) (493) (594) (703) (723) (350) (8) (3,609) Winter Resilience 0 0 0 0 0 0 (706) (706) Transformation reserve 0 0 0 0 0 0 (3,575) (3,575) Planned Underspend 0 0 0 0 0 0 (14,498) (14,498) Total Spend (135) (2) (191) (10) (42) (391) (18,080) (18,851)

4. Primary Care

Nearly all member practices are part of a GP Federation. Three out of the six federations are currently delivering primary medical services under APMS contracts. The remaining three federations will be delivering services under new APMS contracts by October 2018 (Extended Access Primary Care). Two localities have

Page | 9 been accepted as members of The Primary Care Home. Four localities have projects being supported through the ETTF and /or GPRP, which will see new primary care hubs serving populations of up to 60,000.

There have been three practice mergers in the past two years – which has resulted in one practice now with a list size of c. 37,000, one of these mergers took place last year Courtney House and Orford Lodge

The Hertfordshire and West Essex STP has developed an ambitious record sharing strategy called ‘My Care Record’; GP records in a number of localities are currently being shared with the local acute hospital trust or with other GP practices as part of the new Extended Access Primary Care Service.

All localities have developed plans to invest the £3 per patient transformation money 17-18 and 18-19. The CCG is supporting localities with this work to ensure that the money is fully invested and has established a governance process to ensure that the necessary criteria are met.

The CCG has 6 cohort 2 ETTF schemes approved in principle and progressing.

The CCG has delivered Workflow Optimisation training for all practices and the first Active Signposting & Social Prescribing workshop for practices took place in April.

The CCG is currently recruiting a project manager to implement Online Consultation. The CCG, as part of its workforce education and development plans, has a training programme for practice managers, which covers team leadership and development. Three cohorts of practices have already completed the Productive General Practice programme.

East and North Herts CCG was a Care Homes Vanguard site, a key element of this being the utilisation of pharmacists in care homes. The success of this work has been recognized nationally and helped shape integrated service framework development.

CCG transitioned to ‘delegated’ commissioning of primary medical services 1 April 2018 and has completed a rigorous governance /due diligence process as part of this. There are multiple individual practices in E&N Herts CCG benefitting from GP Resilience Programme GPRP support from 16-17 and 17-18, there are also two groups of practices receiving ‘proactive STP support’ in 17-18 and an STP application will be submitted for 18-19 funding for the full indicative amount.

Flu: The Governing Body incentivised localities to develop their own flu plans and improve overall up take across all cohorts of patients. E & N Herts CCG had the best

Page | 10 performance of Midlands & East CCGs in achieving national flu targets and improved on the previous year’s performance in all categories.

5. Quality

The CCG Nursing and Quality Team, PMOT and Commissioning Teams working jointly with NHSE provided bespoke support to all practices that received a rating of either Inadequate or Requires Improvement, this support has translated to substantial practice improvement that has been reflected in re-inspection findings. At year end of those practices that had been reviewed 51 General Practices were rated as 'Good' by CQC with two practices in North Herts deemed to be 'requires improvement'.

Turning to providers, the ENHT was recently inspected by CQC, with the results expected in June. PAH was inspected in December 2017 and was rated as 'Requires Improvement'. As a result this Trust was moved from 'Special Measures'. HCT is expected a CQC inspection imminently and HPFT was recently inspected and again rated as 'Good'.

6. Consolidated Funding Framework (CFF)

The CFF is a tool used by the CCG to incentivise practice changes in primary care to improve patient outcomes and ensure the best use of limited resources, in line with CCG objectives. As suggested by the overall localities financial position, over the past 12 months the CFF appears to have been successful in reducing acute activity that could be appropriately managed in other ways. It should be acknowledged that it is difficult to be able to measure the specific effects of the CFF as it is one of multiple interventions that the CCG is using to manage activity and the best use of resources.

The impact of the specific aspects of the CFF and the learning is being reviewed currently, as the final payments for the last financial year are being calculated. The last three months of the financial year were spent in a collaborative planning process to plan the 2018-2019 CFF. There was a concerted attempt to engage with practice managers GP leads and other stakeholders in the new planning process, which was largely successful. The current CFF has a focus on incentivising primary care to engage in the collaborative localities working, with financial resources set aside for integrated collaborative working on locality priorities.

7. Medicines management PMOT :

Practices continue to engage well with the medicines optimisation team and their locality pharmaceutical adviser. They have welcomed the help and support of dedicated in-practice and care home pharmacists to implement initiatives that have released considerable spend on medicines for use elsewhere or otherwise improve the patient experience from medicines use and improve medicines safety.

Page | 11 In-practice pharmacists and care home pharmacists work in an integrated way and have developed good relationships with practices and provided a valuable resource to prescribers.

Practices have benefitted from support with high risk medicines monitoring aiming to further reduce medicines harm.

Full year financial outcomes for prescribing are not yet available and will be reported on within the next prescribing report to the Governing Body in July.

The latest data available regarding prescribing metrics (February 2018) is reported in the table below.

Of particular note is that localities have worked hard to meet the national antibiotic targets. These important targets aim to reduce antibiotic resistance – a key public health priority and success may also prompt a quality premium payment to the CCG

Page | 12 BLOOD QPa - All QPb Improved Improved GLUCOSE Improved ICS LABA Improved Improved Antibiotic Trimethoprim: on on TESTING on Inhalers on Sip Feeds on Prescribing Nitrofurantoin Previous Previous STRIPS Previous (Target Previous (Target £0.328) Previous (Target = Item Ratio Report? Report? Target Report? 55.0%) Report? Report? 1.161) (Target 0.933) (70.0%)

LOWER LEA 1.046 Y 0.560 Y 71.6% Y 74.4% Y 0.404 Y VALLEY

NORTH 0.945 Y 0.496 Y 75.2% Y 68.3% Y 0.272 Y HERTS

STEVENAGE 1.067 Y 0.657 Y 72.9% Y 70.6% Y 0.276 Y

STORT VALLEY & 1.035 Y 0.498 Y 57.7% Y 62.8% Y 0.228 Y VILLAGES

UPPER LEA 0.999 N 0.561 Y 63.6% Y 63.9% Y 0.286 Y VALLEY

WELWYN 1.069 N 0.607 Y 69.6% Y 64.2% Y 0.252 Y HATFIELD

ENHCCG 1.081 Y 0.566 Y 69.7% Y 67.3% Y 0.299 Y

Key 1.16 0.00933 0.70 0.55 0.328

Threshold not >1.161 >0.933 <70% <55% >£0.328 achieved

Threshold to Achieve ≤1.161 ≤0.933 ≥70% ≥55% ≤£0.328 Indicator

Highest achievement 0.33% 0.299 86% 94% £0.000 in CCG this month

Page | 1 Regular lead GP attendance at prescribing meetings remains key to developing implementing and sustaining consistent prescribing policy and their input is valued.

Practices in Welwyn and Hatfield, Stevenage and Upper Lea Valley, with the support of the medicines optimisation team, have submitted successful bids to NHS England to employ GP based pharmacists as part of the NHS England initiative within the Five Year Forward View to support the primary care workforce.

8. Overview and Issues

The review of the localities progress over the last 12 months shows a range of activity, with some evidence of real progress in achieving changes. As a general observation however there remains variation in the progress and the level of engagement across localities.

The progress over the past 12 months for many localities has been impacted by the lack of consistent supporting resource of project management, administrative support and transformation support. This in turn has for a number of localities resulted in a lack of clear plans, that contain explicit aims and objectives, time frames and documented evidence of impact and outcomes. Those localities where there has been most change has been largely because of individual commitment and energy to drive forward projects despite the limited resource and capacity. The resource issues for localities appear to be based across both the CCG resource, and the resource provided to localities by providers.

There also remains at locality level some continuing lack of clarity about which priorities are being taken forward at an STP level, which are being taken forward at CCG level, and for these what the 'ask' of localities is, and the 'freedom to act' at locality level. This is in some ways an inevitable consequence of the broader system change, with STP workstreams gathering momentum, and with the movement around locality working. However to move forward positively over the next 12 months, this needs to be resolved so that localities have a clear understanding.

The role of Federations also requires further development across some localities, as does the agreement on what are our neighbourhoods. There is further culture change required across localities, to engage front line clinicians in the concept of a different and integrated way of working, one which works with the whole community to shape place based care.

The CCG currently has 6 localities, with significant variation in population sizes. The current localities do not all map well to the District Councils, which creates its own challenge to integrated working. Some of the localities are currently discussing options such as bringing their Integrated Care Delivery Boards together across

Page | 1 localities. This will bring economies of scale, more opportunities to engage the relevant acute trust, and greater capacity to share learning and to roll out similar priorities more efficiently. It is anticipated that as this direction of change continues to progress, there will be some locality driven shift in the number of localities over the coming 12 months.

9. Mitigation

The need for greater resource to support localities in making more rapid progress will be addressed through the finalisation and implementation of the MOU. Localities will have then access to support staff (Project management, transformation and administrative) as well as the appropriate level of engagement from staff across providers. The CFF incentivises the involvement of primary care, which supports their engagement. Clarity will also be provided to localities via the MOU in relation to what is the ‘ask’ and the duties of the locality.

The culture change and engagement issue is one which is relevant across the entire STP. Clarity will be sought from the Place Based Work Stream on the plans at STP level to address this need.

The resource required to support localities from a CCG perspective will be addressed through a CCG re-view of overall resources required to support localities.

Localities will be provided with a planning template document and the support to use this to which will enable a more rigorous approach to monitoring, tracking and evaluating progress.

10. Recommendations

It is recommended that:

10.1 The Governing Body notes the progress in localities in 2017-18 and particularly the overall contribution to CCG QIPP and financial balance. 10.2 The CCG progress at pace with a review of the internal and external requirements to support localities by end of July 2018 10.3 The MOU is reviewed and approved for implementation within the CCG and more broadly by the CEOs and AOs across the system by end July 2018 10.4 Localities are tasked to review and agreed their neighbourhood structures by end June 2018. 10.5 A further internal review of localities progress is undertaken in early October 2018.

Page | 2 Agenda Item No: 11

Date of Meeting: 24th May 2018

Governing Body Meeting in Public

Paper Title: Public Engagement and Involvement strategy and action plan

Decision or Approval Discussion Information

Report author: Mark Edwards, Public Engagement Manager

Report signed off by: Dianne Desmulie, Lay Member for Patient Engagement

Executive Summary: We want to ensure that health and care services in East and North Hertfordshire reflect and respond to the needs and wishes of our population. The model of public engagement and involvement put in place at the CCG’s formation in 2012 now needs to be reassessed and refreshed to ensure we are meeting our duties in this respect. The attached paper reflects and reviews the recent audit and assessment procedures undertaken – including the recent NHS England IAF review of our public engagement function. These evaluations highlight clear areas of focus for the CCG’s engagement work: 1. demonstrate the impact of public engagement and involvement 2. improve communications and patient education, with a focus on developing digital and social media communication and engagement 3. enable and ensure the best possible contribution of public representatives to the CCG’s work 4. make our communications and information accessible and in plain English 5. ensure our engagement work is representative of our community. The resulting actions developed to address these areas have been associated to NHS England’s 10 areas of statutory guidance on public engagement. There is also a time line of activity for the year ahead Recommendations . We ask members to approve the attached strategy and action to the members: plan

Conflicts of Interest There are none identified involved:

Page | 1 Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Page | 2 1. Executive summary We want to ensure that health and care services in east and north Hertfordshire reflect and respond to the needs and wishes of our population. The model of public engagement and involvement put in place at the CCG’s formation in 2012 now needs to be reassessed and refreshed to ensure we are meeting our duties in this respect.

The attached paper reflects and reviews the recent audit and assessment procedures undertaken – including the recent NHS England IAF review of our public engagement function. This has highlighted the following areas of focus for the CCG’s engagement work: 1. demonstrate the impact of public engagement and involvement 2. improve communications and patient education, with a focus on developing digital and social media communication and engagement 3. enable and ensure the best possible contribution of public representatives to the CCG’s work 4. make our communications and information accessible and in plain English 5. ensure our engagement work is representative of our community.

The resulting actions developed within this strategy seek to address these areas, and have been linked to NHS England’s 10 areas of statutory guidance on public engagement. There is also a time line of activity for the year ahead, which the public engagement team will use as a means of reporting against in future reports to the Governing Body.

2. Background

Public involvement and engagement is a statutory requirement for Clinical Commissioning Groups as part of the Health and Social Care Act 2012. In addition there is a growing evidence base suggesting that patient and public involvement in the design and development of health services leads to better patient experience and outcomes.

The previous public engagement strategy has been out of date for some time, as identified by our auditors RSM. At the same time, feedback had been collated from NHS Engand’s assessment of our engagement function along with feedback collated from existing patient and Governing Body members. The collation of this feedback has enabled the public engagement team to develop the attached strategy and ensure the CCG meets its statutory requirements within this area.

3. Issues None identified.

4. Options

N/A

5. Resources implications There are currently no direct resource implications as part of this plan, but it is proposed that the engagement team look into the possibility of financially reimbursing public involvement in

Page | 3 sustained or intensive contributions to our work, which could lead to a need for additional financial contributions.

6. Risks/Mitigation Measures

There are none identified.

7. Recommendations

. We ask members to approve the attached strategy and action plan.

8. Next Steps (including when the decision will be reviewed)

Approval and then publication of the final strategy and action plan, to be shared with wider stakeholders.

Page | 4 Public Engagement and Involvement strategy and action plan 2018/19

This document will be made available in easy read and large print format. If you wish to request any additional formats please contact the CCG’s Public Engagement team on 01707 685 397 or email [email protected] Foreword Our new strategy has benefited from the views and input of current members of our patient participation groups. Our CCG has also gained insight into local views from our major ‘Time to Talk’ engagement this year, and the strong relationship which the Page | 2 engagement team has built with the Patient Network Quality and other patient member groups. The development of our Sustainability and Transformation Partnership (STP) and the challenges of encouraging effective patient self-care mean that listening to patient voices has become even more important. Hertfordshire’s strong voluntary sector has offered us more opportunities and insights into people’s needs and priorities as carers, patients and family members. I welcome this new strategy and plan as an ambitious and positive way to involve more local citizens in all stages of the commissioning process to help translate our plans into successful and fairer improvements for our population.

Dianne Desmulie Lay member for patient and public involvement East and North Hertfordshire Clinical Commissioning Group

Contents table Introduction 03 About East and North Hertfordshire Clinical Commissioning Group 04 Where we are now 05 Working within the Sustainability and Transformation Partnership 07 You said… 08 …What we will do 10 Adopting a new set of involvement principles 14 Action plan 15 Response from Healthwatch Hertfordshire 17 Appendix i: Our duty to engage 18 Appendix ii: Glossary 19 Introduction

East and North Hertfordshire Clinical Commissioning Group (CCG) is committed to putting the patient voice at the centre of our work and decision-making. Page | 3 Patients regularly tell us about the reality of using health and social care services in our area; including the quality of the care they receive, how things could be improved and their ideas for making health services easier to access and more efficiently delivered. We want to ensure that health and care services in east and north Hertfordshire reflect and respond to the needs and wishes of our population. The model of public engagement and involvement put in place at the CCG’s formation in 2012 now needs to be reassessed and refreshed to ensure we are meeting our duties in this respect. This strategy and action plan has been developed after listening to and discussing the thoughts and ideas of current public members of existing CCG patient groups and other stakeholders. It looks to: > foster a culture of engagement and involvement within the organisation > promote opportunities to voice thoughts/concerns/compliments from all of our communities > ensure that health inequalities are identified, considered and responded to within our decision making. About East and North Hertfordshire Clinical Commissioning Group

East and North Hertfordshire Clinical Commissioning Group (CCG) is the organisation responsible for commissioning (planning, designing and paying for) Page | 4 NHS services. The services commissioned by CCGs include: > planned hospital care > rehabilitative care > urgent and emergency care (including out-of-hours and NHS 111) > most community health services > mental health services and learning disability services > GP services (from 1 April 2018)

The CCG is made up of local GPs and health professionals, working together with other clinicians and patients, to decide how the local NHS budget of £724m should be spent. The CCG serves over half a million people (597,000) registered at 57 GP practices across east and north Hertfordshire. A map of east and north Hertfordshire and surrounding areas showing our locality areas, as well as key hospital locations used by our patient population is shown below. Where we are now

Governance Since the formation of the CCG there has been strong and effective public representation within the organisation’s governance arrangements. Along with the Page | 5 three lay members (for patient and public involvement, governance and audit and primary care commissioning) there is both a public and Healthwatch Hertfordshire representative sitting on our Governing Body. Regular reports on the public engagement function are provided to the Governing Body. This strategy and action plan seeks to meet the expectations of the Governing Body that the impact of public involvement in the CCG’s day-to-day work is clearly evidenced. There is public representation on the CCG’s Quality Committee, which assesses patients’ experiences and the performance of our health service providers. The Quality Committee is then closely linked to our ‘Patient Network Quality’ group, where this information is shared with public members and soft intelligence is reported back to staff who monitor patients’ experiences within our area. Further public representation will be sought for the new primary care commissioning committee, following the recent decision by the CCG’s member practices to undertake delegated commissioning of primary care in east and north Hertfordshire. Public involvement Our public involvement work has been built on a network of patient members recruited from our GP practices’ patient participation groups. The CCG regularly meets with public representatives of 44 of the 57 GP practices in the area, which make up almost 100 ‘patient members’ across our population. We meet with these groups to hear and gather intelligence and views of local communities, and also inform and educate our local population about the issues facing local health and care services. Patient members have made a massive contribution, both to the CCG’s decision making and work, but also the health and wellbeing of their individual communities. For example: > volunteers regularly contribute to quality assurance visits to local health service providers and record patients’ stories to highlight examples of good and bad care, > volunteers developed and provided award-winning self-care education events for people living with type 2 diabetes and their carers, > volunteers have undertaken research into patients’ needs and fed into service design and procurements, such as the recent procurement of out-of-hours urgent care services, > patient groups support their practices to identify family and friend carers and provide appropriate support services for them. Page | 6 Equally there are clear challenges that we have identified, including: > patient participation groups are typically small in size and struggle to recruit new volunteers, > patient participation groups are not always representative of their wider community, > it can be difficult to communicate with patient members and/or the wider population, > there is a reluctance from some GP practices to engage effectively with their patient participation group. These challenges affect our current system of public involvement and this strategy and action plan seeks to address them. New opportunities The CCG is approaching a time of major transition and change. We are seeing greater levels of collaborative working between commissioners, health and social care service providers and Healthwatch Hertfordshire as part of the Hertfordshire and west Essex Sustainability and Transformation Partnership (more detail given on page 6). This aims to bring health and social care services together to meet the needs of patients in a coordinated way. Additionally the introduction of delegated commissioning of primary care will enable us to find local, innovative ways to develop GP and primary care services. Both locally and nationally there is a need for greater public involvement in the NHS. New technology, increasing demand and a growing understanding of the importance of patient involvement and engagement in their own health means that individuals are being asked to take more responsibility to manage and monitor their own wellbeing. In east and north Hertfordshire, programmes such as the integrated personal commissioning pilot and referrals to community-based support services called ‘social prescribing’ have provided a good opportunity to begin that conversation with our community. Addressing health inequalities The public engagement team provides advice and support to the CCG to address equality issues and ensure engagement reaches seldom-heard groups. For example, we currently liaise with groups including the Hertfordshire Learning Disability Partnership Board, Herts Equality Group and Gypsy and Traveller Empowerment. Ensuring that health inequalities are identified, addressed and that voices of seldom- heard groups are represented and acknowledged within the CCG’s day-to-day duties and decision-making are a cornerstone of this strategy. Page | 7

Working within the Sustainability and Transformation Partnership for Hertfordshire and west Essex

Across England, NHS and social care organisations have been encouraged to integrate their work to deliver more effective, joined-up and affordable services. In Hertfordshire and west Essex, councils, health and ambulance services, GPs, patient representative groups and the voluntary and community sectors have been asked by the NHS to produce five year improvement plans. These improvement plans are called ‘Sustainability and Transformation Partnerships’ (STPs). The STP for Hertfordshire and west Essex is called ‘A Healthier Future’. A Healthier Future ‘A Healthier Future’ maps the improvement journey that health and care services need to take locally with our residents to achieve our shared ambition to improve the health of our population, within the resources available. It draws on the commitments made in the national vision for the NHS, the Five Year Forward View, which was published in October 2014. The drive is to promote wellbeing, give patients equal access to high-quality care, prevent ill-health and to ‘work hand-in-hand with patients, carers and citizens’. You can find out more information and leave your comments on A Healthier Future by visiting the dedicated website at: http://www.healthierfuture.org.uk/. Public engagement within the STP This new model of collaborative working should result in more consistent communication between STP organisations and residents and the pooling of resources between clinical commissioning groups, service providers and local authorities. Our CCG will continue to advocate for public engagement and involvement to be embedded into all levels of work across the STP. You said… As part of the process of creating this strategy, we have reflected on assessments of our engagement practices and actively sought the views of our stakeholders and public. This has included collating and analysing feedback from the following: Page | 8 > examples of best practice in public engagement and involvement from other CCGs, local authorities, commercial and academic organisations; > assessment of the CCG’s engagement activities from external auditors RSM; > NHS England’s assessment of the CCG’s engagement function for the annual independent assessment framework (IAF), to be published in July 2018; > the annual ‘Stakeholder 360’ research survey conducted by IPSOS Mori; > reviewing earlier evaluations of our engagement function conducted by public members; > two workshops held with patient members, which included presentations from the chief executive of the National Association of Patient Participation and a member of the voluntary sector. A selection of public members comments from these events are shown on page 8.

There were clear areas of focus identified and these are shown in the diagram below: t s F

Provide an up to date The CCG's website is r Demonstrate and n A e I e public engagement difficult to navigate communicate the b G m s strategy for the CCG and identify m impact made by C s e C

e information on public patient members s m

Provide enhanced d

s n

engagement c i

A guidance and support Improve a l

l t b i for patient members to g The annual report does communication u d n P E

u effectively do their role not follow national support to and for

A S

guidance and needs to patients

Ensure a consistent H

M be more engaging for N

S approach to Make better use of R engagement is the public digital media and adopted across the The CCG need to 'virtual' groups CCG's geographic areas demonstrate impact of Incentivise members of Adopt a standard public involvement the public to be approach to The CCG should give involved engagement clearer instructions to Create a simpler evaluation the public about how network and recruit Enable greater use of to get infomation from members based on social media for the CCG in different competence feedback and formats engagement These evaluations highlight clear areas of focus for the CCG’s engagement work: 1. demonstrate the impact of public engagement and involvement 2. improve communications and patient education, with a focus on developing digital and social media communication and engagement 3. enable and ensure the best possible contribution of public representatives to Page | 9 the CCG’s work 4. make our communications and information accessible and in plain English 5. ensure our engagement work is representative of our community. Following the workshops, the principles of the new engagement strategy were presented to patient groups and other key stakeholders for their views. A draft version of this strategy has also been shared for comment on the CCG website and sent to existing public members and stakeholders for their views and input. The actions set out in the following pages seek to address the issues highlighted above. Further comments from public and patient members taken from evaluation exercises and the workshops are given below:

‘There is usually interest in the ‘Recruit for ‘competence to information but little response and contribute’ to CCG’ follow up from others at PCG or PPG ‘Develop a patient briefing’ level’ ‘Retain patients on quality’ ‘Practices should have expectations of PPGs’ ‘Need more involvement of GPs in PPG work and membership’ ‘Information on websites, Facebook groups, Instagram, Snapchat, Patient ‘Right people, skills, time, financial voice postcards, need the tools and expertise, personalities, dynamics’ resources for PPGs’ ‘Community links, schools, etc’ ‘Problematic to identify the impact of ‘Push emails, facebook, coffee our work’ mornings, texts, letters, parish ‘Have a working proportion of magazine, health events, speakers, patients on CCG locality boards and surveys’ GPs on PCGs’ ‘What can they get out of it? People ‘Draw on email groups for ‘reps’ on are only interested if has some commissioning projects’ relationship with advantage for them’ ‘Encourage by small payment for ‘Virtual; groups important role for service (it happens for practice staff!)’ social media’ ‘Team work’ ‘Improve communication between practice and patients’ ‘CCG to be clear on purpose of engagement terms of reference’ ‘Remove ‘token’ structure’ …What we will do

The following section outlines the principles and key actions that our strategy aims to deliver. These have been developed in line with the 10 key actions provided as part of NHS England’s statutory guidance to CCGs on public engagement. Page | 10 Following this section an action plan is given showing timescales of implementation for the forthcoming year.

1. Involve the public in governance > We will provide formal reports of public engagement activities to the Governing Body of the CCG three times a year. The format of these reports will be refined to focus on the outcome and difference public contributions has made to our work. > We will establish a new ‘Health Involvement Network’, chaired by the lay member for public involvement and made up of a wide range of stakeholders, partners and representatives of our population. This will be a forum enabling the CCG to listen to the views of key stakeholders, such as Healthwatch, the community and voluntary sector and public representatives. > The chair of the Health Involvement Network will be a champion for public engagement within the CCG, and scrutinise the resulting work and outcomes.

2. Embed public involvement in commissioning plans/business plans > We will ensure the CCG considers and involves the public at every stage of the commissioning cycle. This would be through workflow reminders and assessments, building in funding for consultations when necessary, sourcing public representatives with relevant experience to assist commissioners. > We will provide training and advice for CCG staff on both the duty and benefits of public involvement.

3. Demonstrate public involvement in annual reports > We will engage with our communities on what they expect to see within our annual report and in what formats they would like to see it. Following this we will support the communications team in supplying appropriate information for the report; and ensure it follows national guidance set out by NHS England (please click here to download). > We will undertake an annual review of public engagement and involvement work, focusing on the impact and difference that patients and members of the public have made, and whether our actions have successfully met the objectives set out in this strategy. We will present this information in a variety of communication formats and channels.

4. Promote and publicise public involvement Page | 11 > In response to the feedback raised through NHS England’s assessment and from patient members, we will make significant improvements and investment into digital and social media engagement. This will include development of a specific digital inclusion plan, which seeks to engage with a new audience via digital and social media and improves patient communications at both the individual practice patient group level, but also with the CCG. We will use our website as an accessible record of public and patient engagement work, capturing and demonstrating the impact of public feedback. > We will utilise digital communications tools to ensure the CCG is more accessible and enable members of the public to contribute their thoughts and ideas on local and national health services at a time and place that is convenient to them. > We will develop and share public involvement resource packs to support our patient participation groups to learn from each other and develop the skills and resources within their community. > 2018 provides our organisation with a good opportunity to raise the profile of public involvement and engagement with the NHS as part of the NHS 70 celebrations. The communications and engagement team at the CCG will seek to benefit from increased exposure, raise awareness and celebrate our volunteers’ contributions to the health service locally.

5. Assess, plan and take action to involve > We will stress the importance of engagement and involvement with CCG staff and partners, and as explained earlier, we will put in place practices to ensure that public involvement lies at the heart of our work. > The introduction of the Health Involvement Network (noted above), will enable greater scrutiny of day-to-day engagement practices and ensure appropriate planning and actions are completed. > We will continue to meet with local networks of patient groups on a regular basis, to share ideas, support campaigns and gather feedback from our communities. We will also continue to support the patient network quality group and look to support that group in growing and recruiting new members. > We will use the requirements of the CCG’s Consolidated Funding Framework – part of the funding system for GP practices – to encourage public participation and engagement at individual GP practice level. > Targeted action plans will enable involvement from specific groups that are typically less active within our engagement activity – for example targeted engagement from young people, parents, disability groups etc. As part of these plans we will look to recruit a range of patient representatives with special interests in specific health areas, such as dementia, heart disease, Page | 12 respiratory, maternity and children’s services.

6. Feedback and evaluate > We will look to introduce evaluation processes for public involvement opportunities in our decision making and work. This feedback will be collated and shared both with the CCG project teams and the public. > We will develop our website and social media channels to proactively capture feedback and evaluation. We will promote the difference our engagement work has made through both the regular Governing Body reports and a refreshed engagement and involvement newsletter. > We will highlight the difference engagement has made within our annual report and look into the possibility of hosting an annual engagement and involvement celebration event; highlighting the positive work undertaken by the public, to encourage more participation.

7. Implement assurance and improvement systems > We will continue to support, listen and learn from ongoing assurance and improvement processes, such as the annual Stakeholder 360 and NHS England IAF assessments. > We will look to conduct our own annual satisfaction survey with the levels of involvement and engagement of the public with our members. > The new Health Involvement Network will play a critical role in scrutinising the engagement and involvement function on a regular basis – ensuring that learning and improvement opportunities are applied as appropriate.

8. Advance equality and reduce health inequalities > Through closer links with our local voluntary and community sector, we will look to develop networks of advocates, enabling us to access and hear the views of seldom-heard communities not previously represented in our engagement work. > As noted above we will seek to develop specific programmes of engagement for certain groups, for example youth engagement may build on existing projects such as the successful careers programme ‘Future Heroes’. > As part of our annual review of public engagement activities we will evaluate the demographic profile of contributors to the CCG’s engagement work to assess how closely it reflects the profile of our wider population.

Page | 13 9. Provide support for effective involvement > We will develop a range of education and training workshops enabling easier access and understanding of the health service for our public members, enabling them to contribute to our work with more confidence. > We’ve had excellent support from our local Healthwatch organisation in this area and will continue to work jointly with them in developing our projects, and look to support their campaigns where appropriate. > We will advocate within the organisation for financial reimbursement for public members involved in long-standing and intensive project commitments and will ask for patient member and stakeholder views on this proposed policy. > We will ensure that opportunities to be involved are promoted and shared in a timely manner and that appropriate recruitment processes are followed. > We will continue to support staff to understand the statutory responsibility to involve and engage with the public and present at staff induction sessions.

10. Hold providers to account > We will look to work with the contract monitoring team to develop clearer oversight of engagement practices by our providers. > We will ensure we work with external, independent organisations such as Healthwatch Hertfordshire, to hold providers to account. > Through the Hertfordshire and west Essex Sustainability and Transformation Partnership, clearer lines of communication and project management are developing between engagement leads across commissioners and providers which will assist with the implementation of this improvement plan. Adopting a new set of involvement principles Through the actions highlighted above, and in order to meet the Page | 14 NHS Constitutional commitment to put patients at the centre of our decision making, we are proposing to adopt engagement principles created by the People and Communities Board of National Voices – a coalition of charities that stands for people being in control of their health and care.

In applying these principles, we will consider and utilise the suggested evaluation and monitoring metrics proposed by National Voices as part of this to enable greater standardisation of our evaluation as highlighted by the RSM audit, but also to support the CCG and its public members in both displaying and seeing the impact that their involvement has played.

Full details of the principles and how they were developed can be found on the National Voices website: https://www.nationalvoices.org.uk/publications/our- publications/six-principles-engaging-people-and-communities . Public involvement action plan for 2018/19

Action Activity (marked against strategic action highlighted in the ‘We 2018 (Year and month) 2019 (Yr & Mth) will do’ section of the strategy above) 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 Page | 15 5 Publish public engagement strategy – following sign-off from Governing Body, patient member engagement and presentations to patient groups and key stakeholders. 1 Provide public engagement reports to CCG Governing Body.

1 Establish a Health Involvement Network group – to be chaired by lay member for public involvement with representative members from stakeholders, partners, community and the public. 2 Develop basic staff guidance on the duty to involve the public for CCG activities and publish internally 2 Meet with project management, commissioning and contracting teams to develop understanding of public engagement and design processes for involvement in their work. 3 Contribute to CCG annual reporting and involve public members in the design and development of content 3 Develop public engagement annual report – designed and developed in partnership with public members 4 Review and undertake a development of the CCG’s digital engagement actions – particularly focussing on the ‘Get Involved’ section of the CCG website, use of social media, provision of support to patient groups, and ensuring the CCG meets requirements set out as part of General Data Protection Regulation (GDPR). 4 Prepare and promote a resource pack for promoting public involvement through patient participation groups. 4 Campaign for public involvement and engagement with the NHS as part of NHS70 celebrations and promotion activities Action Activity (marked against strategic action highlighted in the ‘We 2018 (Year and month) 2019 (Yr & Mth) will do’ section of the strategy above) 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 5 Develop single page plans to engage with key communities within east and north Hertfordshire – for example young people. Page | 16 5 Continue to support patient locality groups (previously known as patient commissioning groups) and the Patient Network Quality – support the groups to grow and campaign effectively within their communities. 5 Inclusion and monitoring of public and patient engagement at GP practice level through the Consolidated Funding Framework. 6 Develop evaluation and assessment forms for involvement and engagement projects to be shared with involved staff and public members 6 Undertake regular ‘You said, We did’ activity showcased on the CCG website. 6 Host a celebration event for public members – showcasing the work that’s been achieved and displaying the impact and difference it has made. 7 Support existing assessment schemes and apply learning from ongoing evaluation methods such as the Ipsos Mori 360 survey and the NHS England CCG IAF assessments. 7 Conduct a review and evaluation of engagement and involvement work with public members and stakeholders to learn from and adapt ongoing involvement work for the CCG. 8 Work with equalities lead in reviewing and meeting equality review – and working through requirements of NHS England’s EDS2 with staff across the CCG. 8 As part of the internal review of engagement and involvement work within the CCG, assess the profile and demographics of public involvement with the CCG – and report on its representativeness of our population. Action Activity (marked against strategic action highlighted in the ‘We 2018 (Year and month) 2019 (Yr & Mth) will do’ section of the strategy above) 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 9 Develop a monthly education programme to enable greater understanding of the local health service and to enable patient Page | 17 members to better contribute to health involvement projects going forwards. 9 Draft a policy for discussion within the CCG looking at reimbursement of public members for contribution to regular or intense involvement projects. 9 Agree a practical process and best-practice for advertising and recruiting to public involvement projects and opportunities. 10 Establish a process with the contract monitoring team for assessing involvement and engagement from our service providers. 10 Develop a means for shared engagement and involvement across providers and commissioners within the STP area of Hertfordshire and west Essex.

Response from Hertfordshire Healthwatch

“We are really positive about the commitments made by NHS East and North Hertfordshire Clinical Commissioning Group to patients and the public outlined in the strategy. “We look forward to increased opportunities to work together to ensure meaningful and effective engagement, which in turn ensures the public are at the centre of their care and are able to influence change.” Geoff Brown, Chief Executive of Healthwatch Hertfordshire Appendix i: Our duty to engage

Under the National Health Service Act 2006, as amended by the Health and Social Care Act 2012, CCGs have a duty to involve the public in their commissioning role Page | 18 (under sections 14Z2 and 13Q respectively). These can be found on the Government legislation portal by clicking here (http://www.legislation.gov.uk/ukpga/2012/7/section/26/enacted}. In addition, statutory guidance set out by NHS England in Patient and public participation in commissioning health and care (published May 2017 and available by clicking here) sets out 10 key actions for CCGs to ensure public and patient involvement is embedded in our work. These are: 1. Involve the public in governance 2. Explain public involvement in commissioning plans/business planning 3. Demonstrate public involvement in annual reports 4. Promote and publicise public involvement 5. Assess, plan and take action to involve 6. Feedback and evaluate 7. Implement assurance and improvement systems 8. Advance equality and reduce health inequalities 9. Provide support for effective involvement 10. Hold providers to account This strategy seeks to address and improve the CCG’s engagement performance in relation to these actions, ensuring that engagement is truly embedded into each part of the commissioning cycle as shown in the diagram opposite.

Engagement in the Commissioning Cycle, Patient and public participation in commissioning health and care: statutory guidance for CCGs and NHS England (Click here to download) Appendix ii: Glossary of terms used in this document

TO BE INCLUDED UPON APPROVAL OF STRATEGY BY CCG GOVERNING BODY. Page | 19 Agenda Item No: 12

Date of Meeting: 24th May 2018

Governing Body Meeting in Public

The Primary Care Commissioning Committee (PCCC): Purpose Paper Title: and Function

Decision or Approval Discussion Information

Report author: Holly Fairhurst, Assistant Director Contracts. James Gleed, Associate Director Commissioning Primary Care. Report signed off by: Denise Boardman, Director of Primary Care Development

Executive Summary: The paper attached was presented to the Governing Body Workshop on 26th April providing an overview of the proposed shared remit of the Primary Care Commissioning Committee.

This paper is shared in public for information. The next meeting of the Primary Care Commissioning Committee is scheduled for 7th June where an update on the work plan and CCG appointments will be given.

The purpose of the paper is to provide an overview of the proposed shared remit of the Primary Care Commissioning Committee (PCCC) following the PCCC workshop held on Thursday 12th April 2018. The workshop included a discussion on the Committee’s strategic plans, proposed annual business cycle, work plan and Terms of Reference. The group agreed that there were a number of key themes for the Committee to focus on including resilience and workforce planning.

The Committee agreed that it was important that there were a number of initiatives that could be delivered in the short term and the focus would be on the schemes that would have the greatest clinical impact. In addition, there was support to ensure that the Committee delivers transformational change. The Primary Care Strategy would support the transformational change, noting the previous input across all stakeholders to develop this Strategy.

Recommendations This paper is for information and noting. to the members:

Page | 1 Conflicts of Interest There were no conflicts of interest in the preparation of this paper. involved: CCG Governing Body GPs are local practising GPs and therefore may be affected by some of the potential future functions and associated decision making of the Primary Care Commissioning Committee (PCCC). However the terms of reference for PCCCs are nationally prescribed as part of the delegation arrangements and this paper is presented to the Governing Body for information only.

Page | 2 1. Executive summary

The purpose of the paper is to provide an overview of the proposed shared remit of the Primary Care Commissioning Committee following the workshop held on Thursday 12th April 2018. The workshop included a discussion on the Committee’s strategic plans, proposed annual business cycle, work plan as well as the Terms of Reference. The group agreed that there were a number of key themes for the Committee to focus on including resilience and workforce planning.

Work is now underway cross directorate being led by the Primary Care Development team to produce a draft work plan for discussion at the next Primary Care Commissioning Committee on 7th June.

2. Background

The first meeting of the PCCC took place on Thursday 12th April and included representatives from ENHCCG, Healthwatch, LMC and NHS England. The PCCC discussed the Terms of Reference, which have been included in the Appendix for information. At the PCCC, it was noted that there needs to be further consideration given to attendance that is required for meetings to be quorate.

The committee considered sub-group requirements and noted that the Risk and Information Sharing Group previously established under Joint Co-Commissioning with NHSE will continue to function.

The group discussed the quality monitoring and reporting arrangements for primary care and a proposal will come to the next PCCC meeting. It will be important to determine, as part of the overall Quality Assurance & Improvement framework, what information comes to the PCCC in public, what comes to parts of the meeting where the public are excluded and what data /information is monitored by other groups /teams.

It was agreed that the Joint Commissioning Operational Group (JCOG) would be stood down and the CCG would instead explore the utilisation of other existing CCG groups and committees within the organisations governance structure, with the option to re-establish any new group(s) as and when required. The last meeting of the JCOG was 16 April 2018.

Reports summarising the work of the Primary Care Commissioning Committee will be submitted to the Governing Body on a quarterly basis.

It was agreed that especially in view of the narrow majority of practices that were in favour of delegation when the vote was taken, it was important to identify some quick wins that will underscore the merit of transitioning to delegated commissioning.

Page | 3 2.1 Short Term Initiatives The Committee agreed that the following initiatives should be a focus on over the next 12 months as they would have the greatest clinical impact:

• Ensure successful delivery of Extended Access • Care Homes • GPFV 10 High Impact Actions • In Hours support • Supporting practices on the requirements for GDPR.

The Primary Care Development team has been tasked with working up these areas in more detail for the next PCCC on 7th June 2018.

2.2 Strategic Direction The Committee noted that there are currently ten key areas that would be worked up as part of the longer term plans.

• Resilience • Information Technology • Quality Assurance • Technical Processes • Workforce • Premises • Primary Care Integration • STP • New Models of Care • Patient Participation

The group also noted that it was important to review the format of GP practice visits to ensure that a supportive approach would be undertaken.

3. Issues With regards to increasing the amount of sharing and reporting of general practice data and information, the Primary Care Commissioning Committee acknowledged the need to balance: • Public interest and service improvement considerations. • The need to broadly ensure the same rigour of monitoring across all healthcare providers.

With:

• The need to respect the sensitive nature of such information. • Implications of the relatively small nature of individual general practices. • The effect on staff morale in general practice, should such measures be perceived as punitive.

Page | 4 4. Options N/A.

5. Resources implications To support this work going forward as advised in earlier Governing Body papers on Delegated Commissioning and presented at the meetings on the 5th January and 22nd February, work has been undertaken to (a) to review the role of clinical leadership on the Governing Body and (b) to recruit additional CCG staff to support the new delegated duties. Both items have been taken forward and in the case of item (b) active recruitments are underway and being made.

With reference to item (a) the role of clinical leadership on the Governing Body, as agreed at the January Governing Body meeting, the following Governing Body GP leads were assigned to supporting the Primary Care Commissioning Committee. This is to ensure strong links are maintained into practices and localities as the CCG develops a strong approach to delegation:

• Dr Nicky Williams • Dr Tara Belcher • Dr Ash Shah

A meeting was held on 12th April with these clinical colleagues and the CCGs Director for Primary Care Development to discuss and agree a work plan for 2018/19. This was against the background of the discussion at the earlier PCC meeting and items to be delivered during 2018/19 aligned to CCGs Operational Plan & Primary Care Priorities. Taking this into account it was agreed to focus on 4 key work areas for 2018/19 including a review and refresh of the CCGs Primary Care Strategy.

The 4 areas are:

1. Extended Access, GPFV Online Consultations, Direct Booking etc 2. GPFV 10 High Impact Actions, for example Active Signposting has been commissioned and NHSE planning guidance for 2018/19 requires all practices to choose 2 High Impact Action’s. 3. New Models of Care –Care Homes and expectations of General Medical Services (GMS) 4. Review/Refresh of the CCG Primary Care Strategy

GB GP Workstream

Dr Nicky Williams GPFV 10 High Impact Actions Review/Refresh of the CCG Primary Care Strategy

Dr Tara Belcher New Models of Care Review/Refresh of the CCG Primary Care Strategy

Dr Ash Shah Extended Access, GPFV Online Review/Refresh of the CCG Consultations, Direct Booking Primary Care Strategy

Page | 5 It was also agreed that these Governing Body clinical colleagues will also support 2 localities in respect of the above 4 key work areas and that these will be different localities to which they represent on the Governing Body. This offers the opportunity to work with and hear from different localities and to offer different perspectives:

GB GP Locality

Dr Nicky Williams Welwyn & Hatfield and Lower Lea Valley

Dr Tara Belcher Upper Lea Valley & Stort Valley & Villages

Dr Ash Shah Stevenage & North Herts.

This is with aim of these GP PCCC roles:

• Providing support to the Governing Body GP Localities lead to ensure the voice of member practices is heard and that they are involved and supported in delivering these priorities.

• Supporting the provision of strong visible clinical CCG Governing Body GP leaders, fostering a culture of collaboration, planned, transparent and outcome focused working.

• Support developing Primary Care in east and north Hertfordshire leading to the delivery of a sustainable and resilient Primary Care culture as required by the General Practice Forward View published in April 2016.

6. Risks/Mitigation Measures

The chief risks for the CCG, associated with the establishment of the PCCC and taking on delegated commissioning of Primary Medical Services, are threefold:

• The quality and performance monitoring of primary medical services undertaken by the committee is perceived by practices as a threat, rather than a supportive measure, which erodes the good relationship between the CCG and member practices resulting in disengagement with key (both current and future) CCG initiatives.

Mitigation: Judicious development of the primary care quality assurance framework; the PCC’s membership includes three local practising GPs.

• The quality and performance monitoring needs to strike a balance between securing material improvement in local primary care services and not to be perceived as punitive (as outlined above) or failure could have serious reputational consequences for the CCG. Failure could open the organisation up to criticism that it has been unable to effectively manage its inherent conflicts of interest, being a GP practice membership organisation.

Page | 6 Mitigation: The PCCC has a non-GP majority membership, the three GPs on the committee are not voting members and the membership includes an Independent GP, Healthwatch and a Patient Representative.

• Member practices and other local stakeholders fail to observe any tangible improvements for patients and also those working in the primary care and community services system. This could cause reputational damage and also cause member practices to disengage as per above.

Mitigation: PCCC has identified a small number of projects that meet the criteria of being important to local practices and also deliverable within the next 12 months.

7. Recommendations This paper is for information and noting.

8. Next Steps The Primary Care Development team has been tasked with working up these areas in more detail for the next PCCC on 7th June 2018.

• Ensure successful delivery of Extended Access • Care Homes • 10 High Impact Changes • In Hours support • Supporting practices on the requirements for GDPR.

Page | 7 Appendix

NHS East and North Hertfordshire Clinical Commissioning Group

Primary Care Commissioning Committee Terms of Reference

Page | 8 Introduction

1. In accordance with its statutory powers under section 13Z of the National Health Service Act 2006 (as amended), NHS England has delegated the exercise of the functions specified in Schedule 2 to these Terms of Reference to NHS East and North Hertfordshire Clinical Commissioning Group (CCG). The delegation is set out in Schedule 1.

2. The CCG has established the NHS East and North Hertfordshire CCG Primary Care Commissioning Committee (“Committee”). The Committee will function as a corporate decision-making body for the management of the delegated functions and the exercise of the delegated powers.

3. It is a committee comprising representatives of the following organisation: . NHS East and North Hertfordshire CCG

Statutory Framework

4. NHS England has delegated to the CCG authority to exercise the primary care commissioning functions set out in Schedule 2 in accordance with section 13Z of the NHS Act.

5. Arrangements made under section 13Z may be on such terms and conditions (including terms as to payment) as may be agreed between the Board and the CCG.

6. Arrangements made under section 13Z do not affect the liability of NHS England for the exercise of any of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it), it must comply with the statutory duties set out in Chapter A2 of the NHS Act and including:

a) Management of conflicts of interest (section 14O); b) Duty to promote the NHS Constitution (section 14P); c) Duty to exercise its functions effectively, efficiently and economically (section 14Q); d) Duty as to improvement in quality of services (section 14R); e) Duty in relation to quality of primary medical services (section 14S); f) Duties as to reducing inequalities (section 14T); g) Duty to promote the involvement of each patient (section 14U); h) Duty as to patient choice (section 14V); i) Duty as to promoting integration (section 14Z1); j) Public involvement and consultation (section 14Z2).

Page | 9 7. The CCG will also need to specifically, in respect of the delegated functions from NHS England, exercise those in accordance with the relevant provisions of section 13 of the NHS Act.

8. The Committee is established as a committee of the Governing Body of each named CCG in accordance with Schedule 1A of the “NHS Act”. 9. The members acknowledge that the Committee is subject to any directions made by NHS England or by the Secretary of State.

Role of the Committee

10. The Committee has been established in accordance with the above statutory provisions to enable the members to, for example, make collective decisions on the review, planning and procurement of primary care services in East and North Hertfordshire, under delegated authority from NHS England.

11. In performing its role the Committee will exercise its management of the functions in accordance with the agreement entered into between NHS England and NHS East and North Hertfordshire CCG, which will sit alongside the delegation and terms of reference.

12. The functions of the Committee are undertaken in the context of a desire to promote increased co-commissioning to increase quality, efficiency, productivity and value for money and to remove administrative barriers.

13. The role of the Committee shall be to carry out the functions relating to the commissioning of primary medical services under section 83 of the NHS Act.

14. This includes the following:

. General Medical Service (GMS), Personal Medical Services (PMS) and Alternative Provider Medical Services (APMS) contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action such as issuing branch / remedial notices, and removing a contract); . Newly designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”); . Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF); . Decision making on whether to establish new GP practices in an area; . Approving practice mergers; and . Making decisions on ‘discretionary’ payment (e.g., returner/retainer schemes).

15. The CCG will also carry out the following activities:

Page | 10 a) To plan, including needs assessment, primary [medical] care services in East and North Hertfordshire; b) To undertake reviews of primary [medical] care services in East and North Hertfordshire; c) To co-ordinate a common approach to the commissioning of primary care services generally; d) To manage the budget for commissioning of primary [medical] care services in East and North Hertfordshire.

Geographical Coverage

16. The Committee will comprise the NHS East and North Hertfordshire CCG.

Membership

17. The Committee shall consist of: . Lay Member for Co-Commissioning . Lay Member for Patient and Public Engagement . Lay Member for Governance and Audit (Conflict of Interest Guardian) . An Independent GP . Five Executive Members o Chief Executive o Chief Finance Officer o Director of Nursing and Quality o Director of Commissioning o Director of Primary Care Development . Three GP members of the Group’s Governing Body (non-voting)

18. The Chair of the Committee shall be the Lay Member for Co-Commissioning.

19. The Vice Chair of the Committee shall be the Lay Member for Patient and Public Engagement.

20. The following representatives will usually be in attendance: . CCG Company Secretary . Healthwatch Hertfordshire . Health and Wellbeing Board Hertfordshire . NHS England

Page | 11 . Associate Director Commissioning Primary Care . Patient Representative . Assistant Director – Premises . Bedfordshire and Hertfordshire Local Medical Committee . Meeting Secretariat

Meetings and Voting

21. The Committee will operate in accordance with the CCG’s Standing Orders. The Meeting Secretariat to the Committee will be responsible for giving notice of meetings. This will be accompanied by an agenda and supporting papers and sent to each member representative no later than three working days before the date of the meeting. When the Chair of the Committee deems it necessary in light of the urgent circumstances to call a meeting at short notice, the notice period shall be such as s/he shall specify.

22. Each member of the Committee shall have one vote. The Committee shall reach decisions by a simple majority of members present, but with the Chair having a second and deciding vote, if necessary. However, the aim of the Committee will be to achieve consensus decision-making wherever possible.

Quorum

23. Six members of the committee must be present for the quorum to be established. No formal business shall be transacted where a quorum is not reached.

Frequency of meetings and attendance

24. A minimum of 6 scheduled meetings shall be held per year. Members of the committee should make every effort to attend all meetings of the committee. The Meeting Secretariat will monitor attendance and will report on this annually. Attendance figures will be published in the Annual Report. In the event of a member being unable to attend all or part of the meeting, they will nominate a replacement to deputise for that meeting.

25. Meetings of the Committee shall: a) be held in public, subject to the application of 25(b); b) the Committee may resolve to exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for

Page | 12 any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time.

26. Members of the Committee have a collective responsibility for the operation of the Committee. They will participate in discussion, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavour to reach a collective view.

27. The Committee may delegate tasks to such individuals, sub-committees or individual members as it shall see fit, provided that any such delegations are consistent with the parties’ relevant governance arrangements, are recorded in a scheme of delegation, are governed by terms of reference as appropriate and reflect appropriate arrangements for the management of conflicts of interest.

28. The Committee may call additional experts to attend meetings on an ad hoc basis to inform discussions.

29. Members of the Committee shall respect confidentiality requirements as set out either in the CCG’s General Contract of Employment or Letter of Appointment.

30. The Committee will present its minutes to NHS England (Central Midlands) and the Governing Body of NHS East and North Hertfordshire CCG on a quarterly basis for information, including the minutes of any sub-committees to which responsibilities are delegated under paragraph 27 above.

31. The CCG will also comply with any reporting requirements set out in its constitution.

32. The Committee will review these Terms of Reference on an annual basis.

Decisions

33. The Committee will make decisions within the bounds of its remit.

34. The decisions of the Committee shall be binding on NHS England and NHS East and North Hertfordshire Clinical Commissioning Group.

35. The Committee will produce an executive summary report which will be presented to NHS England and the Governing Body of NHS East and North Hertfordshire Clinical Commissioning Group each quarter for information.

Accountability of the Committee

Page | 13 36. For the avoidance of doubt, in the event of any conflict between the terms of the Delegation and Terms of Reference and the Standing Orders or Standing Financial Instructions of any of the members, the Delegation will prevail.

Schedule 1 – The Delegation The Delegation will set out the statutory delegation of primary medical care commissioning functions to Clinical Commissioning Groups. The Delegation will be supplemented by the Delegation Agreement, which records the particulars of the agreement made between NHS England and NHS East and North Hertfordshire Clinical Commissioning Group.

Schedule 2 – Delegated Functions a) decisions in relation to the commissioning, procurement and management of Primary Medical Services Contracts, including but not limited to the following activities: i) decisions in relation to Enhanced Services; ii) decisions in relation to Local Incentive Schemes (including the design of such schemes); iii) decisions in relation to the establishment of new GP practices (including branch surgeries) and closure of GP practices; iv) decisions about ‘discretionary’ payments; v) decisions about commissioning urgent care (including home visits as required) for out of area registered patients; b) the approval of practice mergers; c) planning primary medical care services in the Area, including carrying out needs assessments; d) undertaking reviews of primary medical care services in the Area; e) decisions in relation to the management of poorly performing GP practices and including, without limitation, decisions and liaison with the CQC where the CQC has reported non- compliance with standards (but excluding any decisions in relation to the performers list); f) management of the Delegated Funds in the Area; g) Premises Costs Directions functions; h) co-ordinating a common approach to the commissioning of primary care services with other commissioners in the Area where appropriate; and i) such other ancillary activities as are necessary in order to exercise the Delegated Functions.

Page | 14 Page | 15 Agenda Item No: 13

Date of Meeting: 24th May 2018

Governing Body Meeting in Public

Paper Title: Governance and Audit Committee Minutes – 14th March 2018

Decision or Approval Discussion Information

Report author:

Report signed off by: Governance and Audit Committee

Executive Summary: Approved minutes of the Governance and Audit Committee attached for the Governing Body to note

Recommendations To note the minutes of the Governance and Audit Committee to the members:

Conflicts of Interest n/a involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Page | 1 Governance and Audit Committee Wednesday 14 March 2018 Charter House, 1st Floor Room MR1.2, Welwyn Garden City

MINUTES

Present: Dianne Desmulie [DD] Lay Member, Patient and Public Engagement Linda Farrant [LF] Lay Member, Governance and Audit (Chair) Nicky Williams [NW] Deputy Chair

In Attendance: Nick Bernstein [NB] Audit Manager BDO, External Audit Jas Dosanjh [JD] Corporate Governance Manager (Minutes) Sarah Feal [SF] Company Secretary Clive Makombera [CM] Internal Audit Director RSM Alan Pond [AP] Chief Finance Officer Bradley Vaughan [BV] Counter Fraud Manager RSM

1 | P a g e Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE

The Chair welcomed all to the meeting, introducing Clive Makombera and Bradley Vaughan who were attending on behalf of RSM Internal Audit and RSM Counter Fraud respectively.

Apologies were noted from: . Lisa Clampin, Lead Partner BDO, External Audit . Becci Goodchild, Principal Consultant RSM . Chris Rising, Senior Manager RSM, Internal Audit

2. DECLARATIONS OF INTERESTS

The Chair invited the Committee members to reconfirm their current declarations on the Register of Interests and advise of any new interests. All members confirmed their declarations were accurate and up-to-date, with the exception of the Chair who highlighted that the dates for her declaration need to be corrected.

ACTION: Maryla Hart [MH] to correct the Chair’s declaration as MH advised prior to the meeting

The Chair invited the committee members to declare any interests relating to matters on the Agenda. All members confirmed they have no declarations in relation to matters on the Agenda.

3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING

The minutes of the meeting held on 10 January 2018 were approved as an accurate record with the following addition:

. Item 5 (p.4): There was some discussion about user awareness of cyber issues and possible rogue email traffic. PT explained that there are plans to undertake an exercise to test this. The Committee asked for this to be reported when complete. ACTION: PT to provide the Committee with confirmation once the user testing exercise has been completed.

There were no matters arsing.

2 | P a g e Item Subject Action by

4. COMMITTEE ACTION TRACKER

The contents of the Action Tracker were discussed and all actions highlighted in yellow were agreed to be closed.

Updates were provided regarding the open actions which included:

. It was noted that the Fraud Risk Assessment has been deferred twice and that it will need to be ready for review at the next Committee meeting, . Current insurance arrangements with NHS Resolution confirmed that their schemes do not cover cyber-security – action can be closed from the Committee action tracker as cyber insurance is on the agenda at the Chief Finance Officers team meeting.

The Committee noted the updates for the action tracker.

5. FINANCE

5.1 FINANCE RISKS UPDATE REPORT

AP presented the finance risks update report and advised that the CCG is currently managing potential risks of £1.15m, which may impact the delivery of the CCG target financial position.

The Committee discussed the risks which include QIPP under- delivery, Continuing Healthcare growth in number and complexities of activities, patient transport service risk, prescribing risks and system-wide risks, which are currently mitigated by the contingency reserve held by the CCG.

The Committee acknowledged the Executive Teams commitment and achievement of delivering against the QIPP challenge, and noted that lessons will be shared at a Governing Body workshop.

The Committee noted the Financial Risks update report.

5.2 WAIVERS OF STANDING ORDERS

The Committee noted that there are no waiver’s to be reported to this meeting.

3 | P a g e Item Subject Action by

5.3 SIX MONTHLY LOSSES AND COMPENSATION

The Committee noted that there are no cases of losses or compensation payments to be reported to this meeting.

5.4 FINAL ACCOUNTS TIMETABLE AND PROGRESS

AP presented the Accounts Timetable and Progress and highlighted that the:

. Month 9 accounts were produced and analytical review identified no particular issues, . Month 9 Agreement of Balances exercise was completed with no particular issues identified, . Accounts timetable has been agreed, . Allocation of responsibilities between the Financial Services Team and the wider Finance Team has been agreed.

The Committee noted the Accounts Timetable and Progress.

6. RISK PROFILE REPORT

JD presented the Risk Profile Report which includes the Strategic Risk Register (SRR) and Risks, Controls and Assurance Dashboard (RCAD) which were reviewed across the CCG during quarter 4 2017/18 and signed off at the Executive Team Meeting on 06 March 2018. In addition, the Executive Team reviewed the Closed Risk Register and confirmed that none of the previously closed risks require re-opening.

Following the review, 7 risks remain on the SRR, there are now 30 risks on RCAD and the key findings identified since the last update in November 2017 were:-

. 10 risks have been mitigated to a lower risk rating, . 15 risks remain at the same risk rating, . 2 risk has seen an increase of its risk rating, . 9 risks have been mitigated and closed, . 3 new risks have been identified and added.

The Committee discussed mitigation for risk 5.26, which was agreed for closure by the Executive Team, and asked that the

4 | P a g e Item Subject Action by Director of Quality and Nursing (Sheilagh Reavey [SR]) provide an overview of the assurances that have led to the closure of this risk.

ACTION: SR to provide a verbal update regarding the closure SR of risk 5.26 at the next Quality Committee meeting.

The Committee noted the SRR and RCAD and approved submission to the Governing Body.

7. 7.1 INTERNAL AUDIT PROGRESS REPORT

CM presented the Internal Audit Progress Report which details the results of Internal Audit work undertaken for the year.

The following reports 2017/18 have been finalised by the CCG since previous committee meeting:

. Follow-up (good progress) – with one medium and one low recommendation . Risk Management and Assurance (substantial assurance) – with low recommendation

The Committee asked for clarification to be provided regarding the medium recommendation from the Follow-up audit regarding periodic access reviews.

ACTION: CR to provide clarification regarding the context of CR the periodic access reviews (cyber security) recommendation from the Follow-up audit.

The Committee were advised that the Governance and Corporate Affairs Team will begin to seek assurances for medium/high recommendations before they are reported for closure, this will commence for the 2018/19 Internal Audit programme.

The Committee discussed previous agreement of a joint Patient Transport Service (PTS) internal audit (all four CCG’s). It was noted that this audit will not take place as the CCG’s are now in a different position and weaknesses have been identified, with lessons learnt shared via a deep-dive at the Quality Committee meeting.

The Committee noted the Internal Audit Progress Report.

5 | P a g e Item Subject Action by 7.2 INTERIM HEAD OF INTERNAL AUDIT OPINION

CM presented the Interim Head of Internal Audit Opinion, based on work undertaken up to 05 March 2018, which concluded that the organisation has an adequate and effective framework for risk management, governance and internal control (green/yellow). There have been no issues identified as part of the internal audit work that the auditors consider as requiring reporting as a significant control issue within the CCG’s Annual Governance Statement.

An error was highlighted in section 1.3, which should read “…five of these audits resulted in a substantial assurance opinion,…”

ACTION: CR to correct the error regarding number of internal audits reported under section 1.3 (p.2). CR

The Committee noted the Interim Head of Internal Audit Opinion.

7.3 INTERNAL AUDIT STRATEGY 2018-21

CM presented the Internal Audit Strategy 2018-2021 which the Committee discussed and provided the following feedback:

. Page 2 – annual budget is approximately £740m, . Page 4/5 – SRR and RCAD risks to be updated, . Page 13 – the focus of the Workforce audit needs to be re- defined to assess whether the CCG considers availability of staff in the decision making and prioritisation of commissioning services, . Page 14 – data centre at Farnborough, not Waverly Road, . Page 16 – PTS audit to look at whether contract is being adequately managed to meet needs of the population, and to seek assurance of the adequacy of the joint arrangement, review whether this audit could be brought forward . Page 17 – Prescribing audit to look at commissioning decisions and the process flow of the implementation of the decisions made, . Page 17 – Vanguard audit could be scheduled earlier, . Page 17 – GP extended access audit to be rescheduled to the autumn, . Page 20 - an audit regarding Delegated Commissioning needs to be built into the plan for all three years using availability from the 2017/18 budget.

6 | P a g e Item Subject Action by ACTION: CR to update the Internal Audit Strategy in light of the CR Committee feedback and re-issue for approval.

The Committee noted the Internal Audit Strategy and approved the plan subject to the adjustments being made as discussed.

8. 8.1 LCFS PROGRESS REPORT

BV presented the LCFS Progress Report advising that the fieldwork for the fraud risk assessment and findings are currently being analysed and input into the fraud specific risk register. It was also highlighted that the NHS Counter Fraud Authority has released the 2018/19 Standards for Commissioners with changes to terminology and some of the standards.

The Committee were advised that the self-review toolkit will be submitted on 31 March 2018 (green rating subject to DOI returns).

The Committee noted the LCFS Progress Report.

8.2 LCFS WORK PLAN 2018/19

BV presented the LCFS Work Plan 2018/19

An error was highlighted on the Fraud Risk Map, which stated that Cyber Crime and Conflicts of Interest as areas for which assurance has not been provided, however this is incorrect as internal audits have provided a level of assurance in these areas.

ACTION: BG to correct the error on the Fraud Risk Map (p.4) regarding the assurances for Cyber Crime and Conflicts of BG Interests.

The Committee agreed the LCFS Work Plan 2018/19.

9. DRAFT ANNUAL REPORT, INCLUDING THE ANNUAL GOVERNANCE STATEMENT

The Committee members confirmed that, outside of this meeting, they have provided general feedback and comments to SF for consideration in the next draft report.

7 | P a g e Item Subject Action by The Committee noted that this draft is more user friendly and patient focused than previous years.

The Committee focused on the Annual Governance Statement included in the report, and specifically highlighted the following:

. Page 82 – 84 – need to add a footnote to state why there have been a low number of recorded locality meetings (they have been held but in a different format), . Page 90 – list action being taken for the Strategic Risks, . Page 93 – add a section regarding readiness for GDPR and work done to date (training and project group), . Page 96 – bullet point 7 should state regular not bi-monthly, . Within this section the adoption of a Whistleblowing Policy should be added, along with noting that the mechanisms are being utilised.

ACTION: SF to update the Governance Statement as per SF Committee feedback.

The Committee noted the timetable leading up to the submission of the final report to NHS England, and agreed that the next draft will be emailed to the Committee members for review.

10. EXTERNAL AUDIT PROGRESS REPORT

NB provided an update regarding the External Audit progress to date and confirmed that they are still on track for reporting in line with the agreed timescales. NB and LC will be meeting with the Accountable Officer and the Chief Finance Officer to discuss the findings and report back at the next Committee meeting.

The Committee noted the External Audit Progress update.

11. AUDIT RECOMMENDATIONS TRACKER

The Audit Recommendations Tracker was reviewed by the Committee and progress reviewed.

The actions highlighted in yellow were agreed to be closed as the recommendations have been implemented:

8 | P a g e Item Subject Action by . Patient Engagement (16/17) – IA Ref. 1.2 . Prescribing, Delivery of QIPP Schemes (17/18) – IA Ref 2 and 5 . Delivery of the Integrated Urgent Care Service (17/18) – IA Ref. 1.1.6 . Risk Management and Assurance (17/18) – IA Ref. 1.1.5

The updates for open recommendations were reviewed and noted as the implementation dates have not been reached:

. Cyber Security (16/17) - IA Ref. 3.12 due March 2019 . Effectiveness of the Case Management System (16/17) – IA Ref. 1.1, 1.2, 1.5, 1.6 and 1.7 due March 2018 . Patient Engagement (16/17) – IA Ref. 1.1 due August 2018 . Conflicts of Interest (17/18) – IA Ref. 1.6 due March 2018 . GDPR Governance Advisory Audit (17/18) – IA Ref. 1, 2, 3, 4 and 5 due March 2018 . Delivery of the Integrated Urgent Care Service (17/18) – IA Ref. 1.1.8 due April 2019 . Follow-up (17/18) Governance – Committee Effectiveness - IA Ref. 1.6 due September 2018 . Follow-up (17/18) Cyber Security - IA Ref. 4.4 and 4.5 due April 2018

The Committee noted the progress made with the implementation of recommendations on the tracker.

12. REGISTERS OF INTEREST

The Committee reviewed the Declaration of Interests Register, noting that the process has been rigorous, and advised of action to be taken for the outstanding returns:

. Haileybury College to be removed from the list, . Declarations are only required from formal practice representatives as deputies have an opportunity to inform any groups/committees of declarations at the meetings, . Only declarations from formal members of HBL ICT are required (Sue Holland can provide the list), . New forms to be completed using information from previous declarations and provided to the Locality Managers to take to their meetings for the identified individuals to complete.

ACTION: MH to follow-up outstanding DOI returns as per MH

9 | P a g e Item Subject Action by actions identified by the Committee.

The Committee reviewed the Gifts and Hospitality Register and advised of no further comments.

The Committee noted the Registers of Interest.

13. ANTI-FRAUD AND BRIBERY POLICY

BV presented the Anti-Fraud and Bribery Policy which has been reviewed and updated with minor amendments.

The Committee asked for an amendment to be made to para 6.2.3 (p.20) to read “All staff must comply with this policy and...”

ACTION: JD to make amendment to paragraph 6.2.3 as advised by the Committee and arrange for policy to be uploaded to the website and communicated to all staff.

The Committee approved the Anti-Fraud and Bribery Policy.

14. COMMITTEE SELF-ASSESSMENT

The Committee members and attendees reflected on the self- assessment questions and made the following observations:

. In terms of specific training sessions, GDPR and COI have been addressed at the Governing Body meetings, and there was a dee-dive into Cyber-Security at the Committee meeting in January 2018, . The number of Committee meetings has been reduced for 2018/19 due to the robust Committee processes in place, . Audits cover greater areas than just finance, therefore provided robust assurances and actions for improvements, . Risk and governance issues are robustly debated and challenged at the Committee meetings, with issues being escalated to the Governing Body as required, . There was agreement that the Executive Lead for Delegated Commissioning should be invited to a Committee meeting to provide an overview of how actions and risks are being managed with the delegated responsibilities.

10 | P a g e Item Subject Action by ACTION: LF to advise JD of the date to schedule a review of Delegated Commissioning, JD to update the Annual Cycle of LF/ JD Business accordingly.

15. ANNUAL CYCLE OF BUSINESS 2018/19

The Committee reviewed the Annual Cycle of Business for 2018/19 and approved the schedule.

16. ANY OTHER BUSINESS

None.

17. DATE OF NEXT MEETING

Wednesday 16 May 2018: 10:00am – 12:30pm Charter House, 1st Floor MR1.2, Welwyn Garden City

11 | P a g e Agenda Item No: 14

Date of Meeting: 24th May 2018

Governing Body Meeting in Public

Paper Title: Joint Commissioning Partnership Board Minutes

Decision or Approval Discussion Information

Report author:

Report signed off by: Joint Commissioning Partnership Board

Executive Summary: Approved minutes of the Joint Commissioning Partnership Board attached for the Governing Body to note

Recommendations To note the minutes of the Joint Commissioning Partnership Board to the members: . 26th October 2017 . 30th November 2017 . 11th January 2018 . 15th February 2018 . 15th March 2018 Conflicts of Interest n/a involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Page | 1 Joint Commissioning Partnership Board Thursday 26th October 2017 Venue: QE2 Hospital, Howlands, Welwyn Garden City

1 Declaration of interest None.

2 Attendees: Harper Brown (HB) – Director Of Commissioning, East and North Herts CCG (ENHCCG) Anna Hall (AH) – Senior Commissioning Manager, Mental Health, Integrated Health and Care Commissioning Team (IHCCT), Hertfordshire County Council (HCC) Ted Maddex (TM) – Commissioning Manager, Community Wellbeing Team, HCC Beverley Flowers (BF) – Chief Executive, East and North Herts CCG, ENHCCG Kate Barker (KB) – Assistant Director, Maternity Children and Young People, ENHCCG Kulbir Lalli (KL) – Head of Integrated Accommodation Team, HCC Husnara Malik (HM) – Deputy Head of Service, Community Wellbeing Team, HCC Oliver Barnes (OB) – Senior Commissioning Manager, Children’s Services, HCC Marion Ingram (MI) – Operations Director, Specialist Services, Children’s Services, HCC Sarvjeet Dosanjh (SD) – Senior Commissioning Manager, CAMHS, HCC Charlotte Day (CD) – Support Officer, Commissioning Support Team (minutes)

Apologies Simon Pattison (SP) – Head of Integrated Health & Care Commissioning Team (IHCCT), HCC, ENHCCG, and Herts Valleys CCG Prag Moodley (PM) – GP Board Member, ENHCCG Frances Heathcote (FH) – Assistant Director Health & Community Commissioning, HCC Jim McManus (JM) – Director of Public Health, HCC Ruth Harrington (RH) – Head of Community Wellbeing Team, HCC Edward Knowles (EK) – Assistant Director, Integrated Health, HCC Hayley King (HK) – Programme Manager, HCC Maria Nastri (MN) – CAMHS Transformation Manager, ENHCCG and Herts Valleys CCG Kristian Tizzard (KT) – Deputy Head of Service, Integrated Accommodation Team, HCC 3 Previous notes 3.1 Previous minutes agreed.

3.2 Matters Arising Item 6 Exception Update Report from IHCCT AH informed the group HPFT Delayed Transfer of Care (DToC) ‘deep dive’ was included in ENHCCG SRG meeting papers on 13 October 2017. This focused solely on HPFT’s delayed transfers of care. ACTION 1: AH to circulate the paper. AH 4 Terms of Reference AH shared that in regards to the recent review, clarification is needed on whether JCPB is a sub-group of the governing body. BF replied that the JCPB group is not formally a sub-group of the governing body in the current government structure. However the structure is due to be

1 reviewed December 2017 and a change recommended for JCPB to formally become a sub-group of governing body, as it has the ability to undertake actions on behalf of the governing body.

AH also questioned whether a quorum needs to be agreed, and how often JCPB will need to meet in future if the group is due to become a sub-group of the governing body. BF replied that the group will need to meet and report quarterly, and if a quorum is agreed attendance as a minimum should include 3 members namely: 1. Representative from ENHCCG 2. representative from HCC 3. One other member

ACTION 2: AH to amend ToR and forward to ENHCCG Governance Team. AH 5 Community Wellbeing Team 5.1 HVCCG S75 Budget Reductions. Paper issued with agenda.

HM provided an update on Herts Valleys reduction to the Voluntary Sector Contracts Section 75 funding contribution. HCC have agreed to continue funding contracts at the current pricing level until 2019. HCC met with Herts Valleys in September with a proposal which consisted of net savings of £95,000. Within that, East and North Herts net savings are £19,000. Herts Valleys have agreed to this proposal from 1st April 2018 and all providers are aware. HM added that three Community Engagement Services will be ceased by March 2018; these are Guideposts, Herts Mind Network and Bosnia. In addition to this, HM highlighted that HCC are working closely with an additional three services, possibly changing them from ‘block’ contracts to ‘spot’ contracts. These are Tilehouse, Hightown and Three Rivers Trust. HM will provide an update at a future meeting in regards to the review of these models.

HB questioned whether impact assessment has been conducted. TM replied that impact assessment has been completed, after conversations with service users; found that there are other services than can be used with minimal effect. HB questioned what the mechanism will be for tying down partners for this 3 year investment strategy. HB then noted that it would be beneficial to work in a partnership with other organisations due to locality issues. Also, need to use technology to promote the services available as many are unaware. HB gave an example of “www.letsema.com” ACTION 3: HM to coordinate meeting with Harper Brown/Ruth Harrington/David Evans to agree mechanism for commitment to 3 year HM strategy. 6 Exception update report from IHCCT

6.1 CAMHS Tier 4 Models of Care Paper issued with agenda.

SD informed the group that NHS England have negotiated parts of the system they will be funding, going forward. HPFT have put together slides around financial modelling which show predicted savings. These are 269k which will be put into community services, this process will take around 18 months.

2 SD added that HPFT are taking on secure beds locally, and large care packages which reduces the risk to CCGs but increases the gain for the quality of the model and working closer with social care when the model is put in place. Will start December 2017 but won’t be fully in place until April 18, scheduled for an 18 month pilot. Opportunity for alignment with S136 CYP opening in April 2018.

KB questions whether HPFT are going to allocate a Project Manager to support the process. SD is unsure. Discussion re the dynamic risk register / CAMHS Crisis pathway - owning the Tier 4 pathway means Hertfordshire can make the CAMHS crisis element better (can Forest House support people going into crisis rather than waiting for CYP to be bought in under S136) / Transforming Care pathway. ACTION 4: CAMHS Tier 4 to be added to the agenda for the next Crisis SD Pathway meeting and the next CIPICE and Transforming Care meetings. KB

6.2 IHCCT Exception Report Paper issued with agenda.

AH shared that inpatient admissions are improving and the current delayed transfers of care target has reduced to 6.8%. Target is due to drop March 2018 to 3.4%. BF raised concerns regarding how HPFT are calculating DToC. This is being picked up elsewhere.

In regards to routine referrals to Community Mental Health teams, AH noted there were 15 breaches in August. CPQ due to meet 27/10/2017 and will be discussing DNA’s (Did Not Attends) There is a 28 day target of which patients need to be seen in. If patients DNA the first appointment then the expectation is that another appointment should be offered within 28 days. HCC have questioned and are having ongoing conversations with HPFT around safeguarding issues if a second appointment is not offered within 28 days.

HB asked if there is a deadline and noted that many of the DNA’s were for non-clinical reasons e.g.) location of appointment. Needs to be a simple follow up method put in place. BF answered that this is an issue but needs to be discussed at CPQ.

AH explained that IAPT are 131% over target in relation to the number of people going into treatment with HPFT. AQP have had a reduction in providers. The two remaining have filled capacity and have identified new sites east of the A10 and will be offering an additional 80 sessions a week. AH added East and North Herts are 2% below target for Dementia Diagnosis - works out to be 120 patients. Dementia practice visits are being planned, most of these are aligned to care homes and CCG’s have access to data coming through the system showing practices that have unidentified dementia patients and will be targeting those.

AH noted that Jan Gates will give a full update on Learning Disability at the next meeting, however Health Checks have 52.8% and new template has been created. Percentage is only calculated by number of claims so this is a problem as people only claim once a year. MI offered an opportunity to link into her teams to support completing health checks, in regards to looked after children annual reviews - can the two reviews be aligned? ACTION 5: AH to advise Tracey Brennan of MI offer

3 ACTION 6: Kate B to speak with Chantelle. AH SD informed the group HPFT are back on track with CAMHS 28 day wait KB targets. This was fed back at National Mental Health Clinical Commissioners event - impressed that commissioners are part of review and how recoveries of 28 days waiting time were handled. Step 2 are doing well on wait times, however there is a continued increase in referrals for Tier 2. The re-tender of tier 2 due to go live at end of November.

In addition, SD noted that PALMS have had improvement in their wait times. However number of referrals is high so still an issue. CQC highlighted PALMS as a model of good practice. Crisis Pathway had an unannounced quality assurance visit at Lister – found that not working as should be. Will be picked up at next Crisis Pathway meeting in November 2017. 7 Children's agenda 0-25

7.1 CAMHS Local Transformation Plan refresh sign off & Refresh of Integrated 0-25 SEND Commissioning Strategy SD shared that Maria Nastri has been working to tight time scales to provide the CAMHS Local Transformation Plan Refresh. Feedback in light of the CQC review, were to be incorporated ahead of the document needing to be on the system by 31st October. SD highlighted within the plan there are 12 work streams and the whole focus is on ensuring partnership working across the whole system. 5 year plan part of FYFV. KB added that over the next year it is important to review how to learn from the benefits from implementing IAPT and i-thrive model. As children’s/family’s needs are more complex, Hertfordshire are piloting new workforce delivery models, which have been well received. They are integrating well into the universal health and wellbeing workforce – will help aid future workforce development. KB noted that the central recommendation is that public health are part of the strategy, going forward.

0-25 SEND Commissioning Strategy KB shared that following recent feedback from CQC and Ofsted, planning to review the current strategy against headlines from last year’s national review. 2 years ago when the strategy was agreed – Hertfordshire was in a different financial position. There is now ambition for developing children and young people’s BCF, STP and new relationships with West Essex. KB added that a draft refresh will be taken through governance processes and should have a copy available for review end of Jan JCPB. ACTION 7: Anna to put on forward plan – February 2018 AH

7.2 Speech and Language Therapy Digest Paper & Autism Pathway options appraisal

Speech and Language OB updated the group on the re-commissioning of speech and language therapies. Working on a revised specification countywide which will include needs of education and health in one document. The focus is on ensuring everyone is aware of speech and language therapies across the system by implementing effective whole classroom strategies, a holistic way of addressing needs. KB added that previous learning material used was unsuitable, as the market has changed and technology has changed. Provider now needs to be able to recognise and test the workforce’s ability to deliver what they have been trained in. Going forward will be more partnership working.

4 Equipment OB noted that currently lacking a structural framework around service delivery – unable to elucidate an equipment offer. Commissioning team working to define a policy framework in partnership with Herts Parent and carer groups and the equipment service. Main focus is to enable access to curriculum, and ensure functional living in home environment. Needs based assessment to achieve this.

Autism pathway KB shared that in regards to East and North Herts, they have spent 1 year with clinicians producing the preferred model, however still have an unidentified amount of money available for investment via CAMHS transformation. Over the past 3 weeks – working with East & North Herts Trust paediatricians (Palmer Winstanley is ENHT lead at Lister hospital) and now in the process of being able to define a lean approach – proposed pilot for next year. Proposal for delivery 2018. SALT re-design is crucial to this proposal. Duplication of processes to be eliminated. Proposal is to streamline process, using an electronic portal single point of access- 5/6 day a week of virtual experts to do triage/assessment. HPFT to be invited in to be part of the MDT. Cohorts: Pre-school/early school age and post 14 year olds. Once this analysis completed by ENHTcan cross reference against the business case for Hertfordshire to review if HVCCG retain their investment and HCT resource. All Age Autism Board is running a scrutiny process on the strategy. This acute pathway is crucial to the strategy delivery. Will need to have a clear narrative on the pilot/process being proposed.

Feedback on CQC Thematic Review of CAMHS 7.3 SD noted that the action report is due 27/10/2017 – headlines mostly positive. Preparing a press release.

8 Integrated Accommodation Commissioning Team

8.1 Update on beds based discharge to assess and rehabilitation KL presented an update on behalf of Kristian Tizzard regarding the existing arrangements around discharge to assess and intermediate care beds supporting Lister and Princess Alexandra Hospital (PAH). KB noted there has been a big shift in the market over the course of the year. In March 2017, Quantum Care lost 14 enablement beds. There are some issues with current bed profiles - step down beds at Runwood Homes, which is a residential setting – currently trying to manage issues with inappropriate admissions as there have been nursing referrals sent to Runwood causing care delivery and performance issues as the home is not set up to deliver nursing care. Will report on effectiveness of those particular beds early new year. Reports delayed transfers of care (DToC) have not increased due to withdrawal of Quantum beds.

KL continued to share that commissioning of GP and therapy services is proving difficult which is in turn causing delays or preventing capacity being bought online. The current bed capacity at St Christopher’s Home is delayed due to issues with securing a GP. Also, Highfield nursing home currently has two beds that HCC are unable to support residents in as HCC unable to secure therapy resources for them.

Within ACS the supported accommodation strategy has now been signed off.

5 The strategy is due to shift the way HCC engages with care providers and will change contractual models. Will be using ‘block’ contracts – re-landscape commissioning work in regards to this. This will enable access for HCC to get the right mix of long and short stay beds over next 2 years. ACTION 8: KL to circulate paper of detailed road map. KL

KL explained that going forward ACS are hoping to have discussions with CCGs around joint bed modelling to fully understand the most effective pathway to support discharges. ACS also will be working on a procurement framework and putting a capital model in place. Hoping to be in a position to roll out new block arrangements by this time next year.

HB notes that in relation to joint bed modelling a meeting between KL and himself will be suitable in early November. HB hopes to be in a position by the end of October to have a case mix analysis completed by locality and practice, which needs to tie in with the accommodation strategy and bed modelling. ACTION 9: HB and KL to schedule this meeting. HB/KL 9 Integrated Care Programme HK is now acting for Jamie Sutterby as he has left HCC. HK will present an update on the Better Care Fund (BCF) in November 2017. BF confirmation that the BCF has been signed off by NHSE

10 Public Health No Public Health representative present.

11 Any Other Business MI shared that that in regards to Wynchlands Home, there has been difficulties with Herts Valleys. Not going to progress without written contract – HCC have developed a legal arrangement and sent to both CCG’s. Ready to go out to tender but need signed contract/legal agreement by an agreed date. MI stated that if there has been no update by Christmas she will have no choice but to take Wynchlands back to the Transforming Care board and abandon the home.

MI then stated that Herts Valleys revoked their decision on Nascot Lawn due to incorrect legal advice and are now due to review and make a new decision by 16th November.

AH provided an update on Beyond Places of Safety capital funding opportunity. An Extraordinary Crisis Care Concordat meeting took place 13 October 2017 and on the preferred scheme to scope feasibility is a ‘mobile caring bus.’ This will provide preventative care with Voluntary Sector services using during the day, and will be a Crisis Bus in the evening. AH added that the final details need to be worked out, but the final bid has to be signed off by STP and Emergency Care System by 21st January 2018. KB shared that in Milton Keynes, a similar bus has been converted for the homeless during winter. ACTION 10: KB to send a link regarding similar bus in Milton Keynes for the homeless. KB

12 Next meeting Thursday 30th November 2017, 09:30-12:30 QE2, Room 2.098, Howlands, Welwyn Garden City

6 Joint Commissioning Partnership Board Thursday 30th November 2017 Venue QE2, Meeting Room 2.098

1 Attendees and Apologies

Attendees: (Chair) Harper Brown (HB) – Director Of Commissioning, East and North Herts CCG (ENHCCG). Simon Pattison (SP) - Head of Integrated Health & Care Commissioning Team (IHCCT), Hertfordshire County Council (HCC), ENHCCG, and Herts Valleys CCG. Prag Moodley (PM) – GP Board Member, ENHCCG Frances Heathcote (FH) - Assistant Director Health & Community Commissioning, HCC Hayley King (HK) – Programme Manager, HCC Oliver Barnes (OB) – Senior Commissioning Manager, Children’s Services, HCC Jim McManus (JM) – Director of Public Health, HCC Anna Hall (AH) – Senior Commissioning Manager, Mental Health, IHCCT, HCC Helen Cavanagh (HC) – Commissioning Manager, IHCCT, HCC Daisy Sanghera (DS) – Deputy Head of Service, Integrated Care Services, HCC

Apologies: Ruth Harrington (RH) – Head of Community Wellbeing Team, HCC Kulbir Lalli (KL) – Head of Integrated Accommodation Commissioning Team, HCC Beverley Flowers (BF) - – Chief Executive, East and North Herts CCG, ENHCCG Marion Ingram (MI) – Operations Director, Specialist Services, Children’s Services, HCC Charlotte Day (CD) – Support Officer, Commissioning Support Team (minutes)

2 Declarations of Interest

HB shared going forward JCPB will need to have a tighter forward agenda to fit with new interest declaration protocols. A format will be circulated so attendees can sign to say whether there are any conflicts of interest. Also will need to be clearer on core members and their attendance to meetings. Discussions can involve people with interests, but they will not be involved in the ‘final decision.’ Where there is commercially sensitive information coming to JCPB - will need to divide the meeting into two parts. Working assumption is that if the information is subject to FOI then JCPB are to be transparent - need to put papers on public website to comply with auditors requests. 3 Previous minutes

Attached

AH raised that BF questioned whether JCPB should have a non-executive member on the attendee list. Action 1: AH to update terms of reference to include an open invite for non- AH executive.

HB questioned whether any progress had been made on the previous Community Wellbeing team discussion around Herts Valleys - no meeting set up with Ruth and David. Will need to have something set up by January. RH/HM ACTION 2: RH/HM to set up meeting

SP shared that CAMHS Tier 4 was discussed at the previous Crisis Pathway meeting. Overall message was that there is work to do for HPFT and Lister regarding working together more efficiently.

1 KB updated that in regards to Section 7 Autism, there is a potential pilot scheme for 0- 18 year olds which is subject to a business case, this is to be considered with ENHT. Herts Valleys CCG does not provide a full offer for their small paediatric service. Currently testing ENHT to be lead provider and ENHT costing additional SALT and OT resource needed. These volumes are to be determined.

In regards to section 8 FH highlighted that there is a disconnect through the IMC board and JCPB and questioned whether an operational person from ENHCCG is needed on JCPB. HB agreed that this would help. Action 3: HK to highlight to Tom the importance of linking the gaps between IMC HK and JCPB.

Action 4: ACS Commissioning Support (CD) to put this on action tracker and can CD keep on review/open until things improve.

KB provided a further update on Nascot Lawn. Families are going for second judicial review (on grounds that HVCCG did not undertake a full public consultation). HCC received a pre-court action letter dated 29.11.17. Other interested parties are contacting the commissioning team with information requests, so need to be careful regarding this. The current position is that HCT have served notice, dated 17.11.17 and proposing to close Nascot Lawn on 17.05.18 however hoping through contract decisions that end of March 2018 would be more viable. Families have been given transition plans. First county wide meeting of all Nascot Lawn service users is commencing week of 04/12/17.

In regards to Wynchlands, KB stated that the plan is to go out to procurement in the next couple of weeks. There has been further work on reviewing the financial model which would enable both CCG’s to identify what their contribution would be. ENHCCG recommend that we do continue partnership commissioning so that local provision is supported for our most vulnerable children. Paper coming to executives next week.

FH highlighted that the road map from the accommodations team has only just been signed off, so will have this sent round. Action 5: KL to forward final signed road map. KL Action 6: ACS Commissioning Support (CD) to circulate road map with minutes. CD 4 Public Health 4.1 Prevention Concordat

Paper attached

JM reminded the group that two years ago the Health and Wellbeing board adopted a ‘whole systems approach’ to Mental Health. Last time JM provided an updated there were 200 work streams as part of this. There were two things that unified the approach, these were the pathways and the systems approach report overseen by the Health and Wellbeing board. However there was not much in regards to prevention. Public Health England has produced a “Prevention Concordat” similar to the Crisis Care Concordat. The Prevention Concordat was launched in August and Hertfordshire have helped build it and are now one step closer to having a ‘whole systems approach’. The Concordat consists of a ‘Consensus Statement’ and a series of resources – faculty of PMH toolkit. JM highlighted that the reasons for creating the concordat are down to the burden of disease growing exponentially, prevention of developing a mental health issue and to help patients to recover quickly.

HB questioned how this is due to be implemented. Hertfordshire have limited

2 resources, which is a growing problem. HB then highlighted that by just stating a patient has a MH problem there becomes a vague danger to push people towards medical responses which may not be healthy as this then becomes reflected in society also e.g.) schools.

JM replied that Public Health are looking into a whole range of things around non- medical interventions and sees this as an opportunity to build non-medical approach to mental health.

PM then questioned how this is going to operate on the ground and how to ensure it is practical.

JM replied that firstly it would be important to get a collective sense of where the greatest impact the concordat could have on prevention. This would include: • Schools working to early identify and put in place resources rather than automatic referral to CAMHS. • Social prescribing - Primary care/Vol Sec (community navigators remit) • Pathway - stat and non-stat - including Kooth • Early into IAPT • Employers engagement

JM finalised that a one off meeting with is needed to discuss the whole systems approach further, and map where any gaps are and come back with an update. Action 7: JM to meet with SP, Jen Beer (PH), IHCCT, CWB, and Kate Barker: JM commencing in the new year.

Action 8: JCPB to sponsor a meeting between Councillors/GP leads meeting - JM would like to get GPs together with their MH champions - GP JM Leads/councillors evening.

JM then shared a new Sexual Health clinic in Stevenage: Southgate Sexual Health clinic, are due to have an open morning on 10th January 2018. Has 13 consulting rooms, and all staff are trained in mental health response, and are due to be trained in health psychology. Biggest clinic in Herts, centralised for HIV treatment, 5 IHCCT

5.1 Strategy/policy issue (commissioning intentions) • Decision on IAPT Long Term Conditions model for 2018/19, paper attached.

SP shared that there is a national target to increase the number of patients accessing IAPT. The target was 15% but as part of the ‘5 year forward view’ – this has gone up to 25% by 2021. To put into perspective, 15% was 9,500 people, so this means there will be an increase of 6, 500 patients each year accessing IAPT. Target for this year is 16.8%, next year 19%, and the year after likely to be 22%. At the moment, there are two different ways of providing IAPT. HPFT make up 12.8% of target and the balance is made up of two main counselling organisations which are paid on a case by case basis. At the moment on track to reach 16.8% target this year.

SP continued by stating that another driver is more people with long term conditions are accessing IAPT. Both Herts Valleys and West Essex have started pilot schemes. Herts Valleys centring on Diabetes and West Essex on COPD. These are to focus on people in those pathways and how they access IAPT. Very early evidence from first 46 people having a positive impact. SP to look into the contractual position in regards to tension between AQP and practices, regarding employment and management. Action 9: SP to discuss with LS to bring back to Jan 2018 JCPB meeting - pilot in practices from Feb 2018 - how this is going to be measured etc. to be able to propose in CFF from end March 2018. SP

3 • New Leaf (Wellbeing College) Options appraisal.

HC stated that New Leaf project started in June 2016 and due to run to March 2018. Built on co-production, various input from service users, carers, voluntary sector, HPFT, Druglink and Herts Community Trusts. In the early stage, it was a slow process, opened in Jan 2017. Started with 3 courses and are now running 10 courses throughout the whole of the county. Been a drive to get more courses out there to meet wider audience. DNA rates Over 900 enrol, but only 50% attending courses. Contacted other recovery colleges, this is the norm. One thing Hertfordshire has over other recovery colleges is, Herts look at both mental and physical health. Positive feedback so far, as part of this process, a review has been done however to evaluate college fully, more information is needed - limited information, only a small cohort. Options for the future of the college. There are four options: • Decommission the project and take no further • Go to full procurement however not really able to do this at the moment • Extend pilot to end of academic year • Extend it to early 2019.

KB asked what has been transformed by having New Leaf. What the learning from the colleges is to be able to evidence outcomes.

HC highlighted that one issue is the college is lax in developing learning plans with individuals; this may be a factor into the high DNA rates. However HC acknowledges that this wouldn’t be appropriate for everyone. More info needs to be provided from New Leaf to be able to understand this better.

KB proposed to stop the pilot in March 2018 and see what has been learnt around self- care.

HB suggested an implementation plan for year 2 is to come back to JCPB Feb 2018. At that time JCPB will know if HVCCG/ACSMB has bought into the proposals by then. Agree into the principles/concept of wellbeing college, but needs to be the right type of service in Hertfordshire – need to ensure Hertfordshire have got it right. Action 10: HC to pull together the above implementation plan - which measures HC success - what will be achieved by Q4 2018. DNA problem addressed in implementation plan.

5.2 Operational Performance • IHCCT Exception Report, paper attached.

HPFT Performance SP shared an update on HPFT performance. There are continued issues with delays transfers of care. Routine referrals to community MH teams within 28 days are now just below target but up to 96% in East and North Herts. This is an area of concern in Herts Valleys - keeping an eye on this. Staffing, PDPs, training and sickness all remain above target. This was picked up at last quality meeting. Told to keep recruiting and keep on top of staff pressures.

Dementia Diagnosis Dementia diagnosis are below target – 64.6% against 66% target. This has been flat for number of months. Emma Williams is visiting a number GP

4 practices that are furthest away from targets. Locality performance, three are above target and three are below.

LD Health Checks Detailed update in December

SPAR Performance This is back on track generally – going to turn off fax machines properly on 11th December. Significant drop in number of faxes but small number that continue.

CAMHS performance Maintaining 95% target, only 3 cases gone beyond 28 days. Pressures in terms of PARMS, work continues to improve backlog and recruit staff. Tender for Tier 2 provision which will go live 1/12/17.

Employment and Herts Primary Care MH Services Due to go live with 3 pilots across Hertfordshire early in the new year – different set up but looking to loosen support around GP’s and HPFT.

Beyond Places of Safety Capital funding bid, have had a number of meetings regarding the mobile caring bus proposal, 3 non-statutory organisations and HPFT attended. Idea around being used by VCSO’s as a prevention bus in the day and in the evenings being used by HPFT and VCSO’s to respond to crisis. VCSO’s decided not to proceed with capital funding bid, mainly due to revenue funding for asset and concerns regarding meeting value for money criteria. Review of community crisis offer being undertaken by HPFT with VCS organisations in partnership.

Action 11: AH to circulate the BPOS briefing to JCPB members. AH

5.3 Street Triage Update Q2 17/18 – for information

AH shared that HPFT ST KPI's will go into the HPFT QS tracker from Q3. Action 12: ACS to share the HWB link to OPCC Street triage report and CCC 13 CD Dec 2017 presentation from NEF Consulting, when available. 6 Integrated Care Services

6.1 Operational Performance Support at Home update

DS updated group on the tender which went live in September this year, following last year’s termination of Comfort Call. Comfort Call were the lead provider in Welwyn, Hatfield and Broxbourne. There were 9 bids, across the 4 separated lots. Only able to take 2 to final stage. Abbotts Care was the successful provider on all 4 lots. Contracts in place now and being monitored.

7 Integrated Accommodation Commissioning Team

7.1 Operational Performance BUPA care homes

FH presented an update on BUPA care homes; BUPA made a strategic decision to sell homes which have less than 60 beds. 3 of these homes are in Hertfordshire which are now being sold to HC One – KL has circulated notes from previous meetings with HC One. Have had assurances that nothing should change, HCC’s main focus is on keeping staff. Consultations are taking place and letters will be going out to residents and

5 families following those. HCC have created a briefing note for the call centre, for precaustion. Formal contract novation will take place. Hoping this is a transactional process and wont impact strategically. HCC being very proactive with BUPA and HC One. Risk that HC One may increase fees and they have no other homes in Hertfordshire. HCC’s Biggest areas of concern • Ensuring strategic relationships • Continuity of care - staff and patients

Another meeting with HC One is scheduled for 11th December and intended handover date beginning of next financial year. Action 13: AH to put on Forward plan. AH Action 14: KL to provide verbal update at December meeting, following next KL scheduled meeting with HC One on 11 December. 8 Integrated Care Programme

8.1 Better Care Fund Quarter 2 17/18 Update

HK shared that Tom will be presenting update every quarter at JCPB. This has been signed off at Health and Wellbeing board. No risks for quarter 3. In regards to permanent admissions to care homes, this is on track and is continuing to manage new admissions. The proportion of people still at home 91 days after discharge, expecting numbers to increase. Mitigations in place, home to access pilot launched 29.11.17. Herts Home Improvement Agency partnership between HCC/district councils - soft launch Oct 2017. Hoping that this will be another way of keeping people at home with right equipment and care. Finally, DToC very aware not meeting target, but must note that performance better than last time this year. Reduced Q2 delays 16% at the moment, last year was 20% at this point. 9 Any Other Business

No other business.

10 Next meeting - 21st December 2017, 13:00pm-16:00pm, QE2 meeting room 2.098

6 Joint Commissioning Partnership Board 11th January 2018 Charter House, Meeting Room 1.2, Welwyn Garden City, AL8 6JL

MINUTES

In Attendance: Title:

Eleanor Attrill(EA) Commissioning Manager, LD, Integrated Health and Care Commissioning Team, HCC Kate Barker (KB) Assistant Director, Maternity and Young People, ENHCCG Tracey Brennan(TB) Commissioning Manager, LD, Integrated Health and Care Commissioning Team, HCC

Harper Brown (HB) Director of Commissioning, East and North Herts CCG (CHAIR)

Helen Cavanagh (HC) Commissioning Manager, MH, Integrated Health and Care Commissioning Team, HCC

Charlotte Day (CD) Support Officer, Commissioning Support Team, HCC

Jan Gates (JG) Senior Commissioning Manager, LD, Integrated Health and Care Commissioning Team, HCC

Anna Hall (AH) Senior Commissioning Manager, Mental Health, Integrated Health and Care Commissioning Team, HCC

Frances Heathcote (FH) Assistant Director, Commissioning, HCC

Tom Hennessey (TH) Assistant Director, Integrated Health, HCC

Marion Ingram (MI) Operations Director, Specialist Services, HCC

Kulbir Lalli (KL) Head of Integrated Accommodation Commissioning Team, HCC

Prag Moodley (PM) GP Lead, ENHCCG

Simon Pattison (SP) Head of Integrated Health & Care Commissioning Team (IHCCT), HCC, ENHCCG, and Herts Valleys CCG.

Page 1 of 9 Item Subject Action by

1. Welcome and apologies for absence:

HB welcomed all to the meeting. Apologies were received from:

• Jim McManus (JM) – Director of Public Health, HCC • Hayley King (HK) – Programme Manager, HCC

2. Declarations of interest:

HB invited members to declare any declarations relating to matters on the Agenda. All members confirmed they have no declarations.

3. Minutes of previous meeting and matters arising:

The minutes of the meeting held on 21st December 2017 were approved as an accurate record.

4. Action tracker: The contents of the Action Tracker were discussed.

The following actions were agreed to be closed:

• AH to circulate paper on DTOC. • KL to circulate paper of detailed road map RE: Beds • SD/KB to add CAMHS Tier 4 to the agenda for the next Crisis Pathway meeting and the next CIPICE and Transforming Care meetings. • AH to circulate the BPOS briefing to JCPB members. • ACS to share the HWB link to OPCC Street Triage report and CCC 13 Dec 2017 presentation from NEF Consulting. • AH to update forward plan in regards to BUPA/HC One • KL to provide verbal update December meeting in regards to HC One • HB requested that Nightlight tender to be put on the agenda for January.

The following updates were provided:

• Action regarding Non-exec invite to JCPB to be kept open, the intention is having a non-exec invited to each meeting. • A meeting between David Evans, Ruth Harrington and Harper has not been co-ordinated yet. • Marion Mansfield has begun organising meeting for Jim

Page 2 of 9 Item Subject Action by McManus • IAPT delayed until next month. • New Leaf implementation plan next month

ACTION: The Action Tracker to be updated to reflect the updates. CD

HB asked for an update on progress for the Winter Pressures programme.

ACTION: SP to include an update for Winter Pressures progress in SP the IHCCT team update at Feb JCPB

5. Integrated Accommodation Commissioning Team

5.1 Operational Performance

5.1.1 BUPA Care Homes

KL shared an update regarding the sale of three BUPA homes to HC- One:

• Woodlands View • River Court • St Christopher’s

The sale went ahead at the end of last year (2017). KL stated that this transition went smoothly with no disruption of service. There were also no calls from residents or families. KL has met with key people at HC-One; Director of Commissioning Care, Area Quality Director and the Intermediate Care Lead to talk about how the transfer is progressing. They agree it is going well. HC One have started to think about expanding beyond those three homes in Hertfordshire. They are also looking into use of technology to support those with challenging behaviour rather than 1-1 staffing. Finally HC-One are also developing a suite of ‘key performance indicators’ and ‘clinical indicators’ which will be rolled out across the three homes. Data from these will be reported back. KL due to meet with HC-One again in April. KL finished by stating that overall the transfer has been positive and at the moment there is good engagement across all levels.

5.1.2 CCG Annual Fee Uplift

KL updated the group that inflationary offer for 18/19 will be going out to members in the coming weeks. There is a process in place should providers feel the offer isn’t enough.

HPFT alignment of inflationary uplift with their secondary commissioned

Page 3 of 9 Item Subject Action by bed providers.

ACTION: KL to discuss with Andrew Godfrey KL

5.1.3 Resilience and Risk – Care Home Beds

KL stated that Four Seasons have come to a deal with wider partners in regards to the debt that was due in December; however this is only thought to last for the next month or two. A system resilience meeting took place in December 2017 between HCC and CCGs to conduct risk management work. KL continued to say that the advice received from ADASS and CQC is to continue as normal.

IACT have been completing a piece of work around mapping out exposure to risk for the three homes across Herts and are hoping to have this finished by 12/01/18. This will look at financial risk and proxy indicators such as management, staffing levels and a judgement around the overall environment of the homes.

KL shared that HCC are trying to arrange planning meeting with the CEO within Four Seasons to develop a contingency plan should the worst happen.

6. Integrated Health and Care Commissioning Team

6.1 Strategy/Policy Issue (commissioning intentions)

6.1.1 HPFT Contract Negotiations Update and Changes for 2018/19 SP shared that there are two factors in the negotiations currently, first is the agreement of national variation and the second is agreement of finances for next year. Agreement of the national variation: A final version of this was released week commencing 1st Jan 2018. SP stated that this looks very non- controversial and will need to be completed by the end of January. Agreeing the finances for next year: SP shared that this includes a ‘service development improvement plan’ and a ‘data quality improvement plan’ need to be complete by end of February 2018. SP shared that there have been some conversations with HPFT about money, but more is needed to clarify how much extra money is needed. Priority areas are likely to be: • Early Intervention Psychosis (EIP) • Improving Access to Psychological Therapies (IAPT) • Psych Liaison (CORE 24) • RAID • Demography However SP finalised by stating that more detail from HPFT is needed to confirm this and the plan is to be signed off by the end of February 2018.

Page 4 of 9 Item Subject Action by

Nightlight Tender Outcome (CONFIDENTIAL) 6.1.2 This item has been minuted separately.

6.2 Operational Performance

6.2.1 Learning Disability Update – Transforming Care & Health Priorities including LeDeR

TB updated the group in regards to work that has been conducted between herself and Community LD Nurses within each locality team. One of the key priorities is LD health checks, TB shared that it is a struggle to get the correct data around health checks. Health checks are from the age of 14+ and the numbers for 14-17 are particularly low. The target is 70% nationally. Community Nurses promote health checks and encourage those to have health checks but it would be helpful to have regular updates from practices on how many health checks have been conducted. PM added that the data issue is very important, and needs to be addressed as otherwise all hard work from previous years will be lost. A better system is needed. PM suggested that the CCG can produce a template letter to go out to each locality practice to request data for this year so that any that are struggling have 3 months to improve and try to reach the target.

PM also noted that while the link nurses relationships with practices have improved, there should be a formal regular meeting so that nurses can promote LD Health Checks and practices are clear on who their link nurse is. ACTION: TB to report back to the Community Nursing Teams that they should be attending a practice meeting on a regular basis for TB their local practice.

TB continued with the Learning Disability update and stated that there has been a third criteria added to the ‘National Indicators’ around completeness of practice registers. Last year nurses went to all practices and updated the records based on social care transfers of information so this data is reasonably up to date. TB added that there has been some feedback around diagnosis. Patients with a Learning Disability are generally diagnosed by age of 12, however there are always going to be patients undiagnosed so as a result of this there will be a new screening tool for practices so that GPs can use this and this will in turn improve their registers.

KB questioned whether this has to be undertaken by a GP as we need to think about reducing demand for primary care. KB added that possibly need to think about using other professionals who are competent to use a screening tool rather than encouraging patients to go to a GP if they think they have a Learning Difficulty/Disability.

Page 5 of 9 Item Subject Action by PM added that it could be promoted to go to a link nurse for a screening however the tool should be put onto Arden’s so that GP’s have access should they need it. PM then noted that there are some patients on the register who don’t know why they are on a learning disability register or should not be on the register. The register should be reviewed regularly and this should be done electronically.

TB continued with the Learning Disability update in regards to links with STPs. TB has formed a group with a Commissioner who looks after West Essex and is linking in closely. TB added that we also need to see how we link with other work streams, where LD has a separate pathway and have recently developed a pathway around epilepsy. Adding to this, a large amount of work has been conducted in regards to Mortality Reviews. Mortality Reviews mean that every patient over the age of four with a Learning Disability is given a review if they have died. The National Process has been altered a small amount but this will be robust and work for Hertfordshire. TB will gather GP records centrally rather than the reviewer contacting GPs and families ensuring that all reviews are completed quicker.

Finally, TB updated the group on STOMP which is a programme that has been set up looking at the number of patients who are being over medicated or not receiving the right medication. A working group for children has also been developed. The next meeting is in two weeks.

KB asked for the ToR, objectives and notes for STOMP to be circulated. ACTION: TB to provide the ToR, objectives and notes for STOMP to ACS Commissioning Support for circulation. TB/CD

EA then provided an update on Transforming Care. The key update is that Transforming Care will be coming to an end in March 2019. Hertfordshire’s main question to NHSE is what next steps will be. For Hertfordshire, the work and patients will remain so the main focus is trying to mainstream it as much as possible. Hertfordshire are doing really well, although the numbers are low. HB highlighted that an important aspect to consider is continuity of care, and ensuring each patient has a care plan that they own rather than a number of different care plans. KB questioned how we prepare our local accountable care system to take responsibility for this population. While the model remains isolated it still stays as ‘specialist’ and won’t become mainstream. EA replied that at the end of the programme, what has been left is a core group of people who have complex needs that we were unable to crack the model for. EA has been talking to Matt Peirce and Ruth Harrington about what is needed on the framework, looking at specialist providers and trying to grow the model.

Page 6 of 9 Item Subject Action by HB suggested that this needs to be picked up across STP as otherwise there may be duplication. HB proposed a workshop in February and a Workshop in March to try and map out the ranging location of services and agree together what the model looks like, including providers.

6.2.2 HPFT New SPA Telephony Systems AH provided an update on behalf of John Lavelle from HPFT. SPA (Single Point of Access) HPFT has had new contact centre technology implemented for the last quarter. SPA operates as the gateway into HPFT services, is the first point of contact and is an integral part of that experience. SPA supports HPFT to deliver a timely access into services, routine referrals and appointments and a point of contact for those in crisis. SPA is under contractual timescales and waiting targets. Receives circa 1200 calls a week and 50% of those will need to speak to an advisor. SPA has also taken on the MH helpline out of hours which receives 300 calls a week. Old technology was put in place when SPA first started; it was not keeping up with demand so HPFT looked to invest and have appointed Rostrvm Solutions LTD which will manage inbound and outbound contacts. There is a feedback loop. After a call is finished the SPA advisor will ask if patient would like to leave feedback. This is due to change, so that unless a patient ‘opts out’ they will automatically be put through to leave feedback. HB noted that a danger with that method of gaining feedback is if a patient with MH issues is phoning and in distress - asking them straight away for feedback may not be the best solution. Need to ensure the technology understands who is phoning and for what reason. HB provided feedback on lessons from NHS11 - identification of frequent callers and repeat callers. In terms of definitions frequent callers would be people who call with the same issue/need some conversation and/or use SPA as a source of reassurance. Repeat caller is someone who has not had their clinical issue addressed following repeated contacts with SPA. Acknowledgement that it is often difficult to distinguish between the two. Suggested regular analysis of calls - who / where coming from will allow understanding of the profile of people and frequent callers can be supported to access alternative appropriate support.

KB noted that there have been two announced inspections of SPA just before Christmas. There was a lot of deliberate timewasting by HPFT staff to reduce opportunity for scrutiny. Helpful to have an update for next meeting regarding their performance.

ACTION: AH to liaise with Vicki Jefferies regarding quality AH assurance visits to SPA in December and provide an update at February JCPB.

7 0-25 Childrens

Page 7 of 9 Item Subject Action by 7.1 Strategy/Policy issue (commissioning intentions)

7.1.1 Autism and ADHD KB apologised that there is no paper, and only a verbal update can be given due to a paper and presentation currently being prepared for a scrutiny and also still awaiting outstanding business case from E&NH Paediatrician which will be taken to CAMHS transformation board next Wednesday. This will include a new pathway, level of care and what the likely costs will be. Next steps: outline business case will go to board, for implementation by April 2018, soft launch in May 2018. Proposing a single pathway for the whole of Hertfordshire that everyone will work to. Separate conversation for ADHD this is only concerning Autism.

7.1.2 School Nurses, Health Visiting and Family Centres Procurement Update KB gave apologies on behalf of Sue Beck. Tender has been closed, and have a good selection of bids. Decision early March 2018 and announcement following. Mobilisation April 1st 2018 and runs for 6 months, with new contract into effect on 1st October 2018.Part of mobilisation will be interfacing with other services, new providers. CCG’s represented within the working groups. Length of contract is 6+2 years. KB suggested that this becomes a standing agenda item, and March meeting KB will update

ACTION: KB to provide an update on School Nurses, Health Visiting and Family Centres at March JCPB KB

8. Any other urgent business:

FH updated the group on the “Integrated Commissioning Better Outcomes” framework, which is being launched in April 2018. This is a collaboration between NHSE, ADASS and LDA. FH has volunteered Hertfordshire to be a pilot site for this framework. There will be a half day workshop in February with partners to ensure that this will work for Hertfordshire.

SP noted that HCC have CAMHS scrutiny on 12/01/18. Focusing on Early Help and Crisis. SP then added that HCC have yet to have any formal feedback from CQC and have been chasing this regularly.

MI updated the group on Nascot Lawn, the current position is that parents have made another application for judicial review and have now asked for an urgent hearing to be heard by beginning of Feb. Judge will be making a decision on 12/01/18.

AH updated members on the forward plan for next meeting. KB stated

Page 8 of 9 Item Subject Action by that the SEND Strategy will not need to be on the agenda as is not a new strategy – only a refresh. ACTION: KB to provide the SEND Refresh Strategy for circulation. KB

9. Date of next meeting: Thursday 15th February, 09:30am – 12:30pm, MR1.2 Charter House, WGC AL8 6JL

Page 9 of 9 Joint Commissioning Partnership Board 15th February 2018 09:30am-12:30pm MR1.2 Charter House, Welwyn Garden City, AL8 6JL

MINUTES

Present: Oliver Barnes (OB) Senior Commissioning Manager, 0-25 SEND, HCC Harper Brown (HB) Director of Commissioning, ENHCCG (Chair) Helen Cavanagh (HC) Commissioning Manager, IHCCT, HCC Charlotte Day (CD) Support Officer, Commissioning Support, HCC (Minutes) Ruth Harrington (RH) Head of Community Commissioning Team (AD), HCC Head of Integrated Health & Care Commissioning Simon Pattison (SP) Team (IHCCT), HCC, ENHCCG, and Herts Valleys CCG. Kristian Tizzard Deputy Head of Integrated Accommodation Commissioning Team (IACT), HCC

Page 1 of 8 Item Subject Actio n by

1. WELCOME AND APOLOGIES FOR ABSENCE

HB welcomed all to the meeting. Apologies were received from:

• Kulbir Lalli, Head of IACT, HCC • Marion Ingram, Operations Director, HCC • Kate Barker, Assistant Director, Maternity and Young People ENHCCG • Tom Hennessey, AD Integrated Health, HCC • Prag Moodley, GP Lead ENHCCG • Anna Hall, Senior Commissioning Manager, IHCCT

2. DECLARATIONS OF INTERESTS

HB invited members to declare any declarations relating to matters on the Agenda.

All members confirmed they have no declarations in relation to matters on the Agenda.

3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING

The Minutes of the meeting held on 11th January 2018 were approved as an accurate record subject to the following amendments:

• Item 7.1.2: Mobilisation starts on 1st April and runs for 6 months, with the new contract coming into effect from 1st October • Item 7.1.2: The contract is 6+2 years (amendments noted from SP, on Sally Orr’s behalf)

ACTION: The final minutes of the meeting held on 11th January 2018 to CD be updated to reflect amendments.

4. ACTION TRACKER The contents of the Action Tracker were discussed.

The following updates were provided:

Page 2 of 8 Item Subject Actio n by • Action 13: Operational person from ENHCCG to attend JCPB. SP and HB concluded that CD is to include Jo Burlingham/Sharn Elton on the JCPB circulation list (for papers without expectation they attended). • Action 16: JM to meet with SP, Jen Beer, CWB and Kate Barker. SP updated that meeting occurred on 2nd February 2018, and another meeting is due to discuss the Prevention Concordat and Mental Health. • Action 24: SP to arrange meeting with Harper Brown, Ruth Harrington and David Evans. SP updated that this meeting is due to happen Friday 23rd February.

5. Integrated Accommodation Commissioning Team

5.1 Operational Performance

5.1.1 Westgate – Intermediate Care Coordinator

KT explained that Westgate Healthcare were due to present the update around the Intermediate Care Coordinator, however this could not happen as they are now seeking legal advice around the contractual commitments of the role. Westgate believe that HCC are contractually obliged to fund the post of Intermediate Care Coordinator. KT further explained that this was brought to JCPB in June, and the issue is still not resolved. For the short term, IACT/HCC’s aim is to keep the board updated on the conversations being had with Westgate to work out next steps. 5.1.2 Westgate – Review – Project brief and PID KT presented a proposal to conduct a review regarding Westgate Healthcare. HCC have a twenty five year contract with Westgate for 65 beds. This was put into place in 2004. All of the beds are very important to the system particularly in East of the County where there is a shortage. KT shared that HCC is keen to have a review for number of reasons. Essentially there is an increasing number of issues that are being put forward in contractual discussions with Westgate, most of which are related to admissions. HCC are proposing a 2 phase review: • Phase 1 - Bed modelling. Looking at current needs and what needs to change • Phase 2 - returning to JCPB for consensus before any further conversations to provider. KT continued to share that a PID is circulated and is keen to have comments and feedback.

HB replied that overall it is good idea to conduct the review. It is a good exercise to go through as preparation for what might be key issues in other contracts.

Page 3 of 8 Item Subject Actio n by SP questioned whether there will be a need for a CCG rep, and a CCG sponsor. HB advised KT to contact Alison Ryan in regards to sponsorship.

ACTION: KT to contact Alison Ryan with PID for review, and report KT back to JCPB in Phase 1 of the review.

6. Integrated Health and Care Commissioning Team

6.1 Operational Performance

6.1.2 IHCCT Exception Report

HPFT Performance SP shared with the group an update on HPFT performance. Routine referrals have improved further in East and North Herts but still struggling in Herts Valleys due to staffing issues. HCC received early feedback from HPFT, that January was the busiest month going through SPA ever. Pressures on staffing still remain, and continue to have some issues with EMDASS waiting times. CAMHS, Early Intervention Psychosis and Improving Access to Psychological Therapies have really positive performance. Some reductions on Delayed Transfers of Care targets.

Dementia Diagnosis SP continued to state that diagnosis of Dementia still at 64%. Out of the six localities; three are at target or above, and three are below. IHCCT real focus is on those that are below.

SPA SP reminded the group that the faxes were turned off in January and are now no longer being monitored. A quality visit to SPA was conducted by the team in December. There were a number of positive outcomes but need for further work around referral process and making sure that risk assessments are fully up to date. Another visit will be scheduled.

Tier 2 CAMHS In regards to Tier 2 CAMHS, SP shared that now in the middle of the tender process, and is expecting bids back from providers by 28th February. An evaluation will run through March and April.

PALMS SP shared concerns around current waiting lists with PALMS. There are 180 children and young people across county on a waiting list, 90 of these have been waiting over 18 weeks. SP had a contract meeting with PALMS, they have an under spend from the last financial year – trying to use this to recruit but finding it a challenge. Another meeting with them is scheduled for week commencing 19th February.

Page 4 of 8 Item Subject Actio n by

Feeling Good week Schools can put forward small bids for proposals to improve mental health and wellbeing for children and young people. Ninety one bids were received.

Winter Pressures SP confirmed that all winter pressure schemes in place, and completing fortnightly returns to NHS England. HPFT stepdown flats will carry on into next year – only just gone live.

STP Workforce submission is still at validation stage. Primary care mental health models: in Stevenage, currently at point of it going live but have had issues in last few days regarding system 1 excess.

Individual Placement and Support SP shared that this is an Invitation to submit funding for employment support funded by NHS. There are two waves of additional national money. Wave 1 is focusing on areas that have an individual placement support service. As Hertfordshire doesn’t qualify, IHCCT will consider submitting for wave 2.

Community Perinatal MH services SP updated the group that HCC were successful in Wave 1 of the bidding process and received £800,000 this current year and another £800,000 next year. The expectation is that every area has a community perinatal service. The current options are: • Not to put a bid in, and try and work better across the system to see the extra women in need. • Put a bid in for one of the three HPFT staffing options (Bronze/Silver/Gold). A decision will need to be made soon.

HB advised to put a bid in, to test a future model that could be more sustainable. Challenge NHS England.

IAPT Options SP continued to state that IAPT has a target of 19% this year, 22% next year and 25% the year after. HPFT have advised of costs to reach those targets. Alan POnd Felt these may be too expensive, and the future of IAPT needs to be thought through. Currently thinking about procurement and how quickly a standalone service could be procured. April 19 is optimistic. IHCCT are interested in holding a pre-procurement market engagement event and are also in conversations with West Essex who also use HPFT as an IAPT provider.

Operating plan NHS England has released an operating plan guidance document. Each CCG needs to complete this by march. SP shared that there are a number

Page 5 of 8 Item Subject Actio n by of areas in the document that affect mental health and learning disabilities. IHCCT has been through the plan as a team and assessed current position against each item. To finalise, IHCCT are in a reasonable position and know what to do going forward even if targets are not currently being hit. 6.2 Strategy/policy issue (commissioning intentions) 6.2.1 New Leaf – implementation plan for Year 2 proposal.

HC updated the group on the New Leaf Wellbeing College. The pilot has been extended and now, need to assess the future of the college. HPFT are conducting a review and alongside this there is a need for a deeper evaluation of the college. This will be processed three ways: • Student feedback • Tutor feedback • Student reviews (Three months after course has been completed, to assess whether the college has made a different to individual’s lives) The Warwick Edinburgh Wellbeing Short Questionnaire is going to be used. Along with this there will be student stories and interviews to ensure all plans are being met going forward. HC continued to state that another section which is of concern is the weak links with other voluntary sector organisations. An overarching plan has been put in place to improve this, and is already being used. The evaluation will be completed by the end of spring, and will bring back a detailed report to JCPB following this. 6.2.2 Nightlight – update (CONFIDENTIAL) Minuted separately.

7. 0-25 Children’s

7.1 Strategy/policy issue (commissioning intentions)

7.1.1 Update on consultation to HES equipment service

OB presented an update on the equipment public consultation. The paper enclosed went to Hertfordshire County Council’s Children Services Cabinet Panel Committee requesting authorisation, and this has been accepted so now going out to consultation. Need to go through the process of talking to the public about what equipment is available. The consultation is part of a longer term strategy around equipment. OB is hoping to go live with the consultation in the next two weeks, after final sign of from SEND Legal team. This will run for 12 weeks until May.

Update on review of overnight short breaks and Speech and Language 7.1.2 Therapy Service

Page 6 of 8 Item Subject Actio n by OB stated that throughout 2017 the SEND team, were reviewing the service model of the Speech and Language Therapy Service. Following this, the team didn’t want to go to tender this financial year but wanted to introduce a revised service model. One of the critical factors for the new model is to move to an ‘episodes of care approach’. The model has been approved and HCT have been informed. Herts Valleys have also been partners in this process. OB hopes to come back to JCPB at the end of the year with detailed update of the new model.

Overnight short breaks OB shared that the current challenge in the overnight short breaks provision is the closure of Nascot Lawn, and transferring the children to local authority commissioned overnight short breaks in the county, as they are already pushing max capacity. Following the closure, the most impact has been felt in West Herts. East Herts is in a much stronger position as there is a more resilient level of provision and good working relationships with providers. SP also noted that Nascot Lawn went to judicial review week commencing 5th February and no final decision has been made yet.

8. Community Wellbeing Team

8.1 Strategy/policy issue (commissioning intentions)

8.1.1 Update on Voluntary Sector and Adult Disability Commissioning RH presented an update to the group, regarding the changes to the commissioning teams in HCC ACS. Following a review conducted by Ian Mcbeath, a new team has been set up of which RH is the head of. Some of the voluntary sector contracts have now moved over to Tim Parlow’s team (Integrated Community Support). RH highlighted that both herself and Tim still attend the prevention STP meeting. The new team now consists of a micro-commissioning team of service finders and the aim is to create a new framework agreement for providers to transfer on to. The negotiation strategy is currently held with RH and Nadine Raenke, together with IACT – a workshop is booked, to assess the providers that HCC need to have a negotiation with and what the aim of these negotiations will be. The negotiation strategy in the first instance is to focus on the Adult Disability market. The Hospital and Community Navigation Service will also now sit under Tim Parlow’s team. It is currently performing and publicising itself well. There are 14,000 people to be supported every year, the challenge is trying to get the number of referrals up.

Advocacy Tender RH notes that there is currently a main triage lot, and then three specialist lot that sit underneath: • Adult specialist lot (Dementia) • MH Complexity lot • Children’s Specialist lot (under 18) There have been five bids across the 4 lots.

Page 7 of 8 Item Subject Actio n by

Supported Living RH notes that the aim this year is to move forward with a framework agreement for supported living. The framework agreement will be for new placements, and is to go live in autumn. RH has been working closely with IACT to make sure property is available as you care is called off. Matt Pierce has been co-ordinating focus groups, to engage with providers about their experiences of other places, and what they like/don’t like. Have received positive feedback and providers are not worried about a new framework agreement.

Changing Services Together RH shared that ‘Changing Services Together’ is the transformation of day services. This will not be a straightforward process, with some difficult decisions ahead. The idea is to have a hub. Important to try to think about how service users are supported to network in their own communities. 2 different approaches: • Introduction of contractual consistency, likely to be a framework agreement in 2019. As well as a framework agreement, block contracting. • Neighbourhood network events; providers and areas together, led by in house teams.

Complex Needs RH noted that ‘Housing Related Support’ is an amount of money that sat under the IACT team for the sum of £8 Million pounds. Looking further into it, found that this is split into five: • Flexicare: Money has been moved over to Tim Parlow. • Learning Disability and Supported Living: Money has been moved over to the supported living team. • Substance misuse • Low Level Mental Health • Homelessness. A steering group has been set up to bring together commissioners, and the districts to develop the complex needs pathway covering substance misuse, low level mental health and homelessness going forward.

9. Any Other Business No other business.

10. Date of Next Meeting 15TH March 2018, 09:30am -12:30pm. MR 2.6 Charter House, Welwyn Garden City, AL8 6JL

Page 8 of 8 Joint Commissioning Partnership Board Thursday 15th March 2018 09:30am-12:30pm MR 2.6 Charter House, Welwyn Garden City, AL8 6JL

MINUTES

Present: Lisa Powell (Shadowing Marion) (LP) Marion Ingram (MI) Katie Barker (KB) Anna Hall (AH) Mark Gwynne (MG) Sharn Elton (SE) Harper Brown (HB) Prag Moodley (PM) Frances Heathcote (FH) Conor Henderson (Minutes)

Page 1 of 6 Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE

Apologies: Simon Pattison Head of Integrated Health & Care Commissioning Team (IHCCT), HCC, ENHCCG, and Herts Valleys CCG

2. DECLARATIONS OF INTERESTS None

3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING Minutes of meeting 15 February 2018 agreed

4. ACTION TRACKER

4.1 Action 6 KB update - Work in progress between Hertfordshire Community Trust Looked After Team and SCN Education and Children’s Commissioning to look at how to enable access to information sharing so that Looked After Children’s Nursing Team receive earlier notification of the annual reviews of the educational health care checks. Re Health check review – Leads asked to send out letters to stock take position on health Checks. Meeting with East Herts community paediatricians 19 March 2018 to see how their annual health check at the special school and colleges could be used to identify these children and cross reference to GPs as well to see if we increase the quota. Keep action open

Actions 12 /13 Hayley King was going to highlight with Tom Hennessey the gaps between IMC Board 4.2 and JCPB. Keep open until Tom updates.

4.3 Action 16 Jim McManus to meet Simon Pattison, Jen Beer CWB and Kate Barker with regards to discuss integrating the whole systems mental health mapping. This is linked to the prevention agenda and the mental health element of it. Update - a TCON discussion held and Jim has identified someone in the team to do the MH Mapping. Ask Jim for update when attends to discuss Prevention Concordat April 2018 meeting

To note: Public health board meeting was held yesterday with all districts – starting point was to 4.4 explain to each other how they work. Bottom line was that district offer for prevention is being cut by 50% in terms of the money. Need to ensure Hertfordshire has an accurate and up to date directory of social prescribing that GP practices can refer to easily so can signpost/direct them to an appropriate resource that is social as opposed to medical.

4.5 Action 17 Jim to provide update at next meeting.

4.6 Action 18 – closed Action 32 - HPFT reviewing locality teams across Herts (currently working within quadrants) 4.7 Reconsideration of structure will support named individuals for both MH and LD. This will help understand/provide transparency of what is being commissioned for each CCG and provide some

Page 2 of 6 equality.

4.8 Action No 36 KB to provide the SEND Refresh Strategy for circulation – KB updated - only really started work on it. New frame work developed which we’re going to start discussing with parents and other people then we’ll start circulating it. It is much more aligned with Adult Services now. Ready July 2018 – to be placed on JCPB forward planning for July 2018.

5. Integrated Accommodation Commissioning Team

5.1 Operational Performance IHCCT Exception report

5.1.2 EMDASS PM/SE concerned that the proposal to move the waiting time target to 8 week diagnostic appt (as discussed at HPFT CRM technical) penalises people to wait 2 weeks longer for assessment, just because the pathway/delivery of diagnostic appts has changed. JCPB agreed the referral for CT scan should be done (where possible) prior to referral to EMDASS to reduce CT Scan waiting time holding up EMDASS appt. Suggested the pathway should include HPFT to contacts patient following referral for CT scan appt. Need approval from radiology that they will accept CT referrals from GPs for EMDASS. HPFT to engage with acute radiology (and/or private providers to be able to offer CT Scans). Referral criteria needs to be tightened up ACTION: PM would appreciate discussion re this further and proposes to bring to GP Leads for PM discussion

Dementia Practice coding work stream - timing of this is off due to QOF and end of year. ACTION: SE requested the end prevalence/number target for end 2018/19 - acknowledging the AH monthly target will be a sliding scale. HB might request new public health consultant to look at dementia prevalence data

LD There have been a number of meetings with Herts Valley CCG around embedding learning disability statement of intent across all the community services. This goes back to some of the discussions we’ve already had about concerns around what is being commissioned for each CCG . ACTION: HB to raise at concerns re differences in funding and requirement at STP level. HB

LeDeR – relaunch in May 18. People with LD in Hertfordshire are dying older than anywhere else in the UK. Relaunch will include a clear offer of support for the people who investigate the deaths. ACTION: JCPB recommended linking in with the CCG Communications team Mark Edwards to TB support re-launch.

PM requesting opportunity to Review LD register numbers - there is a lot of people on LD register who might in early years been coded as LD. How do we get them off the system? Validate the list? ACTION: PM to raise at GP Leads PM

PALMS ACTION: JCPB request for clear plan going forward re commissioned capacity for 18/19 SD CAMHS transformation money into PALMS - LA would like to put in more money to PALMS as long as the health and LA services come together. Invest to transform bid re behaviour - model of positive behaviour support cross county. Parent support groups are helping to manage demand in PALMS - would like to increase these groups. Investment into Tier 2 prevention work for CAMHS

Page 3 of 6 Investment of GMS growth into core MH primary care Assurance that CAMHS Transformation board have identified PALMS as clear priority for 2018/19. Suggest a complete pathway review of PALMS and process mapping which links to the Neurological development pathway.

HPFT contract negotiation and finance paper Queries: 1. LD transferring cases funding - is it 18+ year only? Marion concerned that funding for children’s has been very low. 2. EMDASS - if capacity has been identified as needed might need to push up the agenda for financial allocation 3. Street triage funding to minimise need to attend A&E.

6. 0-25 Children’s

6.1 Strategy/policy issue (commissioning intentions)

6.1.1 School nursing/health visitor/family centre procurement

The county council will announce it will be providing a family centre service across Hertfordshire bringing together children centres (family centres) health visiting and school nursing to deliver a shared ambition for families from pre-birth through to 19 years to have the best possible start to childhood.

Hertfordshire Community NHS Trust has been awarded the contract for health visiting and school nursing service. Barnardo’s, 1YMCA and Hertsmere leisure awarded the contract for the family support which is now pre-birth to 11 years. Previously pre-birth to 5 years.

Hertsmere leisure will provide for following districts: Watford Three rivers Hertsmere, St Albans and Dacorum 1YMCA: Welwyn and Hatfield, Broxbourne and East Herts Barnardo’s: Stevenage and North Herts.

ACTION: Kate/Joelle Scott to bring Children Centre Summary with high level KPI’s to April JCPB KB/JS Meeting.

PM queried What is going to be different from previous contract? Co-location / integration/working together requirements - how will they be held to account? This is one contract which goes right across providers with tighter/clearer service specification. Commissioning and contract officers in public health have improved their understanding of what HCT services are. Identified where improvements have been made. New family service integral to the SEND offer.

6.1.2 Update on Nascot Lawn Judicial Review Outcome- concluded the way HVCCG made the decision was unlawful as there was no formal consultation with HCC. HVCCG have now opened a formal consultation with HCC and end of consultation is 3 May 2018. Proposed date of closure - August 2018. Other concerns were not upheld Scrutiny meeting next week to consider proposal for HVCCG to cease funding Agreement that HVCCG/ENHCCG will put £100K into pot for delivering overnight short break services. Additional funding will be available for v. vulnerable children. If after 3 May 2018 HVCCG decide to cease funding, CCG's/LA able to sit down with parents to deliver overnight short breaks with health oversight. Service does not need to be nurse led, can train up parents/carers to deliver the care (judge agrees).

Page 4 of 6 Working with parents to move children to other settings. HCT struggling to open 3 days rather than 6 days as the rate of respite reduces. Struggling to provide alternative local settings. Possible option to build x 2 extra rooms at Westhyde. There is capacity at Jubilee.

7. Workforce Development Team

7.1 Strategy/policy issue (commissioning intentions)

7.1.1 Social Care Workforce Strategy Draft documents circulated. Issues aligning with STP workforce groups but proving quite difficult . However, been very mindful of aligning what with the HEE (Health Education England) draft workforce development plans and talking to Local Enterprise Partnership about their strategy and aspirations to raise profile in Hertfordshire of Social care workforce.

This is the first time voluntary sector providers have been integrated into community services and how we use those services to support the more formal services around the nursing homes and care homes is crucial. Aim is to keep people at home longer and that needs to start in local neighbourhoods.

The strategy consists of three basic themes: recruitment, retention and growth. These things are common to work force challenges across the piece at the moment. Recruiting people into vacant posts is proving very difficult. Also demographic growth in the future will place pressure on workforce. The present situation - not enough staff. Strategy also tries to identify what skills the workforce are going to need to support the individuals as they come through.

Opportunities identified with health providers: • Joint recruitment approaches for care staff/mental health/primary care • Joint working to provide consistency in salaries/ working conditions and opportunities to link to professional networks.

8. Adult Community Services

8.1 Integrated Commissioning for Better Outcomes (ICBO)

LGA, NHS and ADASS working together to establish a national steering group for this framework. The (self-assessment) framework was developed in partnership and covers for domains, talks about the principles and values about being person centred. The framework is for anyone commissioning across NHS and government. Outcomes are everyone’s business and everyone has a part of measuring them.

The principles are based on the three P’s: People, place and populations

The four domains: 1. Building foundations 2. Taking a person centred place base and outcomes focused approach 3. Shaping provisions to support PPP 4. Continue to raise the ambition

Page 5 of 6 9. Any Other Business A GP in North Herts has a particular interest in women, children and families and is providing sessions for CCG. Need to agree where GP input will add most value. Particularly in the Autism and ADHD pathway work, opportunities or share care and robust forward planning for children that fall in between the autism and mental health spectrum. Making sure that they get the services they need. There is now a panel that decides in these special cases where the children should be allocated.

10. Summary of Actions Agreed and Forward Planning Items – March 2018

Items for April 2018 JCPB Meeting agenda: AH • Prevention Concordat • Children Centre summary including KPI’s.

11. Date of Next Meeting 15TH April 2018, 13:00pm -16:00pm. MR 1.2 Charter House, Welwyn Garden City, AL8 6JL

Page 6 of 6 Agenda Item No: 15

Date of Meeting: 24th May 2018

Governing Body Meeting in Public

Paper Title: Locality Commissioning Meeting Minutes

Decision or Approval Discussion Information

Report author:

Report signed off by: Locality Commissioning Meetings

Executive Summary: Approved minutes of the Locality Commissioning Meetings attached for the Governing Body to note

Recommendations To note the approved minutes of the Locality Commissioning to the members: Meetings

Conflicts of Interest n/a involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Page | 1

LLV Primary Care Commissioning Meeting Wednesday 7th March 2018 1pm – 3pm The Maples Surgery, EN10 6FD

MINUTES Present:

Attendee Organisation Present 1. Dr Haydar Bolat - Chair (HB) GP, Stanhope Surgery Y 2. Dr Alison Jackson (AJ) GP, The Maples Y 3. Dr Bill Neville (BN) GP, Abbey Road Y 4. Dr Aneela Sattar (AS) GP, High Street surgery Y 5. Dr Navina Sullivan (NS) GP, Stockwell Lodge Medical Centre Y 6. Dr Angela Goodwin (AG) GP, Warden Lodge Medical Centre Y 7. Faisal Ijaz (FI) PM, Cromwell surgery Y 8. Richard Moore (RM) Business Manager Lea Valley Health Y 9. Sherine Sallion (SS) PM, Stockwell Lodge Medical Centre Apologies 10. Helen Moth (HM) PM, Warden Lodge Medical Centre Y 11. Catherine Church (CC) PM, The Maples Y 12. Dr Sheena Patel (SP) GP, Stockwell Lodge Medical Centre Apologies 13. Aiga Puli (AP) PM, Stanhope Surgery Apologies 14. Dr N Malde (NM) GP, Cromwell & Wormley Y 15. Dr Pauline Taylor (PT) GP, Cuffley & Goffs Oak Y 16. Adnan Choudhury (AC) PM, Abbey Road Apologies 17. Teresa Bird (TB) PM, Cuffley & Goffs Oak Y 18. Claire Arno (CA) PM, High Street Y 19. Helen Rouse PPG Apologies 20. Ruksana Parkar (RP) Locality Commissioning Manager Apologies 21. Val Presland (VP) PPG, The Maples Apologies 22. Ann Freeman (AF) PPG, The Maples Y 23. Dr Mo Hossain (MH) GP, Stanhope Surgery Y 24. Julie Sampson (JS) ENHCCG Y 25. Reni Rozbicka Stockwell Lodge Medical Centre 26. Anthony Deitsch (AD) Locality & Primary Care Development Y Manager ENHCCG 27. Tom Hennessey AD, ENHCCG Y 28. Ingrid Cruickshank (IC) Herts LPC Y 29. Michelle Morrissey Team Admin, ENHCCG Y

Page 1 of 9

Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE

The Chair welcomed all to the meeting. Apologies were received from:  Aiga Puli  Sherine Sallion  Val Presland  Helen Rouse

The Chair declared that the meeting is quorate.

2. DECLARATIONS OF INTERESTS

The Chair invited members to declare any declarations relating to matters on the Agenda.

Richard Moore declared an interest during the MIU Future Options item as a provider. The Chair decided that Richard Moore would be permitted to stay for the item but would not be involved in any decision making.

All other members confirmed they have no declarations in relation to matters on the Agenda.

3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING

The Minutes of the meeting held on 11th January 2018 were approved as an accurate record with no amendments.

4. ACTION TRACKER The contents of the Action Tracker were discussed.

The following actions were agreed to be closed:

 Action number 5, change of meeting dates to a Wednesday

The following updates were provided:

 Action number 1 and 4 to be discussed on the agenda.  Finance reports have not been provided since month 6.  Feedback to be provided regarding the target event.

Page 2 of 9

Item Subject Action by 5. Prescribing Update

 Next prescribing meeting to take place on the 21st March 2018.  Financial report for month 9 does not put the locality in a good position. JS recommends managing areas which can make a difference; for example: o Nicotine replacement – reminder that this is no longer provided on an FP10, if the script is now provided on an FP10 money will be charged back. o Freestyle Libre – double red policy, CCG states do not prescribe in primary or secondary care. Practices are

having patients request it now, recommendation is to follow the CCG policy as it is costing £140 a month for each patient.  Further work being done on prescribing movement in and out of the locality, JS highlights that prescribers need to notify PCSE when they leave their previous practice, as well as notifying PCSE when joining a practice. If practices need guidance with this feel free to contact JS.  The Maples, Abbey Road, SLMC are still to confirm that the list of prescribers is still current. Action: JS to resend this to practices. JS  Prescribing movement between LLV and ULV also worrying as cannot be claimed back. JS clarified that any GP covering work in ULV from LLV will need to use a spurious code. Action: RM will RM look into this as all GPs at The Limes should have a spurious code.  This is also the case with HomeFirst and will apply to any extended access work the locality take part in as well, so will need addressing.  NHSE target to reduce the amount of trimethoprim in over 75s is also making good progress.  Gluten free policy is continuing due to extent of public consultation  OTC policy – is about discouraging people from expecting drugs that can be purchased OTC to be prescribed routinely for self- limiting, intermittent conditions. Only a small number of complains have been received. A check list for practices will be going out shortly. It is a re-education process, those who are have longstanding, diagnosed chronic conditions should continue to be prescribed.  Some prescribing quick wins were outlined by MH: o Potential lower cost ICS/LABA inhalers for Asthma swaps will be going on script-switch o Adrenaline auto-injectors: should not be prescribing any more than two. o HRT: practices recommended to use Ardens template. JS also commented on the amount of work carried out by SLMC and Abbey Road surrounding CQC, the work needs to be embedded in everyday repeat prescribing practices. JS encourages everyone to come and speak to her if they have any concerns.

Page 3 of 9

Item Subject Action by

6. Finance & Locality Information Pack (LIP) Update

 AD updated that the packs are still being worked on and fine- tuned. Once finalised they will be added to the new CCG GP&PM website.

7. Invoices and remaining funds

 RM updated that £1/patient has been fully utilised, GPFV £1.50 is almost fully utilised with £16,000 left for training, remaining CFF monies.  In terms of training needs, part of the money will be used for spirometry training; suggestion made that part of the money could be put towards assistant PM course. Details to be sent to RM.  Locality training to ensure every practice has someone trained in spirometry, just waiting on dates.  16/17 CFF monies equals £22,000, CCG did not agree for it to be used as QP money, money will need to be used for transformation of services and needs to be spent before the end of the year. RM encourages suggestion to be sent to him.  Suggestion made to finance RM.

8. Footfall

 AJ advised that going forward activity data will be brought to this meeting for discussion.  Work needs to be done around the wellbeing centre and cancer screening.  Pathways to be worked up, locality are encouraged to feedback issues to the steering group.

9. Feedback from Provider Board

 AJ provided a summary of provider board outcomes. Summary will be provided at each meeting and there will now be 3-4 reps from the locality at each meeting.  RM presented the proposed new structure for integrated working. Social Prescribing  Is now available to use, forms are available on Ardens and are self-populating. Action: RM will send referral forms to be RM circulated with minutes.  Angela Smith is social prescriber for the area. RM queried

Page 4 of 9

Item Subject Action by whether any practices in the area have clinic space once a week for patients from the locality to be referred in to see her. Stockwell Lodge and Cuffley & Goffs Oak expressed as possibly interested; RM to follow up. Clinical Pathway Update  Dementia pathway is being developed with dementia clinic; will be accessed via referral with SPA. AJ asks that all clinicians are made aware.  Should also affect the MDAS waiting list and reduce the waiting time. Diabetes  Aiming to reduce number of people becoming diabetic by mapping out a diabetes pathway. In house medical support for HomeFirst  All practices have now met Dr Muna Sheikh, working pattern is Wednesday and Friday and she aims to help patients with complex medical needs. Care Planning  AJ commented that work is now happening to ensure care plans are being utilised appropriately by patients.  Communications needed to try and embed, although also being included in pathways so this should help.

10. Equalisation Process/ Community Provision

 AJ advised that there is significant reduction in the budget for HomeFirst due to take place which will take locality back to pre- service levels.  HB indicated that no impact assessment has been provided as yet but locality is concerned about the effect this reduction may have. AJ advised that discussions will need to take place with all providers and a memorandum of understanding (MoU) will need to be written.  Discussion took place around possible impact and effect this process could have on the locality and their feelings towards the changes.  HB commented that the locality understand that equalisation needs to be completed, but highlighted the concern that a proper quality impact assessment has not been completed, and the risks have not been highlighted or negated, meaning the whole CCG could lose money should admission rates go up as a result. TH commented that once a quality impact assessment has been completed it will be circulated.

11. MIU Future Options

Page 5 of 9

Item Subject Action by  HB advised that the current contract will come to an end in March 2019. NHSE have released guidance stating that it cannot be called an MIU and will have to change to either an Urgent Treatment Centre (UTC) or a Primary Care Hub.  Contract will be going up for tender so AJ advised that the locality will need to design the model which will be going up for tender. AJ advised that it will need to be a 7 day 8am-8pm service and could incorporate extended access, but it will be funded through the GMS contract.  Discussion took place regarding possible option; question asked regarding space limitations in the current building; comment made that estates plan may be required.  Recommendation made that the locality need to think about what they want. A suggestion of diagnostics service such as x-rays or minor ailments was made.  AJ encourages the group to send any ideas they may have to HB

12. Extended Access

 RM advised that the locality need to provide 36 hour per week, 7 days per week with a GP available in each locality.  Figures have been provided outlining £4/registered patient or around £153 per hour. All federations across the localities have decided best to work together.  RM advised that the federation will run and drive this, however will need clinical and project management support.  First step is to complete the public engagement survey; RM suggested also asking Stellar for help, also as possibility of working with ULV.  RM recommends going away and working through the options, clinical and practice manager help needed. Volunteers without a conflict of interest should contact RM for involvement.

13. Cancer

 AJ asks practices to return cancer diagnosis analysis feedback so she can work on and amalgamate it.  Asks for feedback for cancer diagnosis analysis and PDA so a locality report can be written and submitted.

14. Winter Resilience

 RM advised that there is the opportunity to rollover any un-spent funding up until the 15th April.  RM recommended that practices try to use the money before this

Page 6 of 9

Item Subject Action by time if possible.

15. ANY OTHER BUSINESS

 Federation AGM: RM advised practice to keep the date of the 15th May 1pm-3pm free for the Federation AGM.  Active Signposting: Query regarding the training and whether it should be reception instead of admin attending. AJ commented that it should be the correct clinician attending who will feed back appropriately.  LPC: LLV have been chosen to develop a business case with community pharmacy. IC asked whether community pharmacy could be given a standing item slot on the agenda to feedback on

locality working. Action: Item to be added as standing item to the RP/AD agenda. th  Meetings: ICPB meeting on the 25 May to be moved so provider board due on 2nd May and locality meeting to be on the 9th May. Action: Meeting dates to be changed. RP/AD  Cardiology: CCG have won a bid to install mobile ECG units, HB has put the locality forward to receive one, locality agrees to go ahead.  Carers Café: AF advised that the carers café open morning will take place on the 20th June as a drop in for family of carers.

NewReferralFormPP. docx

LLV ICPB FEEDBACK docx Feb 2018.docx

LLV_primary care commissioning_070318.pptx

16. DATES OF NEXT MEETINGS:

Prescribing 21 Mar Wed 1.00 - Stockwell Lodge Meeting 2.30

ICPB 4 April Wed 1.00 - Maples

Page 7 of 9

Item Subject Action by 3.00

Educational 11 Apr Wed 12.30 - Broxbourne Meeting 2.00 Council Offices

Practice 18 Apr Wed Managers Meeting

ICPB 2 May Wed 1.00 - Maples 3.00

Educational 9 May Wed 12.30 - Broxbourne Meeting 2.00 Council Offices

Locality - Primary 9 May Wed 1.00 - Maples Care Comm 2.30 Meeting

Page 8 of 9

No. Meeting Item No. and Action Responsible Deadline Revised Current Position Status Date Title Manager Deadline 1 07/03/2018 4. Action Share Feb AD 09/05/2018 Feedback document CLOSED Tracker TARGET tabled at LCC feedback 2 07/03/2018 5. Prescribing Re-send JS 09/05/2018 OPEN Update current list of prescribers 3 07/03/2018 5. Prescribing Confirm use RM 09/05/2018 OPEN Update of spurious code by GPs covering work in ULV 4 07/03/2018 7. Feedback Circulate RM 09/05/2018 OPEN from Provider Ardens social Board prescribing referral forms 5 07/03/2018 15. AOB Add AD 09/05/2018 ONGOING pharmacy update as standing item 6 07/03/2018 15. AOB Move May AD 09/05/2018 CLOSED ICDB meeting date and LCC meeting date

Page 9 of 9

Stevenage ICPB and Locality Meeting Tuesday 13th March 12.30pm – 2.30pm Cromwell Hotel, High Street, Stevenage SG1 3AZ

MINUTES Present:

Name Job Title Dr Russell Hall (RH) Chair GP Chells Way Surgery Dr Prag Moodley (PM) GP Stanmore Medical Group Michelle Myers (MM) Chells Way Surgery Mark Banks (MB) PM King George Surgery Dr Rini Saha (RS) GP King George Surgery Fiona Lucas (FL) PM Symonds Green Dr Masood GP Symonds Green Elaine Cook (EC) PM Bedwell Medical Centre Sandra Copping (SC) PM Manor House Karen Smith (KS) Nurse Manor House Ruksana Parkar (RP) Locality Manager CCG Anthony Deitsch Locality Manager CCG Michelle Morrissey Team Administrator CCG Sharn Elton (SE) Director Operations and Resilience CCG Julie Hoare (JH) HCT Director of Service Development and Partnerships Yasha Rai (YR) HCT Community Locality Manager Michael Henderson (MH) HPFT Services Lead Sunday Adeniyi (SA) ENH CCG Finance Lead Mary Bishop (MPB) PM Stanmore Medical Group Dr P Raveendran (PR) GP Bedwell Medical Centre Dr A Cormack GP Shephall Way Surgery Dr M Duggan GP Manor House Ken Moore (KM) PPG Representative Teresa Sutherill (TS) Chells Way Surgery Sheilagh Reavey (SR) Director of Nursing and Quality ENHCCG Julie Phipps HPFT Hannah Wright HCC Tom Hennessey ENHCCG Jayne Dingemans GHHC Director of Patient Services Manjit Phugura PM Shephall E. Whiteford DGM E&N ICT HCT Sabina Tai Senior Programme Manager Agnes Njoka Student Nurse Louis Sanford Mental Health and Learning Disabilities STP Programme Manager

Page 1 of 11

Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE

The Chair welcomed all to the meeting. Apologies were received from:

 Sue Lincoln  Alison Seymour  Maxine Davis  Imon Chakraborty

The Chair declared that the meeting is quorate.

2. DECLARATIONS OF INTERESTS

The Chair invited the members to reconfirm their current declarations on the Register of Interests and advise of any new declarations.

All members confirmed their declarations were accurate and up-to-date.

The Chair invited members to declare any declarations relating to matters on the Agenda.

All members confirmed they have no declarations in relation to matters on the Agenda.

3. ICPB Meeting

Items discussed included:

 Community Frailty Service  HCT “Core Offer” for Adult Community Services  HPFT Community Frailty Plan  Mental Health Pilot  Rapid Response Update

Presentations below:

PIA Final Primary Stevenage Provider HPFT Community Community Frailty Care Mental Health PilotBoard Stevenage Locality ReportV5 27.02.18.doc MarchFrailty 18 Plan.pptx Final.pptx Service.pptx

Page 2 of 11

Item Subject Action by

Adult Community Services.pptx

Discharge Home to Assess – Practices need to see escalation process and know when patient is added to the pathway.

Mental Health – SE suggested involving PM in mental health aspect of community frailty work. PM updated that the mental health pilot clinic has seen 12 patients, out of which 5 had been taken on to secondary care and 7 had been referred back to primary care, saving 28 hours of clinical time at the trust. Positive service user feedback received. Query regarding incorrect referral due to age led to decision that age limit on referral may need to be reviewed and made clearer on referral form.

Action: Louis Sanford contact details to be provided on minutes for queries around PIA - [email protected]

4. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING

The Minutes of the meeting held on 6th February 2018 were approved as an accurate record subject to the following amendments:

 Following discussion in January regarding Silicon Footfall, Bedwell Medical Practice subsequently reviewed and decided to object this proposal.

Matters Arising:

 EC reported that the learning disability data for Bedwell Medical RP Centre is incorrect. Action: Data to be amended.  RH informed the locality of the constitution changes due to take place on the 1st April, meaning from then on PM will chair the locality meetings and represent the locality at the board, and RH will be the CCG quality lead. Also informed the locality that the number of commissioning meetings due to take place as reduced to 4 per year and up to 8 provider board meetings.

5. ACTION TRACKER The contents of the Action Tracker were discussed.

The following actions were agreed to be closed:

Page 3 of 11

Item Subject Action by  Action 28  Action 30  Action 36  Action 37

The following updates were provided:

 Action 1: Awaiting written agreement from Harper Brown to begin. RH to copy SE into reply so she can chase as well.  Action 5: Issue was discussed at LTC meeting, and has also been raised at the contract meeting. RH will try to carry forward.  Action 27 and 29: still ongoing.  Action 34: RP to re-circulate with a deadline of the 31st March for LTC lead, alongside Education lead job description. KS will also share the new meeting outline.  Action 35: RP to chase Fiona Oliver again.

6. Nursing Ward Rounds

 RH outlined that SL had previously sent round an email regarding Summer Resilience which aims to continue the ward rounds on Mondays, Wednesdays and Fridays through the summer as the locality did last year through the £1/patient funding. RH encourages practices to respond to the email with feedback.

7. Prescribing Update

AS provided the following update:

 Gluten Free - the position on Gluten Free it is believed that the local press have printed something which is potentially misleading. There is not a blanket ban on gluten free prescribing –there are some patient group exclusions and the board has now met and said they are going to maintain the current position and NOT go with the National consultation outcome of limiting prescribing to flour and bread – this is because our local population were consulted with and this is what they wanted.

 Freestyle Libre - this is still not approved for use locally and prescribers are reminded to refer any requests back to DSNs / secondary care.

 RH also commented that the new constitution indicates 4 prescribing meetings a year, down from 6 a year.

Page 4 of 11

Item Subject Action by

8. Finance Update – End of Financial Year, Budgets and Invoices

 SA updated that at month 9 the locality are delivering an underspend of £831k. SA encourages the locality to keep working towards this.

 SA will seek clarification from Alan Pond whether the £1/patient can be rolled over.

9. Mental Health Update

 PM commented that there is nothing further to add and reiterated that the pilot is going well and encouraged practices to continue referring.

10. LTC Update

 KS updated that a new Terms of Reference for the group is due shortly.  New pathways will be available on Ardens soon.  Three cardiology pathways have been agreed, and are waiting on a decision regarding order of implementation.  The respiratory pathway has also been extended, but KS highlights a change in NICE guidelines. KS recommends practices carry on doing what they are doing until this has been resolved.

11. Localities GPFV £1.50 Non-Recurrent Monies Spend

 MB updated that a meeting had been held with Deena Keefe and Feima Ndoeka. This funding includes Extended Access so a bid has been put in for a Project Manager and also sourcing GPs and PMs to attend meetings. The bid for Silicon Footfall has been put on hold. These business plans have been submitted to Deena Keefe and Feima Ndoeka and are waiting on confirmation.  Regarding Extended Access a verbal agreement with HCT has been obtained to run the service from Kingsway, and a 12 month contract is due to be signed. The service is due to run evenings and weekends.  The patient engagement survey has been extended until the end of March, MB encourages practices to send out texts and post on their websites to try to engage with as many patients as possible.  Stevenage Extended Access workshop is due to take place on

Page 5 of 11

Item Subject Action by the 20th March at Stanmore Medical Group.

12. PPG Update

 KM updated that the health watch stall at Lister is going very well and looking to increase from once a month to once a fortnight. Currently running 10am-2pm.  Bedwell PPG meeting was very good.  KM highlighted that there was a health action day on the 24th Feb 2018. An event was held, but a better venue will be sought next time to increase footfall.

13. AOB

 Specialist Palliative Care Nurse – changes to staffing, a nurse has been appointed and will be joining shortly. A locality clinical lead to look at quality and complaints is also due to be recruited.  Locality Practice Managers Meeting – RS queried whether she could attend the meetings, and asks whether dates could be sent.  Robertson House – RS updated that Robertson House is due to be shut due to maintenance works so the team will be working from Kingsway, so asks practices to ensure patients are calling the swap number instead of the landline during this time.

 HUC – PR queried whether HUC will be attending the provider

board meeting, PM agreed that he will look into this. Action: PM PM to look into asking HUC to attend provider Board Meeting.

 Sharn Elton – PM expressed appreciation towards Sharn as her last meeting as Exec lead for the locality.  CFF – to be included on the agenda for the next meeting. Action: RP RP to add CFF to agenda.  District Nurses – query from practices as nurses do not seem to be attending GSF meetings anymore. Issue is being investigated.  Flu Vaccines – KS wanted to highlight changes to orders.  MSK Referrals – EC commented that MSK are sending a high number of referrals back to practices, she has reported back to the contracts hotline. RH updated that the pathway is due to be smoothed out, examples to be sent to RH, PM, SE and JH.  Microphone – KM queried whether microphones could be used during the meeting, PM commented that speakers will be asked to speak louder; SE highlighted the need for meeting etiquette to aid this.  AiHVS – Capacity issues being experienced with the service and practices being turned down and patients being sent back to GPs.

Same issue being experienced with HUC and 111. PM suggested RP inviting AiHVS contract manager to present at the provider board, Action: RP to ask AiHVS to attend meeting and present.

Page 6 of 11

Item Subject Action by

Page 7 of 11

No. Item No. and Action Responsible Current Position Status Title Manager Need a phlebotomist to work from the surgery for their patients. Issue ongoing since Jan 2017. HED was dealing with the matter with the Contracts team at the CCG and TPP team. Need to escalate to Harper Brown to resolve, as Patients have a petition and are escalating. 09.05.17 – HB to contact practice directly to discuss 11.07.17 – Ongoing, DK to discuss with HB and keep RH in the loop 12.09.17 – locality agreed to use £1pp 17/18 to purchase additional clinics for Shephall. 10.10.17 – now with contracts team to organise, and liaise with the Trust 14.11.17 – Stanmore to employ phlebotomist and share with locality from £1pp – to be approved Ongoing - 13.03.18 Awaiting written Shephall – 12.09.17 - £1pp money agreed to be used to ask TPP agreement from Harper Brown to begin. phlebotomy whether they can provide staffing MP to liaise with RH to copy SE into reply so she can chase 1 service Commissioning Team and DK to resolve DK as well. Ongoing

Page 8 of 11

Issues raised by Karen Smith and locality, SE to liaise with the service 11.04.17 – KS has a meeting 12.04.17with the service to discuss Update 09.05.17 - KS spoke to HCT awaiting to meet up with them. 11.07.17 – KS reported that templates not being completed by consultants which affects 8 Care Processes and national guidance – feedback to diabetes group, practices to collect examples and issues and let DK know. 10.10.17 – JL will take this back and liaise with the team. 12.12.17 – All practices to continue sending queries to contracts hotline who will send to GP liaison. 16.01.18 – KS reported no further update, queried whether a meeting can be organised with all to standardise expectations. AC agreed to take this back and advised that this had been formally logged as a Ongoing - 13.03.18 Issue was discussed contract issue. at LTC meeting, and has also been raised 12.09.17 – No update, waiting to hear from at the contract meeting. RH will try to Diabetes secondary care carry forward. 5 service Practices to send queries to the hotline SE / JL/ KS Ongoing Guidance on prescribing for recurrent UTIs will be circulated shortly MD 12.12.17 – Still awaiting guidance 16.01.18 - Still awaiting guidance David - Waiting for urology. Nothing due anytime soon. Will update all as/when, probably wise to take Prescribing off your action list. 27 Guidance MD Ongoing Ongoing

Page 9 of 11

Mental Health PM to send letter of when mental health pilot will 28 Pilot start so referrals can start coming in PM Closed Closed Employ and share phlebotomist - MB and SL to put a plan together and cost it. To be discussed at PMs 29 Phlebotomy meeting and agreed next locality meeting. MB/SL Ongoing Ongoing Summary of hotline queries for this issue to be Diabetes provided up to 6 months if possible, Anna Cason to 30 service be invited to attend locality meeting RP/ Hotline Closed Closed Contracts Anna Cason to attend locality meeting every 6 33 Hotline months to report on issues RP Ongoing Ongoing Ongoing - 13.03.18 RP to re-circulate with a deadline of the 31st March for LTC lead, alongside Education lead job description. KS will also share the new 34 LTC Lead RP to link with Imon to advertise vacancy. RP/ IC meeting outline. Ongoing British Heart Foundation Blood Pressure Award Fiona Oliver to share red criteria for programme with 35 Programme locality FO Ongoing - FO to be chased again Ongoing SE to share presentation of Discharge Home to Assess 36 DH2A with KM SE Closed Closed Community RP to contact Ardens lead in the PMO team to add Navigator Community Navigator Model link on to the Ardens 37 Model template. RP Closed Closed PM to look into asking HUC to attend Provider Board 38 HUC Meeting. PM Ongoing Ongoing Next Meeting 39 Agenda RP to add CFF to agenda RP Ongoing Ongoing

Page 10 of 11

RP to ask AiHVS contract manager to attend Provider 40 AiHVS Board Meeting and present. RP Ongoing Ongoing

Page 11 of 11

Stort Valley & Villages Locality Commissioning Meeting 7th December 2017 4:00PM Fielders Centre, Hatfield AL10 9TP

MINUTES

Present: Dr Sarah Dixon GP, South Street Surgery Dr Deborah Kearns Locality Co-Chair, Central Surgery Dr Nathalie Oates GP, Much Hadham Health Centre Dr Mark Penwill GP Representative, Church Street Sheilagh Reavey CCG Executive Director Dr Nabeil Shukur Apologies Dr Jag Takhur Apologies

In Attendance: Dr S Das GP, Central Surgery Dr Kwasi Appiah GP Federation Chair, South Street Surgery Andrew Wilkinson Practice Manager, Much Hadham Health Centre Michelle Ford Practice Manager, Parsonage Surgery Liz Scott Practice Manager, Central Surgery Pam Jardine Locality Manager, CCG Liz West Transformation Manager, Stort Valley & Villages Helen Hemmingfield Team Administrator, CCG Mohammed Ali STP Programme Manager, CCG

Page 1 of 4

Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE DK The Chair welcomed all to the meeting. Apologies were received from:

 Dr Jag Takhur

 Dr Nabeil Shukur

The Chair declared that the meeting is quorate.

2. DECLARATIONS OF INTERESTS

The Chair invited Practice Representatives to reconfirm that their current declarations on the Register of Interests which were circulated with the meeting papers were accurate and up-to-date.

 Members confirmed their interests were accurate and up-to-date  No conflicts of interests to agenda items were reported.

3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING

N/A

4. ACTION TRACKER

5. LOCALITY PERFORMANCE AND FINANCE

The Locality Financial Information was reviewed; locality is currently underspent overall but some of the narrative was difficult to understand. Feedback will be given to the CCG Data Analyst Team with regards to the coding in order to get a more detailed understanding of some of the areas such as the minor injuries unit, gynaecology, cardiology and peer review.

Page 2 of 4

6. MATERNITY PATHWAY

A presentation was given by Mohammed Ali (MA) the STP Programme Manager for maternity transformation across Hertfordshire and Essex who is looking at existing maternity pathways across the STP patch. MA asked for information and feedback from the GP practices.

For the purpose of the minutes it was reported The Rosie Hospital provides maternity and neonatal services to the local population of Cambridgeshire at Addenbrooke’s Hospital.

MA made a request to the locality for a GP to represent the locality at the Local Partnership Board and to be a point of contact.

7. PRACTICE MANAGERS’ FEEDBACK

AW attended the CQC (Care Quality Commission) training session which was extremely good. It included a presentation by Debbie Ryan representing Church Street Surgery which was fantastic and very well presented. Presentation explained how the practice had gone from requires improvement on 2 occasions to good.

The CQC process is being changed and will incorporate more of a working relationship with the practices. Some changes mentioned are as follows:

 20% of practices will be visited in one year  The audits must be kept up to date.  Annual returns will need to be completed.  Sharing protocols and policies between practices.

Dr Dixon stated that Central Surgery is supporting the training and development of 2 nurses, and this raised a discussion about Nurse Tutor’s in the Locality.

Page 3 of 4

8. GOVERNING BODY UPDATE

DK reported that the neurology referral has changed and clarification is needed on the fast track referral form.

DK reported that the Governing Body was reviewing the criteria for the referral process to for AIHVS and will report back in due course when signed off.

9. PATIENT ENGAGEMENT AND WORKFORCE TRAINING UPDATE

 Dr Sarah Dixon reported that a patient group meeting was scheduled for 31st January 2018 and that a Social prescribing person will be present.  NHS England has coordinated a pre diabetic course.  A meeting was held at the Council Offices regarding South Street and Church Street extended access and how to work collaboratively with these surgeries.

10. ANY OTHER BUSINESS

 It was reported that the dementia prevalence is rising. The GPs were asked whether they would be interested in working on changing the attitude on Dementia for patients and public. Liz West is working on a business case for a Dementia pathway and will be circulating this.  A discussion was held on the remit of district nurses and the boundaries of patients in catchment areas.  Care plans were discussed and the issue on how to complete them.  Changes to the referral process for fracture clinic, minor injuries and A&E were reported. Comms on the referral process are awaited.

Action: LW to circulate the business case for dementia pathway.

12. DATE OF NEXT MEETING:

19th April 2018 Time: 12-2pm Rhodes Centre, Bishops Stortford, CM23 3JG

Page 4 of 4

Upper Lea Valley Locality Commissioning Meeting 17th January 2018 13:00PM Priory Hall, Ware Priory, SG12 9AL

MINUTES

Present: Dr Jo Roberts GP, Amwell Street Dr Will Nicholson GP, Buntingford & Puckeridge Dr Nicky Williams GP Co-Chair, Church Street Dr Martyn Davies GP, Dolphin House Dr Rob Mayson GHC Federation Clinical Director, Orchard Surgery Dr Rob Mayson GHC Federation Clinical Director, Ware Road Dr Rob Mayson GP, Hailey View Dr Anita Oates GP Hanscombe House Dr Mark Andrews GP Co-Chair, The Limes Dr Jacqui Sheridan GP, Park Lane Dr Jay Kuruvatti GP, Wallace House

In Attendance: Lucy Eldon Locality Lead Nurse, Church Street Julie Tripp Practice Manager, Amwell Street Teresa Davidson Practice Manager, Buntingford & Puckeridge Val McCann Practice Manager Hailey View Rachael Hunt Practice Manager, Wallace House Elaine Alles Practice Manager. Ware Road Charles Ledsam Chair, PCG David Eyre Manager, GHC Federation Pam Jardine Locality Manager, CCG Alison Saward Finance Manager, CCG Helen Hemmingfield Administrator, CCG Steven Muggridge Apologies, CCG

Page 1 of 7

Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE

The Chair welcomed all to the meeting. Apologies were received from: Chair

 Dr Dilesh Shah

 Anna Makepeace  Harper Brown  Sanjeev Sharma  Dr Giles Pratt

The Chair declared that the meeting is quorate.

2. DECLARATIONS OF INTERESTS

The Chair invited Practice Representatives to reconfirm that their current Chair declarations on the Register of Interests which were circulated with the meeting papers were accurate and up-to-date.

No conflicts of interests to agenda items were reported.

Page 2 of 7

3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING

Action Log from last meeting

 AM to provide a list of Care Homes to be piloted to Practice Managers. We need to specifically find out which residential homes are not participating.  AM to formally advise of this at the next meeting.

Action: PJ to follow up with Transformation Manager regarding the list of Care Homes in the pilot and which ones were not participating.

4. ACTION TRACKER The contents of the Action Tracker were discussed.

The following actions were agreed to be closed:

 PJ to liaise with SS re prescription pad. PJ

The following updates were provided:

 PJ to chase up AM re a list of Care Homes to be piloted and PJ those not participating, To update at Aprils Locality Meeting  Invited AM to April Locality Committee Meeting to discuss care home models  Kate Cote to be invited to Locality Board to discuss the Rapid PJ Response Service (Deferred until after review of equalisation project)

Page 3 of 7

5. GP into Rapid Response – Dr Laura Smith (LS) LS  Dr Laura Smith gave a presentation on Rapid Response.  Presentation circulated to all Practice Managers.  Practices to contact LS with any issues which need to be escalated.  NW suggested that Practice Managers meet and agree how best to support LS with communication in this role.  NW suggested that the Service Manager from HCT (Kate Cote) be invited to the next meeting as HCT is responsible for delivering

this service.

 Further update to be provided later on in the year.

 Discussions were held around the issues of record sharing, access to full clinical records and complex patients. Practices were asked to contact LS, NW or AM if there were any problems.

Action: Invite Kate Cote to Locality Meeting PJ Liaise with Sanjeev Sharma as LS has still not received a prescription SS pad.

6. Finance Update – Alison Saward (AS)

 Month 6 figures indicate that the locality is almost £1m overspent, driven mainly by non-elective admissions. However, there are material differences between costs in SUS/Mede and the costs in Trust’s SLAM billing reports which may be affecting how total costs are attributed across localities. These differences are being investigated by CCG finance and information leads, and refreshed locality reports will not be shared until the finance team is confident that the locality split is correct.  AS hopes that the problems will be resolved in time for Month 9 reports to be issued. In the meantime, it was suggested that the locality focuses attention on non-elective admissions. It was noted that there had been a recent increase in admissions for COPD.

7. CFF Update – Dr Nicky Williams (NW)

 NW reported on current progress with the CFF. CFF development meetings are being held at the CCG who are looking to improve, modify the current CFF to which practices were invited. NW reminded practices that it is not too late to input into the process.  There was a general discussion on the areas of reduction in

Page 4 of 7

admissions, A&E attendance and non-electives, Frailty review, reducing Poly Pharmacy, Cancer Screening, Care Planning and advanced Care Planning, less home visits in care homes this winter, Social Prescribing, reducing the use of antibiotics, continue with inhalers, DNAR through Frailty work.  The Board were informed that the next CFF development meeting was scheduled for 30th January 2018 at 10.30 am.

8. Provider Board Update (NW)

 Locality priorities are Care Homes, review of the Rapid Response service/ development of the Community Frailty Service, Frailty MDT focus.  Locality is currently exploring new ways of managing care homes.  It was reported that the CCG are only informed of new Care Homes when the request for planning permission is officially submitted by the developer. James Gleed in the CCG Primary Care is usually the first point of contact.

 Anna Makepeace is currently looking at business models and will

be invited to attend the next Locality Meeting. LES money, global

sum and QOF money could be used for this.  The equalisation project was briefly discussed. ULV is under- resourced for community services and rapid response. More staff and money should be available when the review is completed. Action:  Invite AM to April Locality Board PJ

9. PCG Update – Charles Ledsam (CL)

 CL informed the locality that he and his wife had visited the Lister Hospital as day care patients and this went very well. He felt this was positive for the hospital.  The PPG event on COPD/Respiratory awareness at Sainsbury’s went very well and was supported by Elaine Richardson from Breathe Easy which was very positive in raising awareness.  CL welcomed feedback from the GP Practices, especially on how the group can be more supportive.  CL informed the Locality about Dementia week which is from 15- 21 May 2018. CL was hoping that this event would be held at Sainsbury’s.  Silicon Footfall is currently being successfully trialled at Castlegate and was looking good.  The next PPG will be held at the end of January and the effectiveness of the structure is being looked at.  CL announced that he will be stepping down as Chairperson.

Page 5 of 7

10. Governing Body Update – NW

 NW informed the Board that following the public consultation last year with Herts Valley regarding the prescribing of gluten free products, over the counter medicines and IVF policy, it was agreed by the Governing Body to stop prescribing gluten free products, over the counter medicines for acute conditions, to

restrict IVF to one cycle and to stop female sterilisations.

 A communication has been sent to all practices and patients leaflets are being sent out to support patients.  It was also reported that there had been overwhelming support from the public to stop over the counter medicines for acute conditions.  NW reported that there was a recent outbreak of Flu just before Christmas in a couple of care homes and clarified the procedure around AIHVS and HUC going into care homes. Practices will be notified about this.

Delegation – MA

 MA informed the Locality that the practices in the CCG voted in favour of delegation. 3 practices were not represented. This has now been approved by NHS England. MA stated that this still needs to be finalised and worked through and will develop over the year.  MA stated that he will be in post until April 2019, and will continue to work in the Locality and chair the Board. He stated that he will not continue beyond April 2019 and that the Locality needed to think about a succession plan. He suggested that a shadow role be developed and invited GP Representatives to consider this.  He stated that if anyone was interested that they should speak to either himself or NW.  CCG Executive leads will be changing in localities and we are currently awaiting confirmation of the new lead director.  Since this meeting, Dr Rachael Joyce, Clinical Director for the CCG has been appointed as Executive Director for ULV locality.

11. Federation Update - David Eyre (DE)

 Silicon footfall is up and running at Castlegate Surgery and the plan is to get the rest of the practices in the locality to sign up.  Generating Healthcare was successful with their in-practice Pharmacist bid and are awaiting information from NHS England.  DE reported a Task and Finish group was held just before Christmas and confirmed that the Locality is working to deliver extended access themselves via GHC Federation and were liaising with various persons in this respect. GHC also met with Ephedra as Welhat were going live first.

Page 6 of 7

12. ANY OTHER BUSINESS

 PJ reminded the Locality about the MSK training which was scheduled for 30 January 2018 for GP and Nurses. HUC cover to be provided.  The next Locality meeting will be held in April 2018. The meetings dates for the Locality have not been published as yet.  LE also reminded the Locality that funds for training were still available.

13. DATE OF NEXT MEETING:

18th April 2018 Priory Hall, Ware Priory, SG12 9AL - 13:00pm

Page 7 of 7