` Governing Body th Tuesday 4 March 2014 13:30 – 16:00 Room 22a, Brockington, 35 Hafod Road, Hereford, HR1 1SH
AGENDA
Agenda Item Time Lead Enclosure
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1. Welcome and Introductions Chair Verbal
2. Apologies for Absence Chair Verbal
3. Declarations of Interest Chair Verbal
4. Minutes of Previous Meeting Chair To approve the minutes of the meeting dated 4 February 2014 Item 04 Final DRAFT MINUTES Feb 2014.pdf
5. Matters Arising and the Schedule of All Actions To discuss Item 05 Action Log February 2014.pdf
6. Chair and Chief Officer Chair/Chief Officer Verbal Announcement’s
For Decision 1400
7. NHS Planning round To approve CCGs plan on page and Chief Officer, CFO, and Head review current process towards of Business Delivery developing the 5 year strategy Item 07 Front Sheet Planning Update.pdf
Item 07a 2 Year Plan on a Page.pdf
Item 07a 2 Year Road Map.pdf
Herefordshire CCG – Governing Body Page 1 of 5
Item 07a HCCG Everyone Counts Plan v02.pdf
Item 07a Herefordshire_2 Year Delivery plan_DRAFT.pdf
Approve Financial Plans Item 7b - Front Sheet to Financial Plan Paper v2.pdf
Item 7b Financial Plan Board Paper v2finalfinancialplanjw.pdf
Item 07b 14-15 Budget setting timetablev1.pdf
Better Care Fund Item 7c - Better Care Fund.pdf
Contract Update Item 7d - Contracts Update.pdf
8. Presentation Urgent Care – COBIC Head of Commercial Development/Head of COST To approve scope of COBIC programme
For Discussion 1500
9. Performance and Risk report Head of Business Delivery
CCG Performance Report – Item 09 Front Sheet Assurance Report February 14.pdf performance against key NHS Constitution and Outcome measures Corporate Risk Register
Item 09 Strategic Risk Register January.xls
Herefordshire CCG – Governing Body Page 2 of 5
10. Finance – Month 10 Report (including Chief Finance Officer budget setting) To discuss Item 10 Front Sheet Month 10 Finance Report.pdf
Item 10 - HCCG Mth 10 Summary.pdf
Item 10 - M10 GB Finance Report240214finance.pdf
11. Quality Update (including key quality Executive Lead Nurse issues) Item 11 - Board report March 2013.pdf
12. Anticipatory Care Plans (ACPs) Practice Manager Lead – Service Specification Governing body Item 12 GB Front Sheet to ACP FN 26.02.14.pdf
Item 12 Service Spec ACP v3 0 18 02 14 FN.pdf
13. Local Incentive Scheme (LIS) Head of COST
Item 13 - LIS Gov Body 140224_(2).pdf
For Information 1530
14. Key committee meeting updates
a. Quality and Patient Safety Executive Lead Nurse (including updates on any serious incidents and never events) Item 14a - QPS Minutes January 2014.pdf
b. Finance, Performance & CFO/Head of Business Delivery Item 14b Front Resources Sheet Summary Finance and Performance Committee.pdf
Item 14b - Ratified FPR Minutes January 2014 version 2.pdf
c. Communications and PPI Deputy Lay Member Engagement Item 14c - Front Sheet C&I Update.pdf
Herefordshire CCG – Governing Body Page 3 of 5
Clinical Chair d. Service Transformation and Item 14c - C&I Minutes January 2014.pdf Improvement Group
Verbal Executive Lead Nurse e. Urgent Care Working Group – Bed Census update
Item 14e Bed Census front sheet.pdf
Chair Item 14e bed census for CCG.pdf f. Health and Wellbeing Board
Cancelled by Chair of HWB
Chief Finance Officer g. Audit and Assurance
Item 14g Audit and Assurance Committee Update and Front sheet Christine Daws (1).pdf
15. CCG Forward Plan Head of Business Delivery Verbal
Other 1545
16. Items for Risk Register Chair Verbal
17. Any Other Business Verbal
Dates of next meetings:
Date Time Room Tuesday 1 April 2014 (in 1.30pm TBC public)
Tuesday 3 June 2014 (in 1.30pm TBC public)
To ensure that the CCG’s business shall be conducted without interruption and disruption and, without prejudice to the power to exclude on grounds of the confidential nature of the business to be transacted, the public is required to withdraw upon the CCG Board resolving as follows:
`that in the interests of public order the meeting is adjourned to enable the Board to complete its business without the presence of the public'. Section 1(8) Public Bodies (Admissions to Meetings) Act 1960.
Herefordshire CCG – Governing Body Page 4 of 5
Please note that this Governing Body session will be recorded.
Herefordshire CCG – Governing Body Page 5 of 5
` Governing Body th Tuesday 4 February 2014 13:30 – 16:00 Room 22 a, Brockington, 35 Hafod Road, Hereford, HR1 1SH
MINUTES Present:
AW Dr Andy Watts GP, Clinical Lead, HCCG (Governing Body Chair) CF Dr Crispin Fisher GP, Primary Care Lead (from 1.55pm) RW Dr Richard Williams Secondary Care Clinician JW Jo Whitehead Chief Officer JS Jill Sinclair Chief Financial Officer CD Christine Daws Lay Member for Audit and Governance DJ Diane Jones MBE Interim Lay Member FN Fiona Nikitik Practice Manager Lead
In attendance:: ME Mike Emery Head of Business Delivery, HCCG AG Adrian Griffiths Head of Commercial Development ATS Alison Talbot-Smith Head of Clinical Outcomes and Service Transformation LR Lynne Renton Head of Safeguarding from 3.30pm GW Gail Williams Senior Business Support Officer (for the Minutes)
Agenda Item
Action
1. Welcome and Introductions
On behalf of the governing body the Chair extended a warm and special welcome to the Chief Officer, Jo Whitehead
The Chair declared that the running order of the agenda would be revised. Item 7a, a presentation on the primary challenge fund submission delivered by Dr Mike Hearne would be taken at the start of the meeting.
It was also agreed that the review of local enhanced services would be moved off the confidential agenda and discussed under the main agenda.
2. Apologies for Absence:
Apologies were noted from David Farnsworth, Lead Executive Nurse who will be represented by Lynne Renton, Head of Safeguarding to answer any questions on performance and assurance, and Dr Ian Tait, GP lead for Quality and Patient Experience
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3. Declarations of Interest
Declarations of interest were noted from Dr Andy Watts and Dr Crispin Fisher in respect of the discussions around: the review of local enhanced services the update on RAAC the primary care challenge fund submission The above discussions were chaired by the deputy Chair, Christine Daws, lay member for audit and assurance.
Dr Alison Talbot-Smith as a part time consultant at WVT also declared her interest.
4. Minutes of Previous Meeting
In terms of accuracy the following comments were made on the minutes of the last meeting:
All GPs and Dr Alison Talbot-Smith declared their conflicts of interest.
On page 6 where it reads: “It was confirmed and noted that two GP members is sufficient on what is mainly a procurement based programme board” should be amended to read “one GP member is sufficient“ On pg.12 route cause analysis should read root cause analysis. On pg 12 the paragraph relating to the mortality improvement work at WVT the wording should be revised to reflect that the governing body wanted to ensure the pace of change of embedding mortality improvement be maintained. On pg. 13 under the summary from the December STIG meeting where it reads that the STIG received a proposal on the : “gain share agreement between Primecare and the hospital around high cost drugs within rheumatology sector” it was agreed this should be revised to read “an agreement between HCCG and WVT around high cost drugs, in the first instance around rheumatology drugs”.
5. Matters Arising and the Schedule of Actions
The governing body reviewed the actions that were not marked as complete or updated as follows:
07.01.14 6 The Head of Business Delivery confirmed that as he had not received any feedback on the new format of the Governing Body agenda and order of presentation of papers the format will be continued.
07.01.14 8 The Chair confirmed that he has sent a letter of thanks to the family who provided the patient story.
07.01.14 9 A paper was expected in response to the action that the final clinical scope of Herefordshire CCG’s urgent care service will be presented to the Governing Body in February for sign off. In response the Head of Commercial Development confirmed verbally that a full Action AG discussion of the clinical scope was held at the programme board, where it was agreed – forward that the project team needed to put more detail into the scope and it would therefore be plan presented to the governing body at its meeting in March after the programme board has March had another opportunity to finalise the scope.
With regard to the other actions for the Head of Commercial Development in relation to the Outcome Based Commissioning Programme he confirmed that the scoping document had been corrected to incorporate the 24 practices and wider stakeholder involvement and that Sue Price, Director of Commissioning from the area team is now a member of the programme
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board.
07.01.14 10 The Chair confirmed that a press release is ready for publication around the action for a public letter of thanks to all those who contributed to the urgent care events outlining the key themes raised from it.
With regard to action over the suggestion that care companies are given leaflets and information to hand out to the frail and elderly, this was not well understood, however it was explained that it will have referred to engaging the lonely frail elderly with the urgent care work. It was agreed that the Head of Business Delivery would liaise with PWC to build this Action ME action in to the urgent care project plan.
07.01.14 12 Further to the update included on the action log the Head of Business Delivery confirmed that there is further information with regard to cancer which would be referred to later in the Performance report. The HoBD is working with QPS colleagues and committee to think Action ME through greater visibility on community services performance, and after a wider discussion with QPS and FPR in April.
07.01.14 16 With regard to the forward plan and quoracy for meetings in August the Head of Business Delivery was tasked to liaise with GP leads and lay members to confirm if Action ME they are available for key meetings during the summer holidays.
6. 2. Chair and Chief Officer Announcement’s
The following announcements were made:
That a letter to the Chair from NHS England dated 21 January 2014 has confirmed that “following the NHS England CCG authorisation and assurance committee meeting on 17 January 2014 it was agreed that the two conditions should be removed leaving no conditions remaining. Accordingly, HCCG is now authorised in full”.
The governing body noted that this information is embargoed until 6 February 2014. The Chair thanked all those involved and the executive team in-particular for their hard work, commitment and acting up responsibilities, especially during a challenging period when the CCG was without a substantive Chief Officer.
That regrettably Christine Daws, lay member for audit and assurance and deputy Chair for the governing body had handed in a letter of resignation as from 1 may 2014. The governing body thanked Christine for her valuable contributions and disciplined sense of challenge. The CFO thanked Christine in particular, appreciating her help in the development of the CFO role. Since the lay member for patient and public experience has resigned to take up a role in the South East, the Chair stated that he and the Chief Officer will use this opportunity to look at the lay membership of the governing body before starting the recruitment process for replacements. That it was necessary last week to convene a meeting with WVT to discuss their position over the clinical strategy project. The CCG assured WVT over their particular concerns and the project is continuing as planned.
Strategy and Governance
7. NHS Planning Round
i. 2 year plan progress The governing body received an update on NHS Herefordshire CCG progress against the key requirements of the NHS Planning round and related submissions.
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The Head of Business Delivery summarised the key elements and initiatives as set out in the paper, offering to share on request any further information and the detailed templates, which for assurance have been scrutinised in depth by the Finance & Performance committee with input from individuals around the table.
The governing body was asked to note and comment on work to date, highlight any key work programmes or issues missing from the plan on page narrative for the 2 year plan and to delegate to the SMT and the Chief Officer sign-off of key template submissions, in consultation with governing body where appropriate.
The governing body asked: That on the plan on a page: o Reference is made to engagement with public health; o Reference is made to the categories and schemes which are part of the Better Care Fund; o Reference is made to the cross cutting themes and worthy projects,
particularly around patient engagement. That the important strategic challenges and elements of the 2 year and 5 year plan are presented and articulated more clearly, and the operational detail is strengthened; That reference is made to familial hypocholesterolemia and access to psychological therapies. In response, the Head of Business Delivery confirmed that IAPT was mentioned but recognised that the simpler version currently in development will ensure these schemes are not as difficult to find; That the use of three major adjectives in the HCCG vision are reconsidered; That a ‘cradle to grave’ presentation is considered to ‘create a story’ for the 5 year plan; That it clearly reflects the detail around the main strategic projects the CCG wants to deliver, particularly around community hospitals and integration.
To assure the governing body the Chief Officer stated that SMT colleagues have been asked to sense check the targets and ensure the CCG have realistic plans in place on the ground that will deliver the kind of reductions that some of the planning process are leading to.
The Head of Business Delivery was asked to encapsulate the comments made. Action ME
The CFO delivered a presentation on Everyone Counts: Planning for Patients 2014/15 – 2018/19, first cut financial plan (attached) covering: allocations; income and expenditure; QiPP; 2.5% headroom 14/15; Better Care Fund 2014/15; risks; mitigation.
Financial Plans 4 Feb 2014.pptx
The following observations were made:
The allocations show recurrent base line 13/14 to 18/19 The Better Care Fund is shown as a separate line as it is held outside of the CCG budgets by NHS England and the CCG will have to demonstrate resources deliver the required outcome measures to enable transformational outcomes for health and sustaining social care. In future years the Better Care Fund will become part of the CCG’s general allocation. Key to the delivery of current CCG utilisation of the Better Care Fund in 14/15 and delivery of the urgent care system is enhanced social worker support, investment in domiciliary care, community equipment and rapid access to care and virtual wards. With regard to the QIPP building on schemes over the last year, urgent care should say ‘access to the non-elective care’ (or it was suggested to use the expression ‘admission avoidance’) and the savings will link in to the virtual wards and hospital at
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home schemes. The secondary care drugs QIPP is a joint piece of work with the CCG and secondary care targeting certain secondary care drugs to get some gain sharing. With regard to the assessment of risk on the CCG 14/15 QIPP the CFO confirmed that the biggest challenge is the £3.6m QIPP is linked to WVT and contingency plans will need to be put in place; The CFO summarised the changes in the system from April funded out of the 2.5% headroom to enable transformation: for example around the COBIC programme (non- recurrent commitment); clinical strategy to link to the sustainability of WVT; pump priming the e-referral project pump; MSK pilot, discharge and CAU co-ordination linking in to the work around urgent care. The MSK pilot is to be renamed to the MSK scheme; Investment per head in primary care is set at £5.00 per head. . The full evaluation data on virtual wards is expected from the portal at the end of week commencing 10 February. The CCG is working with Healthwatch on the qualitative component. It was recognised that the governing body could not make a decision on virtual wards before analysing the data. A bigger conversation is needed on scoping a piece of work on community services as a whole, what are the functions and outcomes the CCG want to deliver in the community.
The CFO summarised the risks as set out in the presentation and observations were made:
Current risks are WVT, ICES, 2g & 111.
Mitigations are delivery of QIPP
The CFO was thanked for the clear presentation.
ii. Better Care Fund – Head of COST (Presentation) The Head of COST delivered a presentation on Integrated Commissioning and the Better Care Fund which was received by the Health and Well Being Board on 28 January 2014. The presentation covered the principles and vision; key themes; engagement of partners; commissioning and planning workshop outputs; on-going progress and next steps.
The ensuing discussion noted:
That the timelines over deadlines of submissions has created an element of tension in the system. The CCG Chair stated that he had written to the Local Authority Chief Executive to confirm that the CCG and Council have not, at the time of the meeting, jointly agreed the individual schemes submitted by both organisations for Better Care Fund investment for 2014/15 and 2015/16, and there remains a lack of detail for individual Local Authority spending proposals which means the CCG is unable to understand their benefit to the system at this time.
The Chief Officer stated that she had a useful, open and honest conversation with the local authority Chief Executive that morning. One of the positive outcomes of the meeting was an acknowledgement of the disjoint in timings of the submissions and it was agreed that both organisations would arrange a meeting with key individuals to map out key deadlines and timelines for next year so that we are clearer sooner about timetables for the sign off process. They both acknowledged the good work and time commitment to working on proposals by individuals in the CCG and social care and on the governing body. The CFO and the CO are meeting with NHSE to agree a joint approach prior to sign off of BCF.
The governing body supported the Chief Officer in her interactions and negotiations with the local authority on behalf of the CCG and delegated authority to the CO to sign the BCF submission on 14 February subject to sufficient assurance back to the CCG that processes will change for the future and that any agreement was non-recurrent. iii Call to Action – Primary Care Event and Feedback (Verbal) It was noted that the Herefordshire was well represented by Dr Crispin Fisher, Fiona Nikitik
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and David Farnsworth from the CCG, the LMC and Paul Deneen from Healthwatch. The purpose of the event was to: Create a joint view for 2 and 5 year primary care strategy; Describe the outcome for patients of the above; Agree local actions required to deliver ‘call to action’ and CCG strategies; Share the above with other participants to stimulate further iterations of local strategy development; Agree next steps for all participants.
Dr CF reported the main themes from the meeting: That Mike Buckle from the area team has been allocated to Herefordshire in terms of his primary care work; LMC’s were well represented Sustainability of general practice and recruitment problems An innovative approach needed for new premises to be fit for purpose ; Addressing access to hard to reach groups; Nurses and health care assistants Working with Worcester university Innovation Links to the urgent care agenda and the importance of primary care playing a major part in the solution. Patients did not feel they had a voice. Robust discussions between Healthwatch and LMC colleagues.
7a. 1. Primary Care Challenge Fund Submission
Dr Andy Watts, Dr Crispin Fisher and Dr Alison Talbot-Smith declared a conflict of interest. Christine Daws chaired this discussion.
The governing body welcomed to the meeting, Dr Mike Hearne, GP at Fownhope and Medical Director for Taurus Healthcare.
Dr Hearne conveyed apologies from the Chairman Dr Nigel Fraser and the Managing Director, Graeme Cleland.
The governing body received the presentation (attached):
Challenge.pptx
on theTaurus bid, (for submission on 14 February 2014), for the government initiative Challenge Fund to improve access to Primary Care.
It was noted that the presentation had also been received by the Health and Well Being Board.
It was recognised that:
It is important for the CCG to work closely with Taurus;
GP support in A&E is key; A key component of the support offered is help to evaluate and disseminate learning both nationally and locally; The assumption is that money has to be spent in-year; The Executive Lead Nurse should lead the QPS function to monitor the bid; When presenting the bid further on it was suggested that Taurus refines the bid to categorise and narrow it down to 4/5 objectives with a focus on estimates and projections of what will be achieved such as, for example, a reduction in A&E attendances; That to provide assurance to the governing body Taurus works closely with the Head of COST to evaluate the outcomes;
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The governing body commended Taurus on gaining the support and engagement of all 24 Action JW practices as evidenced in their agreement to share data within the Taurus model and therefore supported the model of care described in Taurus Healthcare’s Challenge Fund Bid. It was agreed that a letter of support to accompany the Herefordshire Challenge Fund bid would be provided to articulate the governing body’s view: That it provided an excellent opportunity for primary care to step up and jointly play a role in transforming the landscape of care in Herefordshire. That it provides a more integrated approach to providing general practice; That it provides a more integrated approach to providing urgent care capacity including additional out of hours primary care urgent appointments and long term conditions support at 3 hubs – services which are complementary to existing WiC and OOH provision. This will have the outcome of providing care in appropriate and accessible locations, reducing attendance at ED; That it offers the opportunity to evaluate a range of evidence based interventions across the County which are designed to reflect local and national best practice and provide an opportunity to reduce variation in standards and provision whilst providing innovative means of access for groups who find it difficult to access primary care, and hard to reach groups; That it supports interventions which see access to the broader primary care team as key to supporting vulnerable and hard to reach groups – targeting our services to provide parity of access and experience; That it uses systems and processes which capture patient views in a meaningful way backed up by a new provider governance model which brings together learning where patient experiences have not been of the standard they and we expect; That it fits well with other programmes of work – including but not limited to the CCG’s strategic plans, and the Better Care Fund.
8. Conflicts of interest policy
The governing body received an updated Conflicts of Interest Policy for approval for agreement to the amendment of the constitution.
It was noted that the policy was initially drafted in October and tabled at the F&P Committee. Due Diligence review was requested and completed to compare policy content with other CCGs. Subsequently the Audit committee reviewed the policy in January 2014 and recommended approval.
The Chief Officer was alerted to section 3.5 of the policy:
The Chief Officer is responsible for making decisions on arrangements for mitigating conflicts or potential conflicts of interest once declared, based upon the decision making framework set out in section 4.7 of this policy and to raise any concerns with the Lay member for Audit and Governance as appropriate. The CCG’s Chief Officer is also responsible for communicating these mitigating arrangements in writing back to the individuals concerned the decision making framework set out in section 4.7 below. The CCG’s Chief Officer and Chair are also responsible for reviewing the operation of this policy and will consult with the Lay member for Audit and Governance for proposing changes to this policy for consideration by Audit Committee as part of its annual assurance review
There were no further comments and the governing body approved the policy.
Assurance & Delivery (reports in this section are provided for information - governing body members are requested to raise any issues on an exception basis)
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9. Performance & Assurance Report
The governing body received detail of delivery against the CCGs key objectives and performance measures, as described in its plan on the page for 13/14, and further information on key performance and quality measures. The Head of Business Delivery was thanked for compiling the comprehensive report.
The Chair asked that performance and assurance issues were addressed under each of the sub-committee discussions in item 11.
10. Finance – Month 9 Report
The governing body received the financial report for the period up to Month 9 (April to December 2013)
The CFO summarised the main highlights: At Month 9 Herefordshire CCG is reporting that it is achieving its planned year to date and forecast surplus position 2013/14 year end position agreed with Wye Valley Trust. Prescribing and other in year emerging risks identified within report An update on devolvement of the former Herefordshire PCT closing balances As at Month 9 QIPP year to date delivery of 76.1% of annual plan An update on the 2% non-recurrent reserve and section 256 monies
The governing body noted with no additional comments:
the Month 9 reported financial position, the risk identified at Month 9 and the emerging in year risks highlighted in this report the risks identified at paragraph 2.2 of this report and to note the year end agreement with Wye Valley Trust. the use of the 2% non-recurrent monies in 2013/14 as identified within this report the update on the non-recurrent Section 256 monies the QIPP year to date delivery the feedback on the revised Recovery Plan the CCG continues to declare a 0.5% forecast surplus that the Finance Team will continue undertaking a forensic review of all expenditure areas in future months
11. Key committee meeting updates
a. Quality and Patient Safety (including updates on any serious incidents and never events)
The governing body received an update on the key priorities and issues discussed at the QPS committee on 17 December and noted the ratified minutes from the November meeting. As there were no comments on the paper the Chair invited the Head of Safeguarding to update the governing body on the publication of the upcoming serious case review and forthcoming Action DF inquest which is now in the public domain. It was noted that the governing body will forward receive a full formal report together with the NHS action plan across all organisations at plan its next meeting in March. It was noted that there has been national and local press interest March in the death of the 17 year old Looked After Child, The inquest will take place in the next few
months, and names and services will not be anonymised which will present a challenge to
some of the NHS services involved. The Safeguarding Board has released documentation
relating to the serious case review to the coroner who will soon take a decision whether the
inquest will take place in Hereford, or possibly London, due to the great interest in the death of
this young person from complications of diabetes.
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It was noted that the governing body will have the overall responsibility of monitoring the action plan.
It was noted that a media plan is in place from the publication of the serious case review and the Safeguarding Board took the lead on the media communications. The Area Team also had a statement ready for GPs who may be questioned in relation to the case.
It was reported that the Corporate Parenting Panel had been told that the coroner is conducting a deep dive into the case which involves a lot of work to feed in all the information.
The Head of Safeguarding assured the governing body that the GP practice involved in the case has been offered support and that the action plan includes key learning around diabetic management which will be shared amongst other practices.
b. Finance, Performance & Resources
The governing body received an update on the key priorities and issues discussed at the FPR committee on 28 January.
The CFO was asked to update the rag rating on the delivery of financial QIPP savings for 13/14 which should read amber green and not red as shown in the report. Action JS
Since the last meeting it was noted that CCG staff have now completed the mandatory training modules around information governance and the completion of PDPs have moved on significantly.
Cancer 62 day waits - the Head of Business Delivery acknowledged the need to provide further assurance.
PROMS - the Chair asked the Head of Business Delivery to investigate how to use the Action ME CCG feedback mechanisms to present that useful information in a digestible format to all GPs.
Accommodation - it was confirmed that the Head of Commercial Development is still awaiting the full report and options appraisals from DTXZ and PropCo. It was noted the FPR committee had been given delegated authority by the Governing body to agree accommodation options in liaison with the Chief Officer.
Concern was raised over gaps in mental health nursing support for Looked After Children. The Head of Cost confirmed that there is currently an on-going review of CAMHS and Looked After Children, that there are concerns over the fact that the Local Authority have served notice on Section 75 around CAMHS and they have been asked formally for a Quality Impact Assessment (QIA) around CAMHS. The Head of COST was asked to chase the QIA which Action will inform a report currently being compiled by programme managers for the STIG in ATS March, combining all the issues around CAMHS.
c. Service Transformation and Improvement Group
The governing body received an update on the key priorities and issues discussed at the STIG on January and the ratified minutes of the December 2013 meeting. Clarity was sought over the comments in the summary that “STIG was asked to comment on and approve partnership work to progress with relevant stakeholders, and confirm a named signatory on behalf of STIG who will sign the joint working Agreement between HCCG and Pharma”. In response the Head of COST explained that a number of strands of work are planned across primary and secondary care to improve outcomes for stroke patients and raise awareness in high risk groups. A partnership approach is envisaged across HCCG Medicines Management Team, Primary Care WVT, Public Health, Stroke Society, Health Watch, Carers Support and Pharma to support pathway development and local actions to improve outcomes. Patients identified will be invited to a clinic run by local PNs/CNS and/or GPs to provide patient education and discuss anticoagulation options where appropriate. The Head of COST assured
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the governing body that a robust debate was held at STIG around governance and in accordance with DH and ABPI Guidance, a Framework for Joint Working between NHS and Pharmaceutical Industry is under development to map risks and benefits and a joint working Action AG agreement will be signed off between partners. In terms of governance the governing body forward asked that the framework is presented to the Audit Committee. plan Audit March
d. Urgent Care Working Group (verbal)
The Chair apologised for the absence of a paper and summarised that the last meeting focussed mainly on: Action DF a bed census carried out by WVT looking at the blockages in the system. The Chair forward asked that the bed census report is made available to the governing body at the plan March meeting. March Delays in social care and placements, and also delays related to internal processes within WVT. When challenged WVT apologised for some of the discharge planning processes that are not working well, however they are producing an action plan in response to that, which will be monitored by the urgent care working group.
It was confirmed that Powys LHB are invited to the urgent care working group however they choose not to attend but the CCG attend theirs.
e. Health and Wellbeing Board (verbal)
The Chair summarised that the Health and Well Being Board received the same presentation as delivered earlier at this meeting on the primary care bid and there was a discussion over the Better Care Fund. There was also a paper presented on the Local Authority response to the CCG planning process.
12. LES Review (late addition to the agenda: moved from the confidential section of the meeting) The Chair introduced the report which proposed how the HCCG will move its existing LES’s to contracts from April 2014, in line with NHSE policy, explaining that as from April 2014 the CCG will no longer be able to hold LES agreements with primary care – and can only hold contracts.
The report proposed how HCCG would:
Convert existing optometry LES’s directly into contracts with existing providers; Convert existing pharmacy LES’s directly into contracts with existing providers; Convert existing General Practice LES’s and the anticoagulation NES into a single contract through a prime contractor model; Make some amendments to the existing schemes having reviewed outcomes; Add GP practice support for leg ulcer healing beyond that defined in the GMC contract; Provide the ability to add additional service specifications into this contract in the future as appropriate and with Governing Body approval; “roll-over” existing General Practice LES’S into interim 3 month contracts whilst the Prime Contractor is identified and the contract is agreed.
The chairing of the discussion was handed over to the deputy Chair, the lay member for audit and governance as Dr Andy Watts and Dr Crispin Fisher declared their interest in line with the conflicts of interest policy. It was agreed however that the GPs would remain in the room to comment from a practice perspective.
The governing body raised the following comments: That there are approximately 16 optometrists but they do not provide the whole range of schemes; it was agreed that the Head of Commercial Development would Action AG
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circulate the full matrix of schemes. The CCG has met with representatives of the LOC with the senate representative as there is a history of joint partnership working with ophthalmologists and optometrists. Equity of provision of the LES schemes is variable amongst GP practices however it was noted that through the LOC there is provision in every market town and an even distribution across the county. It was noted that the LMC do not currently operate a similar approach to ensure an even distribution amongst the whole population. 6 months’ notice has been served on all LES schemes to end 31 March 2014 to ensure fairness for all contractors involved; The majority of practices have expressed the preference for a prime contractor model; It was confirmed that assurance has been sought on revising the service specifications that there is no duplication of funding for services that should be core GMS. With regard to LES’s currently held by optometrist It was confirmed that the total spend across all schemes of £97k is per annum in total across all the 16 contractors. Concern was expressed over the lack of detail around performance outcomes for the schemes:
Dr CF urged the CCG to continue to engage the enthusiasm of all 24 practices which
a year or two ago did not exist.
Action AG It was agreed to ask the Head of Commercial Development to market test activity,
prepare a more detailed report and a more robust understanding of deliverability,
governance and processes, particularly around the prime contractor model for the
Audit Committee to consider at the meeting on 11 March 2014, that is:
Action AG The governing body agreed that the Audit Committee in March scrutinises the forward governance and process around the recommendation for LES’s currently held with plan General Practice: - to use a Prime Contractor Model for: 6 new contracts based on previous March LES schemes with amendments; Ceasing of 2 schemes; 2 new schemes funded through
QIPP efficiencies across other schemes; Addition of further schemes to be delivered by
General Practice if and when approved by Governing Body.
It was agreed to “roll-over” existing General Practice LES’S into interim 3 month
contractors whilst the Prime Contractor is identified and the contract is agreed
The governing body agreed to the recommendations for LES’s held with pharmacy and optometrists with the caveat that there is clear communication with practices as there are implications for staff involved.
13. Items for Risk Register
It was noted that there has been a refresh of the financial risk following the 2 year financial plan. There were no other risks identified on the agenda.
14. Any Other Business
2gNHSFTcontract
The CFO reminded the governing body that 2g had been awarded an extension of one year to their initial 3 year contract which was due to expire on 31 March 2014, however reported that 2g have now formally requested a 3 year extension.
The governing body was asked to accept the recommendation that the contract team is delegated the authority to negotiate a plus one or plus two extension to the contract.
The governing body debated the quality of the service delivered by 2g, and acknowledged that although there were some frustrations there were no major quality concerns. It was agreed
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therefore that contract negotiations focus on: Service redevelopment; Restructuring and ways of working; QIPP delivery; Complex mental health needs pathway to form strategic partnerships with the Third Sector and memory clinics; Dementia; IAPT
The governing body was clear that a three year extension was not acceptable, however it was agreed that a plus two option would allow time to focus on the areas set out above. It was Action JS agreed that the contract team is delegated authority to negotiate the contract As part of that it was agreed that the CAMHS work is fed in to the process.
Board to Board with WVT
It was agreed that a pre meeting would be arranged for the governing body to prepare for the Board to Board meeting with WVT at 9 – 11am on 25 February. It was proposed to meet from 10 – 11.30 on 20 February and again for one hour immediately before the Action GW Board to Board meeting to provide another opportunity for those who cannot make the 20th. It was agreed that non-voting members of the governing body would also attend the pre-meetings and the Board to Board meeting.
Dates of next meetings:
Date Time Room Tuesday 4 March 2014 1.30pm 22a, Brockington Tuesday 1 April 2014 (in 1.30pm TBC public) Tuesday 6 May 2014 1.30pm 22a, Brockington Tuesday 3 June 2014 1.30pm 22a, Brockington
To ensure that the CCG’s business shall be conducted without interruption and disruption and, without prejudice to the power to exclude on grounds of the confidential nature of the business to be transacted, the public is required to withdraw upon the CCG Board resolving as follows:
`that in the interests of public order the meeting is adjourned to enable the Board to complete its business without the presence of the public'. Section 1(8) Public Bodies (Admissions to Meetings) Act 1960.
12
Item 05
Date agenda no. Issue raised Responsible Date Due Update / Status Officer item (where appropriate)
04.02.14 5 07.01.14 9 A paper was expected in response to the action AG March that the final clinical scope of Herefordshire CCG’s urgent care governing body service will be presented to the Governing Body in February for sign off. In response the Head of Commercial Matters arising and schedule Development confirmed verbally that a full discussion of the clinical scope was held at the programme board, where it was of actions agreed that the project team needed to put more detail into the scope and it would therefore be presented to the governing body at its meeting in March
07.01.14 10 With regard to action over the suggestion that ME/AG Completed Being incorporated into care companies are given leaflets and information to hand out COBIC projects to the frail and elderly, this was not well understood, however communications plan it was explained that it will have referred to engaging the lonely frail elderly with the urgent care work. It was agreed that the Head of Business Delivery would liaise with PWC to build this action in to the urgent care project plan
07.01.14 12 Further to the update included on the action ME May Governing log the Head of Business Delivery confirmed that there is Body further information with regard to cancer which would be referred to later in the Performance report. The HoBD is working with QPS colleagues and committee to think through greater visibility on community services performance, and after a wider discussion with QPS and FPR in April.
07.01.14 16 With regard to the forward plan and quoracy for ME Completed Responses have been noted meetings in August the Head of Business Delivery was tasked for the August GB meeting. to liaise with GP leads and lay members to confirm if they are available for key meetings during the summer holidays. Apologies have been received from Dr Crispin Fisher.
04.02.14 7 The Head of Business Delivery was asked to encapsulate the ME March Thae plan on page has been comments made on the plan on a page narrative. governing body updated, item is on the NHS Planning Round agenda
04.02.14 7a The governing body commended Taurus on gaining the JW Completed support and engagement of all 24 practices as Primary Care Challenge Fund evidenced in their agreement to share data within the submission Taurus model and therefore supported the model of care described in Taurus Healthcare’s Challenge Fund Bid. It was agreed that a letter of support to accompany the Herefordshire Challenge Fund bid would be provided to articulate the governing body’s view.
04.02.14 11 QPS DF March With regard to the serious case review, it was noted that the governing body will receive a full formal report together with governing body Key committee updates the NHS action plan across all organisations at its next meeting in March
JS FPR The CFO was asked to update the rag rating on the delivery of financial QIPP savings for 13/14 which should read amber green and not red as shown in the report.
Update in April On forward plan The Chair asked the Head of Business Delivery to investigate how to use the CCG feedback mechanisms to present PROMS information in a digestible format to GPs ME
The Head of COST was asked to chase the QIA which will ATS inform a report currently being compiled by programme managers for the STIG in March, combining all the issues around CAMHS
STIG ATS Audit A Framework for Joint Working between NHS and Pharmaceutical Industry is under development to map risks Committee in
and benefits and a joint working agreement will be signed off March between partners. In terms of governance the governing body asked that the framework is presented to the Audit Committee
DF March Urgent Care Working Group The Chair asked that the bed census report is made governing body available to the governing body at the March meeting.
04.02.14 12 That there are approximately 16 optometrists but they do not AG provide the whole range of schemes; it was agreed that the Head of Commercial Development would circulate the full LES Review matrix of schemes
It was agreed to ask the Head of Commercial Development to market test activity, prepare a more detailed report and a more robust understanding of AG Audit committee deliverability, governance and processes, particularly around the prime contractor model for the Audit March Committee to consider at the meeting on 11 March 2014, that is:
The governing body agreed that the Audit Committee in ATS Audit committee March scrutinises the governance and process around March the recommendation for LES’s currently held with General Practice:
It was agreed to “roll-over” existing General Practice ATS LES’S into interim 3 month contractors whilst the Prime Contractor is identified and the contract is agreed
The governing body agreed to the recommendations for ATS LES’s held with pharmacy and optometrists with the caveat that there is clear communication with practices as there are implications for staff involved.
04.02.14 14 The governing body was clear that a three year extension was JS not acceptable, however it was agreed that a plus two option Any other Business would allow time to focus on the areas set out above. It was agreed that the contract team is delegated authority to negotiate the contract As part of that it was agreed that the CAMHS work is fed in to the process. .
04.02.14 14 It was agreed that a pre meeting would be arranged for the GW Complete – pre meets were governing body to prepare for the Board to Board meeting with arranged for 20 Feb and 25 Any other Business WVT at 9 – 11am on 25 February. It was proposed to meet from 10 – 11.30 on 20 February and again for one hour Feb. immediately before the Board to Board meeting to provide another opportunity for those who cannot make the 20th. It was agreed that non-voting members of the governing body would also attend the pre-meetings and the Board to Board meeting.
Governing body - Item 7a
CCG Governing body
4th March 2014
SUBJECT NHS Planning update
PRESENTED BY Chief Finance Officer & Head of Business Delivery
PURPOSE OF THE REPORT
To provide an update on NHS Herefordshire CCG progress against the key requirements of the NHS Planning round and related submissions, the development of the CCGs 5 year plan.
KEY POINTS
Background As part of the NHS Planning round all CCGs, working with partners, are expected to deliver the following First draft of 2 year operational plan templates to be submitted by 14 February with final version at the end of March; Narrative on how the 5 year plan will be developed by 14 February; First draft of 5 year ‘unit of planning’ strategy by end of March with key partners, with final version by end of June; Contract negotiations completed by 28 February; Better Care Fund plan and template; first version by end 14 February and final version early April. Update of work to date The CCG have submitted first versions of the operational plan and financial plan templates to regional teams. The Better Care fund draft submission has been agreed by the HWBB leaders group and was submitted on the 14th February A narrative and plan outlining the roadmap and steps to developing the 5 year strategy has been provided to NHS England (Attachment 4 – Plan for developing the 5 Year strategy) A revised 2 year plan on page has been developed and tested with clinicians and senior colleagues (Attachment 1 – 2 Year Plan on a Page) The Planning team have profiled and identified key metrics and targets for the Quality Premium and planning submissions which has included agreement by the Finance and Performance committee of a Local Quality
Herefordshire CCG – NHS Planning update Page 1 of 4
Governing body - Item 7a
Premium metric focused on long-term conditions. The draft templates submissions, both finance and planning, have already been discussed and initially reviewed by Area Team colleagues Content of plan The draft 2 year plan builds on existing plans but takes account of how these need to be developed to move Herefordshire from its current state to a desired future state (see Attachment 3 - 5 year roadmap) Underpinning the CCG’s key values are 8 key delivery streams, which have clear programmes of work and defined success measures. These are: o •Preventing ill-health and improving health o •Improving planned care o •Improving urgent care o •Greater integration of care including transformation of community provision o •Modernising mental health services o •Developing primary care o •Improving health outcomes for children o •Improving quality of clinical services and outcomes Next steps The development of the 2 and 5 yr plans will be an iterative process over the next 3- 4 months as negotiations continue with providers and partners, and sessions with Governing Body members. All key strategy documents will be provided to the appropriate CCG committees. The key decision points and engagement activities involving main stakeholders are: GP Parliament 26th February Health and Wellbeing workshop – 18 March Review and involvement of HWBB Leaders Group – March, April, May Review of first 5 yr draft by CCG governing body 1st April Health and Wellbeing board - April & May (May date identified as HWBB sign-off) Strategic partners - February to April CCG Governing Body approval of final Unit of Planning Plan – 3rd June Forums with Voluntary Sector and Healthwatch colleagues – March to May Strengthening how we engage and involve public and patients is also a key priority for the next 3 months. The CCG already has a repository of information from service redesign forums, feedback from PPGs and Urgent Care work, it needs however to strengthen the co-ordination of this work and how it synthesis and analyses this intelligence to support priority setting and strategy development. This will include Further Urgent Care events in March Development of Patient leaders Call to Action style events with PPG and other key patient groups in March Attendance at established patient and carer forums (through HVOSS)
Herefordshire CCG – NHS Planning update Page 2 of 4
Governing body - Item 7a
RECOMMENDATION TO THE Governing Body
To agree the 2 year plan on page and implementation plan
To comment on and approve the next steps in developing the 5 year plan
CONTEXT & IMPLICATIONS
Financial There are significant financial challenges in the system these need to be understood, modelled and responded to within the 5 year plan.
Legal Health and Social Care Act 2008
Health and Social Care 2012
Children Act 1989, 2004
Mental Capacity Act 2005
Mental Health Act 1983, 2007
Risk and Assurance The CCGs corporate risk register identifies the key (Risk Register/BAF) delivery risks for the CCG and underpins the business plan
HR/Personnel OD plans will be key to ensuring the delivery of the CCGs objectives, and capacity to deliver the transformational change across the system
Equality & Diversity Ensuring patients are at the heart of commissioning and service redesign is essential for all pieces of work, and this has to include those groups that are harder to engage
Strategic Objectives Underpins delivery of all strategic objectives
Healthcare/National Policy Everyone Counts and NHS Planning guidance and associated documents (e.g. CQC/Annual Health Check)
Partners/Other Directorates NHS England Area Team Local Authority Providers of commissioned services
Herefordshire CCG – NHS Planning update Page 3 of 4
Governing body - Item 7a
Carbon N/A Impact/Sustainability
Other Significant Issues N/A
GOVERNANCE
Process/Committee approval with date(s) (as appropriate)
KEY ATTACHMENTS
Attachments Attachment 1 – Draft 2 year Plan on page
Attachment 2 –2 year Implementation plan
Attachment 2 – 5 year road map from current to future state
Attachment 4 – Plan for developing Unit of Planning
Herefordshire CCG – NHS Planning update Page 4 of 4
Herefordshire's Two Year plan is focused on 8 key strategic work areas aimed at delivering our priorities, each having a Clinical and CCG lead Herefordshire CCG - Two Year Plan on a Page 2014-16 - DRAFT Our Vision Our Priorities We will achieve our vision through local • Greater integration of care system leadership by ensuring: A high quality, sustainable, • Long term conditions – care closer to home and integrated health • Modernising Mental Health services • Strong patient and public engagement economy, with the patient • Delivering high quality primary and • Quality care is seamlessly provided and the public at the heart secondary care • Access to services is improved of everything we do • Improving urgent care system • Meaningful Clinical engagement • The CCG manages the system
Delivering System Change
Preventing Ill Health & Improving Health Improving and Enhancing Planned Care Improving Urgent Care Greater Integration of Care CCG Lead: Alison Talbot-Smith CCG Lead: TBC CCG Lead: David Farnsworth CCG Lead: Alison Talbot-Smith Clinical Lead: tbc Clinical Lead: TBC Clinical Lead: Dr Ritesh Dua Clinical lead: tbc • Local agreed care pathways for key • Improved CVD and CHD outcomes and • Improve the delivery of urgent care services • Seamless working across all care settings conditions to ensure equitable access and reducing associated inequalities by moving to an outcomes based approach • Improved signposting for patients and consistent practice and improve access • Greater proactive anticipatory care and • Ensure the Urgent Care system provides public for health and social care services specialist opinion supported self management high quality services and good access • Putting in place a model for 7 day working • Electronic referral systems to replace paper • Greater focus on preventative care • Reducing the number of avoidable • Enhanced reablement & intermediate care system to reduce variability of referrals pathways reductions in admissions due to admissions, readmissions , repeat visits and • Modernising community services • Greater proactive anticipatory care and alcohol, smoking and obesity related LOS • Enhanced end of life care supported self management conditions • To integrate voluntary sector & community • Enhanced end of life care • Enhanced use of technology to support support into all care services and pathways healthcare (Telecare/ telehealth) • Information sharing between health and social care (including NHS Number)
Improving Health Outcomes for Children High Quality Clinical Services Developing Primary Care Modernising Mental Health Services CCG Lead: Alison Talbot-Smith CCG Lead: Andy Watts CCG Lead: TBC CCG Lead: Alison Talbot-Smith Clinical Lead: tbc Clinical Lead: David Farnsworth Clinical Lead: Dr Crispin Fisher Clinical Lead: Dr Simon Lenanne
• Improved outcomes and access to health • Enhanced Quality Assurance process • Ensuring equitable access and provision of • Delivering Parity of Esteem through: services for vulnerable children • Establish future options for Herefordshire CCGquality Lead: primary Dr Crispin care fisher & tbc • Patient Centred care pathways for mental • Better respite and short term care for health & social care system which are • Reducing variation in quality of care and health services vulnerable children clinically appropriate, high quality, patient improving standards • Improved Community focused memory • Better outcomes for children with centred & value for money – successor to • Putting in place a model for 7 day working service for people with dementia disabilities and long-term conditions Wye Valle futures and clinical strategy work • Delivering prevention and early • Complete Mental Health needs assessment • Robust safeguarding practice • Improving local access to secondary care intervention • Psychiatric liaison in acute services (RAID) • Specific work on medicines optimisation, • Establish future options for Primary Care • Increase in psychological therapy in stroke and cancer services services in Herefordshire Herefordshire • Robust safeguarding practice (adults) 1 Our Two Year plan leads into the Five Year planning process – indicators of success are shown below
Where we are now 14/15 15/16 16/17 17/18 18/19 Where we want to be
“High quality, sustainable, integrated health Delivering a new operating model for health and social care commissioning and provision in Herefordshire and social care economy with patients and public at the heart of everything we do”
Excellent patient Preventing ill health and improving health and service user outcomes and satisfaction with Mixed patient services experience and Improving and enhancing planned care outcomes of care High quality, seamless provision Urgent care system of care services in under pressure Herefordshire, in Focus on inputs, Improving urgent care the right setting activity and outputs, Services ‘wrapped not outcomes around’ patients Fragmented provision Greater Integration of care (Health and Social Care through Better and users of health and social Care Fund) Financially viable care services and sustainable Silo-based health and social care economy – commissioning of Modernising Mental Health Services services ‘one system, one budget’ Embryonic collaboration between Joined-up care system partners Developing Primary Care systems and organisations Poor use of technology and limited Innovative use of IT sharing of information and electronic Improving Health Outcomes for Children shared care Financial challenge records Flexible, motivated and fulfilled High Quality Clinical Services workforce 1 The Health and Social Care system partners are developing a clear roadmap for change as part of the Five Year planning & implementation process (part 1)
2013/14 14/15 15/16 16/17 17/18 18/19 19/20 System Vision, Values & Key: Planning Implementation Business as usual Principles embedded firmly in all health and Planning Risk stratification and anticipatory care planning (virtual wards) Business as usual social care partner Planning Long term conditions and self-care strategy Business as usual organisations Preventing Ill-health and Planning Optimisation of medicine use improving health Planning CVD and CHD Programme Business as usual 5 year ambitions Planning Preventative pathways (including alcohol, obesity, smoking) delivered
Planning E-referral Business as usual Improving • Outcomes and Planning Map of Medicine Enhancing Planned Care Planning Enhance End of Life Pathways Business as usual • Patient Services
Planning Hospital @ Home Business as usual Patient & Public Public Patient & Engagement Planning Outcome Based Commissioning COBIC Business as usual • Access
Urgent Care Improvement Plan Improving Planning & reviewing Evaluation • Quality Urgent Care Planning Clinical Assess Unit Business as usual
• Innovation
Planning Community Team Development Business as usual • Delivering
Value Clinical Clinical Engagement Planning Improving access to services (7 day working) Business as usual
Greater integration of care Planning Single front door for health & social care Business as usual Sustainable health and social care system Planning Reablement and Intermediate Care Business as usual
Planning Integrated Falls Pathway Business as usual The Health and Social Care system partners are developing a clear roadmap for change as part of the Five Year planning & implementation process (part 2)
2013/14 14/15 15/16 16/17 17/18 18/19 19/20 System Vision, Values & Key: Planning Implementation Business as usual Principles embedded Planning Memory service for dementia firmly in all health and social care partner Modernising Planning Mental Health Reprocurement Business as usual organisations Mental Health Planning RAID Business as usual Services Psychiatric Liaison in acute
5 year ambitions Prevention and early intervention delivered Value Bases service commissioning
Improved Quality/ Variation reduction Developing • Outcomes Primary Care Business continuity through PCS transition Planning Improving access to services (7 day working) Business as usual • Patient Services Primary Care Strategy (Medical, Dental, Ophthalmic, Pharmaceutical)*
Planning Optimisation of medicine use Public Patient & Engagement • Access
Planning Children’s Integration (Health, Social Care, Education) Business as usual Improving Health Disabilities and LTC service transformation • Quality Outcomes Improvement of Maternity Services (midwifery-led) for Children • Innovation Develop the market for children’s services provision
Planning Enhanced Quality Assurance Framework Business as usual • Delivering
Access to secondary care services Clinical Engagement Value High Quality Planning Clinical Modelling Business as usual Clinical Medicines optimisation Services Planning Herefordshire Health & Social Care Modernisation and Change Sustainable health and Cancer services social care system Stroke Services 3 Herefordshire CCG Everyone Counts Planning Departments / Functions / Actors
Herefordshire R Responsible A Accountable C Consulted I Informed
Week commencing
Milestones/ outcomes RAG status
Stuart Hydon Stuart Emery Mike Smith Talbot Alison Mclean Lindsey Hamer Neil Patel Indira Sinclair Jill Whitehead Jo Bhalla Munish Leads GP Support Business Watts Andy Lead Comms
20-Jan 27-Jan 03-Feb 10-Feb 17-Feb 24-Feb 03-Mar 10-Mar 17-Mar 24-Mar 31-Mar 07-Apr 14-Apr 21-Apr 28-Apr 05-May 12-May 19-May 26-May 02-Jun 09-Jun 16-Jun 23-Jun 30-Jun Mobilise Kick-off meeting with client completed 20 Complete R R Project scope agreed Complete R R
2 year operational plans Initial draft submitted to AT for early feedback 31 Complete R A Confidence checking of schemes on 2YOP Complete R A R R R R A A R C C Triangulation of 2YOP with BCF/ Finance/ QIPP plans Complete R A R R R R A A R C C AT/ SMT assurance meeting 11 Complete R A Drafts submitted onto Unify2 14 Complete R A AT review; further triangulation of plans; feedback incorporated R Refresh of drafts following contract round negotiations if necessary 5 R R A Final 2YOP submitted 4 R A
5 year system strategy Collaborative working sessions - vision, priorities/ funding, initiatives 15 ? ? R R A R Narrative for developing the 5Y plan drafted 31 R R Draft plan/ milestones for developing 5YSP agreed 7 R A R Stakeholder meeting plans agreed and diarised 10 A R R Senior Challenge Workshops (Leader's Group?) 20 20 20 A Collating content for 5Y plans R R R R R R R A R C C Triangulation of 5YSP with Finance/QIPP/BCF plans R C R C R R C A C C C First draft WIP 5YSP submitted to AT for comment TBC 5 Submission of final draft of 5YSP to NHSE 4 R A AT review and feedback incorporated R Sign off 5YSP with all key signatories R R A Public engagement/ presentation/ consultation on 5YSP A R Submission of final 5YSP to NHSE 20 R A
Continuous engagement of 2Y/5Y plans through key meetings Herefordshire Leaders (CEOs) Group 20 20 ? R CCG Governing Body 4 4 1 6 3 R R A Health & Wellbeing Board 25 R GP Parliament 26 17 R R 2gether Board R Wye Valley Trust Executive Team (GB to Board) 25 R R R R A Ambulance Trust - Local Lead R Local Authority Leadership Team R R Mental Health Clinical summit 25 Overview & Scrutiny Committee (LA) R R Patient / Service User groups (HCCG Membership Scheme / TBC) R Community Services (vision workshop) 11 R R R R A Third/ voluntary sector partners - HVOSS Mgmt Team R Healthwatch R STIG 17 R A FPR R A Communications & Involvement Committee 26 26 A Clinical Cabinet 11 25 11 25 8 22 6 20 3 17 R A Clinical Strategy Group 25 A
Item 07a HCCG Everyone Counts Plan v02.xlsx : RACI Action Plan Page 1 of 1 Finnamore Ltd Printed: 26/02/2014 Herefordshire CCG - 2 Year Implementation Plan
Strategic Vision Aims JSNA National Ambitions National Constitution NHS Outcomes Programme Initiatives KPIs Themes •Improved CVD and CHD outcomes and reducing associated Risk stratification (e.g. virtual wards) (*) Increase Dementia diagnosis rates to 67% by inequalities March 2015 Proactive anticipatory care and supported self management for long-term conditions proframme (including ePcP & paper Action Care Plan) (*) Reduction in referrals for dermatology, gastro and cardiology by 5% in 2013/14; x x x CVD and CHD Programme Reducing premature mortality due to Access to Primary Care services programme (including 7 day working) cardiovascular disease - under 75 mortality rate
oint work with Public Health on preventative pathways including alcohol, obesity and Reductions in admissions, re-admissions and •Greater proactive anticipatory care and supported self smoking length of stay for people with a LTC (12/13 management baseline to be determined)
Avoidable emergency admissions reduced x x x Reduction of proportion of older people not at home 91 days after hospital discharge
Permanent admissions of older people to •Greater focus on preventative care pathways reductions in residential and nursing homes reduced admissions due to alcohol, smoking and obesity related conditions Increased in number of people who feel supported to manage their long term condition
x x Emergency admission for alcohol related liver disease; enhanced quality of life for those with long-term conditions reduced
Preventing Ill-health and improving health improving and Ill-health Preventing Reduced time spent in hospital for people with •Enhanced use of technology to support healthcare long term conditions & including under 18s (Telecare/ telehealth) Positive experience of GP services
Reduced number of patients falling into crisis and needing admission to hospital or care home
x x x Reduction in admissions due to smoking, alcohol an obesity related conditions
Local agreed care pathways for key conditions to ensure •Improving access to specialist opinion and efficient use of secondary care services Increase Dementia diagnosis rates to 67% by equitable access and consistent practice and improve access through e-referral March 2015 specialist opinion x x Integrated clinically-led pathways through Map of Medicine Increase in proportion of people with MH disorders receiving psychological therapies to Enhance EOL care pathways by providing more choice in partnership with EOL forum 15% by March 2015 Electronic referral systems to replace paper based system to reduce variability of referrals Proactive anticipatory care and supported self management for long-toerm conditions Growth of Elective FFCEs limited by x& in 14/15 programme x x Maximum 18 week wait RTT (maintained above Improved signposting and development of single front door (i.e. Health and Social Care 95 %); Hub) (*) Greater proactive anticipatory care and supported self Improved Patient Experience (inc Friends and management Family test) ; •Integrated Falls pathways involving multi-agency partners (including local authority and x x x independent sector) Improving outcomes from planned treatments avoidable emergency admissions reduced
Improved stroke pathways and outcomes Bereaved carers views of quality of care in last 3 months of life x x x Reduction in number of people with Length of stay >30 days (5) Improving and enhancing Planned Care Planned enhancing and Improving Improve access to and quality of Cancer services Improved choice in end of life care x x x
Enhanced end of life care x x
•Improve the delivery of urgent care services by moving to an • Outcome based recommissioning of urgent care services (COBIC) Reduction in non-elective admissions in 2014/15 outcomes based approach by xx%. Delivery of Urgent Care Recovery Plan (with Urgent Care working group) Reduction in non-elective FFCE by x% in 2014/15. Continued development of Community teams A&E Waiting times (max 4 hrs.) (performance x x x x Develop Clinical Assessment Unit maintained at >95%) Maintain A&E attendances at 2012/13 levels
Category A calls resulting in an emergency response arriving within 8 minutes – 75% (standard to be met for both Red 1 and Red2 calls separately (1) •Ensure the Urgent Care system provides high quality services and good access Improved Patient Experience (inc Friends and Family test) (1)
Reduction in number of people with Length of
x x x stay >30 days (5) Improving Urgent Care Urgent Improving Reduction in delayed discharges/performance maintained > 2%
•Reducing the number avoidable admissions , readmissions , repeat visits and the LOS
x x
•Seamless working across all care settings Undertake a Clinical Service Review to establish future options for Herefordshire health and social system Improved Patient/service user experience (inc X X X Friends and Family test) (1 Working with partners to ensure a clear plan for 7 day working is in place across the Health and Social Care economy to improve accessibility (*) Access to services 7 days a week •Improved signposting for patients and public for health and social care services Single front door for health and social care Reduce avoidable hospital admissions X X Re-ablement and intermediate care programme Reduced admissions to residential and care homes •Putting in place a model for 7 day working Embedding the patient experience and patient involvement in all we do X X x Reduced delays in transfer of care DTOC Patients feel supported with self management •Enhanced re-ablement and intermediate care and independence x x x Improved choice in end of life care Increased number of people with a health and social care personal budget
Maintain the numbers of older people at home 91 days after discharge from hospital care into re- Greater Integration of Care Integration Greater ablement
Reduced number of patients falling into crisis and needing admission to hospital or care home
Patient and service users are involved in service
planning/redesign High quality,sustainable, High integrated health the with economy patient the and the at public everything of heart do. we Governing body - Item 7b
CCG Governing Body
4th March 2014
SUBJECT Financial Plan 2014/15 to 2018/19
PRESENTED BY Jill Sinclair, Chief Finance Officer
PURPOSE OF THE REPORT
To update the Governing Body on the two and five year strategic financial plan.
KEY POINTS
The report highlights:
The environment in which Herefordshire CCG will operate including: The financial planning assumptions used The national tariff assumptions The CCG allocation for the five years The CCG running cost allowance Better Care Fund resources The alignment of plans with key stakeholders The income and expenditure plans for the five years QIPP plans Associated risks and mitigation strategies
RECOMMENDATION TO THE COMMITTEE
To approve the draft income and expenditure plan at summary level. A final plan will be presented at the April CCG Governing Body meeting. To approve the QIPP targets for 14/15 To note the negotiation of QIPP for 2014/15 is ongoing and to receive a verbal update on progress at the CCG Governing Body To note that there are risks against the delivery of QIPP and to sign off the mitigation plan.
Herefordshire CCG – Financial Plan Page 1 of 3
Governing body - Item 7b
CONTEXT & IMPLICATIONS
Financial The Strategic financial plan is being developed in line with the national planning requirements and is designed to deliver the CCGs statutory financial duties and delivery of the required national key financial metrics
(delivery of 1% surplus year on year, maintain a contingency of 0.5%,demonstrate 2.5% to be held non recurrently in 2014/15 dropping to 2% from 2015/16 onwards and to note that the running costs allowance drops by 10% in 2015/16 which is circa £400k for HCCG).
Legal The Strategic Financial Plan is Part of the national planning requirements set by Department of Health.
Risk and Assurance The following risks exist (Risk Register/BAF) Wye Valley Trust contract negotiation gap for both Acute and community contract. ICES store Risk of overspend in 2014/15 of Continuing Healthcare and Special Placement budgets and QIPP delivery
HR/Personnel Considered as part of report
Equality & Diversity Considered as part of report
Strategic Objectives The Financial plan underpins the delivery of HCCG’s 5 year plan. The 5 year plan is due to be submitted in June.
Healthcare/National Policy As part of the National planning requirements
(e.g. CQC/Annual Health Check)
Partners/Other Directorates Wye Valley Trust, 2g Foundation trust, Herefordshire council. Voluntary sector NHS England
Carbon Impact/Sustainability Considered as part of report
Other Significant Issues Considered as part of report
Herefordshire CCG – Financial Plan Page 2 of 3
Governing body - Item 7b
GOVERNANCE
Process/Committee approval with date(s) (as appropriate)
Herefordshire CCG – Financial Plan Page 3 of 3
Governing body – Item 7b
FINANCIAL PLAN 2014/15 TO 2018/19
1. Introduction
This paper outlines the latest financial plan submission of 14th February. It is recognised that the plan is part of an iterative process through to June (see attached planning timetable).
The paper covers the financial climate within which the CCG is expected to operate. It also sets out the planning assumptions for the next five financial years, mandated financial requirements and the national efficiency challenge. The CCG’s running cost allowance which reduces by ten percent in 2015/16 is covered, as are the national expectations around the Better Care Fund and current scoping of the delivery requirements of the Quality, Innovation, Productivity and Prevention (QIPP) initiative.
The paper also provides an update (to date) on the ongoing contractual negotiations for 2014/15 with major Providers and the transformational programmes of work that are being addressed through these negotiations. A verbal update will be provided at the Governing Body.
The paper identifies the financial risks as at the time of writing, and mitigation strategies that will aim to minimise these risks for sign off by the Governing Body.
2. Background
2.1 Environment
The UK population is living longer than ever before and according to the Office for National Statistics (ONS) life expectancy has increased between 1990 and 2010 by 4.2 years. The July 2013 NHS England (NHSE) publication ‘The NHS belongs to the people: a call to action’ points out that there has been a noticeable increase in secondary care for those people over the age of 75. The publication continues to note that factors such as an ageing population, out of date management of long term conditions and poor joined-up care between adult social care and health bodies including community and hospital services has had an impact on the increase of emergency admissions and secondary care of the elderly. It also states that, in order to preserve the values that underpin the NHS, the NHS must change to survive, specifically implying that services must be reshaped to meet the health needs of the future.
HCCG – Finance Plans Governing body – Item 7b
The publication draws on the national efficiency target of £20 billion that was expected to be delivered between 2010/11 and 2013/14, and adds that if the NHS continues working with the current model of care, this will result in a funding gap of approximately £30 billion between 2013/14 and 2020/21 over and above the existing £20 billion target.
December 2013 saw the release of ‘Everyone Counts: Planning for Patients 2014/15 to 2018/19’ the national planning guidance for Clinical Commissioning Groups. The guidance draws upon the delivery of the vision based upon the notion of ‘high quality care for all, now and for future generations’ and sets out how this is delivered through the deployment of NHS resources and to continuously improve NHS services.
The planning guidance stresses that the essential elements of quality, access, innovation and value for money must be delivered and implemented to increase better outcomes for patients and local communities. This means that the recommendations as outlined in the Francis Report, Winterbourne and Berwick Reviews must be integral to CCG commissioning re-design decisions.
The above gives a summary of the environment within which Herefordshire CCG will operate. The CCG will receive limited growth resources with the expectation that the ‘must dos’ as laid out in the planning guidance will be delivered. Across the health economy, this work is already beginning to take shape, with the development of joint working with the Herefordshire Local Authority to roll out schemes such as Rapid Access to Assessment and Care and the implementation of the Virtual Ward initiative across the city with the roll out of this for rest of Herefordshire, planned during 2014/15. (dependent upon the successful evaluation of the pilot scheme across the city).
2.2 Financial planning assumptions
Table 1 below, details the Herefordshire CCG financial planning assumptions over the next five years.
Table 1 – Planning assumptions
2014/15 2015/16 2016/17 2017/18 2018/19
Demographic Growth 0.83% 0.84% 0.82% 0.79% 0.79% Non Demographic Growth 1.00% 1.00% 1.00% 1.00% 1.00% Cumulative Surplus 1.00% 1.00% 1.00% 1.00% 1.00% Contingency 0.50% 0.50% 0.50% 0.50% 0.50% Non Recurrent Headroom 2.50% 2.00% 2.00% 2.00% 2.00%
HCCG – Finance Plans Governing body – Item 7b
Demographic growth has been based upon ONS population projections for Herefordshire.
Non demographic growth is an estimate determined locally, and covers pressures arising from technological developments and innovations and increased prevalence. Cumulative surplus is in line with mandatory requirements. The surplus generated in 2013/14 will be carried to the following financial year and the same methodology will apply to subsequent years.
The Contingency of 0.5% is also in line with mandatory requirements, and will be used to offset any in year pressures that may arise.
Non-recurrent headroom is a mandatory requirement and increases from 2% (2013/14) to 2.5% in 2014/15 and then drops to 2% from 2015/16 1nd thereafter. It is mandated that in 2014/15, 1% of this spend is used for the transformation of local services. As in previous years the non-recurrent headroom is to support service changes and to accelerate the delivery of efficiencies for future years.
2.3 National tariff assumptions
The national tariff for 2014/15 was published in December 2013 and this was supplemented by an update to the planning guidance. The tariff allows for cost uplifts of around 2.5% on average which is then offset by the 4% efficiency requirement. Tariff also applies to locally determined prices.
Both the national tariff and planning guidance advise that gross tariff uplift is inclusive of costs associated with the implementation of the recommendations of the Francis and Keogh reports. The efficiency rate remains at 4% each year, and represents the providers contribution towards the national QIPP target.
Table 2 below shows tariff planning assumptions over the 5 years.
Table 2 – National tariff assumptions
2014/15 2015/16 2016/17 2017/18 2018/19
Gross Inflation 2.60% 2.90% 4.40% 3.40% 3.30% Efficiency -4.00% -4.00% -4.00% -4.00% -4.00% Net Inflation/(Deflation) -1.40% -1.10% 0.40% -0.60% -0.70%
HCCG – Finance Plans Governing body – Item 7b
The tariff guidance recommends that -1.8% net deflation is to be applied to non acute services. This is currently being negotiated with non acute service providers for 2014/15.
2.4 Allocations
Two year allocations for 2014/15 and 2015/16 were issued in December 2013, and guidance covering growth assumptions for the 2016/17 to 2018/19 were issued during February 2014. NHS England has updated the CCG allocation policy and this has resulted in Herefordshire CCG being in excess of target allocation. The methodology underpinning the target is based upon local demographics including inequalities and growth in population (the latter as determined by the ONS).
Herefordshire CCG’s 2014/15 opening distance from target is 5.10% over above where the CCG should be, but once growth in population is taken into account and minimal growth of 2.14% is applied, 2014/15 ends with the CCG in excess of target by 3.82%. This represents a ‘pace of change’ move towards target allocation.
Table 3 below details the allocations and the % growth received by the CCG. For 2014/15 NHS England (NHSE) Local Area Team will continue to hold the Better Care Fund on behalf of Herefordshire CCG, however in 2015/16 the allocation will transfer to the CCG. The table below identifies that the non-recurrent allocations are r the carried forward surplus from the previous year.
Table 3 – Recurrent and non-recurrent allocations
2014/15 2015/16 2016/17 2017/18 2018/19 £'ms £'ms £'ms £'ms £'ms Baseline Recurrent Allocation 205.2 209.7 213.3 217.1 220.8 Growth 4.4 3.6 3.8 3.7 3.8 Better Care Fund 4.0 4.1 4.2 4.2 Total Recurrent Allocation 209.7 217.3 221.2 225.0 228.8
Running Cost Allowance 4.5 4.0 4.0 4.0 4.0
Non Recurrent 1.0 2.1 2.2 2.2 2.3
Total Allocation 215.1 223.4 227.4 231.2 235.1
% Growth on Recurrent baseline 2.14% 1.70% 1.80% 1.70% 1.70%
HCCG – Finance Plans Governing body – Item 7b
On the 12th February NHS England advised that they are expecting CCGs to contribute towards the National CHC legacy provision which will be held by NHSE on a risk share arrangement with other CCGs. For Herefordshire CCG this amounts to £814k and is in addition to the PCT provision set aside in 2012/13 for CHC legacy (see point 2.9 of this report table 6 identifies the proposed funding of this additional cost pressure). Further clarity is awaited from the Local Area Team of the process that needs to be undertaken to extract this amount from the CCG. Additionally, clarity is also being sort on the monitoring of the 2012/13 provision and the utilisation of this provision. The CCG also needs to be clear around any further potential in year risk associated with this.
2.5 Running cost allowance
The CCG running cost allowance for 2014/15 and 2015/16 has decreased from 2013/14 rate of £25 per head of unweighted registered population, to £24.73 and £22.07 respectively. For future years planning NHSE have released indicative allowances and rates.
Table 4 – Running cost allowance
2014/15 2015/16 2016/17 2017/18 2018/19 £'ms £'ms £'ms £'ms £'ms Running Cost Allowance 4.5 4.0 4.0 4.0 4.0
Rate per head £ 24.73 22.07 21.88 21.70 21.53
Work is ongoing across the CCG to ensure that the CCG is on target to live within its running cost allowance. This includes working with CSU colleagues to optimise resources.
2.6 Better Care Fund
In 2015/16 the Better Care Fund (BCF) will be devolved to the CCG. The fund will rise from £3.1m to £3.8m in 2014/15 and £ 11.7m in 2015/16. It is recognised that the CCG needs to release over £7m from existing resources (2014/15 levels) to the BCF and that this will be a challenge for the CCG.
The CCG and Local Authority have identified five major themes for the BCF. These are: Creating Care Closer to Home Transforming Community Hospitals Promoting Ambulatory Care improvements Delivering 7 day access to health and social care interventions
HCCG – Finance Plans Governing body – Item 7b
Implementing all ages mental health pathways that include enablement and crisis resolution
See separate Board paper on the Better Care Fund.
2.7 Alignment of plans with key stakeholders
The starting point of the financial plans have been formulated by utilising the 2013/14 month 9 financial forecast outturn position therefore the baseline is aligned with provider and key stakeholder expectations. 2014/15 contract negotiations and agreements are fully testing this assumption. It is recognised that ongoing work will take place to refine and test the planning assumptions for future years and that this is part of the iterative process over the next 12 months.
The continuing work with key partners around the Better Care Fund is critical to the delivery of future years’ plans. Clarity around assumptions and delivery alignment to providers and stakeholders to ensure that the key principles are met, needs to be taken forward through the Health and Wellbeing Board and joint leaders meetings so that the full impact of the plans is understood and aligned to providers and stakeholders.
2.8 Income and expenditure plans
The income and expenditure plans for Herefordshire CCG aims to deliver a surplus in each of the 5 years, however this will be dependent on the delivery of the QIPP target in tandem with the ongoing development and roll out of the Herefordshire Clinical Strategy. Table 5 below is a summary position of the income and expenditure plans of the CCG.
Table 5 – Income and expenditure plan
2014/15 2015/16 2016/17 2017/18 2018/19 £'mms £'mms £'mms £'mms £'mms
TOTAL ALLOCATION 215.1 223.4 227.4 231.2 235.0
Programme Costs 208.6 209.0 211.1 213.9 217.0 Running Costs 4.5 4.0 4.0 4.0 4.0 BCF 11.7 11.9 12.1 12.3 Non Recurrent Headroom 5.2 4.2 4.3 4.4 4.5 0.5% Contingency 1.0 1.1 1.1 1.1 1.2 TOTAL EXPENDITURE 219.3 230.0 232.4 235.5 239.0
QIPP (6.3) (8.8) (7.2) (6.6) (6.3)
SURPLUS 2.1 2.2 2.2 2.3 2.3
HCCG – Finance Plans Governing body – Item 7b
The 2014/15 expenditure plan is being developed into operational budgets that will reflect contractual agreements with providers of healthcare which are currently being negotiated with a deadline of the 28 February 2014. Other budgets are being re-set and there is a timetable to ensure agreement and involvement of key budget holders prior to the end of March 2014. It is intended that the Governing Body in early April will receive a paper reflecting signed contracts and the finalised HCCG budgets by operational area.
2.9 Non Recurrent Headroom
As laid out in the national planning guidance the CCG must set aside 2.5% of the recurrent allocation for non-recurrent purposes. In 2014/15, 1% must be used to support the transformation of local services. It is proposed that the 1% will be utilised on the roll out of the Virtual Wards initiative across the rest of the county, as the current phase only covers Hereford City, and the pump priming of Mental Health services associated with RAID and crisis resolution.
Table 6 below sets out in detail of how the headroom is proposed to be spent in 2014/15, this is inclusive of the investment in tailored care for vulnerable adults aged 75 or older as laid out in the planning guidance. The CCG are currently ascertaining the planning requirements around this investment. Plans are yet to be formulated for future years beyond 2014/15.
Table 6 – Non recurrent headroom expenditure plan
2014/15 2015/16 2016/17 2017/18 2018/19 £'ms £'ms £'ms £'ms £'ms
TOTAL HEADROOM AVAILABLE 5.2 4.2 4.3 4.4 4.5 Use 1% for Transformation: 2.1 COBIC 0.2 Clinical Strategy 0.5 Urgent care Programme of Work 0.1 Electronic Referral 0.1 MSK Pilot 0.1 LIS 0.3 Tailored Care for Vulnerable Older People 0.9 Stroke Rehabilitation 0.5 CHC Legacy issues 0.8 Prioritisation of the above (0.4) Other 4.2 4.3 4.4 4.5
TOTAL EXPENDITURE 5.2 4.2 4.3 4.4 4.5
HCCG – Finance Plans Governing body – Item 7b
2.10 QIPP
Herefordshire CCG is operating in a challenging financial environment. It is recognised that countywide partners and the CCG are facing challenging operating budgets. The demographics of Herefordshire show there is an increasing proportion of an ageing population that is rising year on year and it is acknowledged that services will need to be designed and transformed to ensure that resources are utilised in the most effective way possible to ensure that the healthcare provision meets the demands of the Herefordshire population.
2014/15 identifies a HCCG QIPP target of £6.3 million.The details of this QIPP target have been identified and shared with partners as part of the ongoing negotiations and contract discussions. As identified in section 2.6 of this report, the Better Care Fund (BCF) grows from £3.1m (2013/14) to £3.9m in 2014/15, then to £11.7m in 2015/16. It is key that the BCF is fully utilised in an integrated and transparent manner by all partners across the health and social care system to meet the key principles of BCF. Creating additional resources for the BCF of an additional £7m from the CCG existing baseline has impacted upon the 2015/16 QIPP target, and these assumptions will need to be tested further as part of ongoing discussions with partners.
The QIPP target for the 2015/16 is £8.8m assuming that the £6.3m QIPP target of 2014/15 is fully delivered recurrently in 2014/15. The target in 2015/16 is focused on reducing planned care admissions as per the NHSE Commissioning for Value advice, a continuation of the re-design work in Mental Health services and better management of admission into the Continuing Healthcare system and a continued focus on reducing prescribing costs.
During the 2014/15 financial year work will be undertaken to strengthen the 2015/16 QIPP programmes and to further develop programmes to support the QIPP target for 2016/17 onwards.
3. Risks and mitigation
3.1 Risks
A major risk to the planned forecasts in future years is that contract negotiations are ongoing and the CCG’s major provider Wye Valley Trust are identifying within their initial plans for 2014/15 a significant financial gap. The current 2014/15 contractual negotiations are challenging.
Wye Valley Trust has also identified a funding gap around the community element of the contract and the CCG is currently in discussions with the Trust, NHSE Area Team and Trust Development Authority (TDA) representatives to understand this gap.
HCCG – Finance Plans Governing body – Item 7b
Within the planning assumptions it is assumed that QIPP delivery of £500k will be negotiated out of the 2gether Mental Health Trust contract. Discussions are still ongoing around the delivery of this QIPP target. It is recognised that further work is on-going; the CCG has undertaken work to define robust service specifications linked to this risk.
Prescribing and Continuing Healthcare are identified as other specific risks within the CCG portfolio together with the ICES contract.
It is recognised that further risks may emerge as HCCG’s contracting timetable progresses to the 28 February 2014 and that further risk may emerge in year.
3.2 Mitigation strategies to minimise risks
Herefordshire CCG is working with its key partners to develop the commissioning led Clinical Strategy. Secondary care and primary care clinicians are reviewing clinical services on a line by line basis as part of the Clinical Strategy project. Discussions are ongoing with Wye Valley Trust around the partnership working that is needed to deliver the key outcomes of this project. It is recognised that the savings associated with this project will materialise in later years (after 2014/15).
The CCG has identified investments from the 2.5% non-recurrent reserve and Better Care Fund that will drive delivery of the QIPP targets. The CCG’s direction of travel and programme of work is articulated within the plan on the page (see Board paper). Commissioning decisions will be made in line with this strategic commissioning direction.
It is recognised that there may be slippage on the delivery of investments and this slippage may assist in mitigating in year risks.
The CCG has identified a budget for emergency threshold investment, of which £1.6m is committed for the full year implementation of virtual wards and hospitals at home existing development. As part of contractual must dos for 2014/15 the CCG are required to demonstrate how the emergency threshold monies are being utilised. This requires formal sign off by Providers.
4. Recommendations
Recommendations to the Governing Body are:
To note the financial planning assumptions made within the 14th February submission. To note that the financial plan is part of an iterative process and that key dates are detailed within the report. To approve the income and expenditure plan at summary level.
HCCG – Finance Plans Governing body – Item 7b
To approve the QIPP targets and acknowledge that further work needs to be undertaken to finalise and agree these plans with key partners. To acknowledge that there are risks against the delivery of the QIPP targets and that mitigation QIPP plans may be required to be developed in year. To acknowledge that the CCG needs to engage partners to the delivery of QIPP across the Herefordshire healthcare system. To note that the CCG is operating within a countywide challenging financial environment and that the next stages of the clinically led transformation work is key to delivering a financially sustainable Health and Social Care economy. To note that HCCG‘s operational budgets for 2014/15 will be presented to the Governing Body in April.
Jill Sinclair Chief Finance Officer Herefordshire CCG 24 February 2014
HCCG – Finance Plans Herefordshire CCG Budget Setting Timetable 2014-15
Day Month Action Oct -Dec Continual Refresh of MTFP approved AT in Oct Dec Operating Framework Published 16 Dec PbR Road Testing - DMIC are due to release their “Multi-Tariff” tables week commencing 16th Dec which will contain PbR 14/15 Road Testing 23 Dec Joint view from Regional Teams NHSE and TDA re the interpretation of national views, re 2%, business rules and TDF. 23 Dec Regional and Area teams to assess the level of intervention that may be required for the finacial plan, based upon the assessment of 2013/14. 14 Jan Agree QIPP plans 14-15 14 Jan 1st draft 2 year Financial Plan to AT 21 Jan 14-15 QIPP to January STIG 21 Jan CFO & Deputy meeting AT to review 2 year financial plan 30 Jan Complete Budget setting and sign off with Budget Holders & CFO Subject to changes in Contracting round 31 Jan 1st cut MTFP submission 14 Feb 1st cut MTFP re-submission 14 Feb 1st cut BCF submission By this date, a joint assessment of commissioning plans, including assumptions, rules and scrutiney of QIPP. Review of delivery mechanism, and organisational 14 Feb capability issues and support requirements. 28 Feb Contract sign off 4 Mar Refresh of Financial Plan for submission 4 Mar March Public Board Sign off 14-15 Budgets/Financial Plan/Financial Strategy/QIPP by Board (NHSE request that 2 year plans are signed off by Board at the latest 31 March). Needs to be 1 Mar audit trail from Board sign off to final. 14 Feb Sign off Final CCG Budgets with Budget Holders
25 Mar 14-15 Budgets to F&P Group to Approve
1 Apr CCG Board - apporoval of 14/15 budgets 4 Apr Final 2 year operational plan submission and draft 5 year plan to be submitted 4 Apr Final BTF plan to be submitted 20 Jun Final 5 year financial plan submitted - consistent with main providers 20 Jun 4 Apr 2 year operational plan will be fixed Governing body - Item 7c
CCG Governing Body
4th March 2014
SUBJECT Better Care Fund
PRESENTED BY Jill Sinclair, Chief Finance Officer
PURPOSE OF THE REPORT
To update the Governing body on the current Status of the Better Care Fund (BCF) Submission and next steps.
KEY POINTS
This report highlights:
That the Draft BCF submission on behalf of Herefordshire Council and Herefordshire CCG through the Health and Wellbeing Board for review and subsequent sign off at the Leaders meeting was submitted on 14th February, the CCG having previously delegated decision making to the Chief Officer.
The plan for the next 28 days leading up to the “Final” submission due on the 4th April.
The report indicates how the BCF will be tied into the Modernisation Plan and the CCG’s 2 and 5 year on going planning process.
The Report outlines the next steps in reviewing the proposed governance structure and terms associated with the management of the fund.
RECOMMENDATION TO THE COMMITTEE
The Committee is asked to note the progress to date and agree the proposed Governance structure to manage the fund and to confirm the process for review of the governance Terms and Conditions.
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CONTEXT & IMPLICATIONS
Financial 2014/5 Min £734k , 2015/6 £3.38m, 2015/6 £11.69m pooled or transferred funds with HC/CCG.
The Governing body to note that the 2014/5 budget is held by the NHS LAT for release once HC/HCCG confirms agreement over the detailed spend.
Legal Existing statutory duty associated with healthcare spend and those associated with S75 and S256 monies.
Risk and Assurance A risk log has been provided as part of the BCF (Risk Register/BAF) submission.
HR/Personnel Any impact on staff will be associated directly with individual projects which make up the overall plan and will be subject to engagement with providers, stakeholders and the Local Medical Committee/Health Overview and Scrutiny Committee.
Equality & Diversity Equality Impact Assessment to be conducted jointly.
Strategic Objectives To create an integrated and efficient method of service delivery between council and CCG services and their providers which is centred on the individual and their support needs. The BCF should contribute to providing a response to the geographical challenges of the area and its ageing population while applying the lessons learned and meeting the mandatory requirements in relation to protecting Social Care spend, 7 day services to support early discharge, data sharing and joint assessment while achieving a defined set of outcomes.
BCF agreed objectives:
To provide proactive anticipatory care that promotes supported self-management and prevents crises presentations To embed reablement across all health and social care settings as a fundamental building block of preventative care To integrate voluntary sector services and community support into all services and pathways of care To align services (statutory and voluntary) around primary care, making it the heart of community services that provide real
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alternatives to emergency hospital admission and facilitate earlier discharge home To enable effective liaison and integration of process’s across organisational boundaries to ensure seamless pathways of care – in particular between primary, secondary, mental health and social care services To embed patients and service users views into commissioning plans, service developments and monitoring/evaluation
Healthcare/National Policy The £3.8bn Better Care Fund (formerly the Integration Transformation Fund) was announced by the (e.g. CQC/Annual Health Check) Government in the June 2013 spending round, to ensure transformation in integrated health and social care. The Better Care Fund (BCF) is a single pooled budget to support health and social care services to work more closely together in local areas.
NHS England, the Local Government Association (LGA) and the Association of Directors of Adult Social Services (ADASS) have worked closely with the DoH and Department for Communities and Local Government to shape the way the BCF will work in practice.
The BCF aligns with the strategic process set out by NHS England, and supported by the LGA and others, in The NHS belongs to the people: a call to action.
Its aim is to provide the investment to achieve it.
Partners/Other Directorates Herefordshire Council (Adult Social Care), HWBB, NHS and other providers of health and social care.
Carbon Impact/Sustainability Considered as part of report
Other Significant Issues Forms an integral part of the "Modernisation programme” and the “2 and 5 Year Plan”. Reviewed by NHS LAT and Local Government Association (LGA) via a defined assurance process, both being aware of existing pressures.
Implications for the Acute sector are a mandatory consideration as part of the BCF.
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GOVERNANCE
Process/Committee approval Final plan to be signed off by the CCG, HC and HWBB with date(s) (as appropriate) prior to April 4th 2014.
Governance structure as proposed is attached with initial meetings monthly.
The Better Care Fund (formerly the Integrated Care Fund) is the source for joint spend between Hereford Council and HCCG to be deployed locally by the two bodies. The fund will by 2015/6 incorporate Carers Break and Reablement funding, Capital Grant Funding including DFG (Disabled Facilities Grant) and the existing transfers from Health to Social Care.
Funding is expected to cover demographic pressures in adult social care and some of the Costs associated with the Care Bill. A proportion was initially earmarked to be performance related, with half paid on 1 April 2015 (based on performance in the previous year) and half paid in the second half of 2015/16 (based on in year performance). This performance requirement has unofficially been withdrawn.
The key projects for 2014/15 have had funds assigned to them, some at pilot phase including; Discharge support, RAAC, Virtual Ward and Hospital at Home plus 7 Day working. The balance of the 2014/15 budget is expected to be agreed in the next two to three weeks.
Local providers of NHS care have been involved in agreeing BCF proposals. Key transformational outcomes which the BCF is designed to deliver:
Creating Care Closer to Home Transforming Community Hospitals Promoting Ambulatory Care improvements Delivering 7 day access to health and social care interventions Implementing all ages mental health pathways that include enablement and crisis resolution
Measures: The aims and objectives will be measured through national and local metrics.
Permanent admissions of older people (aged 65 and over) to residential and nursing care homes Proportion of older people (aged 65 and over) at home 91 days after hospital discharge to reablement/rehabilitation services Delayed transfers of care from hospital Avoidable emergency admissions – adults and children
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Patient/service user experience – using current measurement tools such as the annual adult social care service user survey and the Friends and Family Test until the National metric has been developed Local metric – A greater proportion of people aged 18 and over suffering from a long-term condition feeling supported to manage their condition
Timetable:
Our broad timetable for delivery for the BCF is set out below:-
February – March 2014
Complete and finalise details of proposed schemes and supporting financial models Agree the joint HC/HCCG spend across 2014/15 and 2015/6 Develop a joint programme of change, with a route map , critical path, risks and interdependencies fully shared and an agreed governance structure in place across the health and social care system Undertake a system wide financial risk appraisal and develop a shared risk mitigation/risk sharing plan across the health and social care system Via a 28 day work plan prepare the final submission of the BCF
April 2014 – March 2015
Continue to evaluate agreed city pilot schemes and roll out, where agreed as effective, across the county Develop and implement a Health and social care performance dashboard for monthly reporting on key metrics for the BCF Commence mobilisation of BCF schemes and integrated governance structure ready for full implementation by March 2015
Alignment of other Key Plans
Implementing the better care fund is part of a wider transformation programme in Herefordshire, and is part of a wider programme of legal change e.g. the Care and Support Bill implementation, Children’s and Families Bill and the Primary Care Challenge Fund.
Governance
The HWB adopted the transformation and integration agenda as a priority - recognising that the challenges facing Herefordshire’s health and social care system need a system wide solution. The HWB has overseen development of the Joint Commissioning priorities for 14/15, the Better Care Fund and a governance structure that will bring joint commissioning and system wide transformation together with accountability and leadership for delivery at Chief Executive and Chief Statutory
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Officer level. This ensures professional leadership and executive leadership share responsibility for delivering transformational change and through the HWB elected members, carers, voluntary sector and patient /service user views (through Healthwatch) are able to hold the health and social care partnership to account.
A Joint Service Transformation & Commissioning Board (JST&CB) will be developed as the engine room to take our high level “design blueprint” system wide solution for Herefordshire into delivery. This board will be responsible for delivering the change required to achieve the future services and interventions that are important for the residents and children of Herefordshire.
The JST&CB (consisting of senior commissioners, finance directors and performance managers from Hereford Council and Hereford CCG) is a new Board that will initially meet monthly and will:
• Be accountable for health and social care partnerships between Hereford Council and Hereford CCG – including the Better Care Fund • Provide leadership for the development and delivery of the Better Care • Manage and monitor the finances of the Better Care Fund to ensure that funding is spent as planned and in the best way to deliver the agreed outcomes to the defined parameters. • Manage and monitor performance in relation to key outcomes and metrics • Report quarterly to the Health and Wellbeing Modernisation Board • Escalate key issues/concerns or successes to the HWB via the Health and Wellbeing Modernisation Board
This joint commissioning board will be supported and facilitated by the Health and Wellbeing Modernisation Board (formerly known as the leaders group), bringing together
Joint Commissioning V5 Draft Herefrod Board - Governance Structure D3 0 V2.ppt bcf-pln140212.xlsx
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Governing body - Item 7d
CCG Governing body
Tuesday 4th March
SUBJECT Contracts Update
PRESENTED BY Jill Sinclair, Chief Financial Officer
PURPOSE OF THE REPORT
This paper provides an update to the Governing body on the current position of the main contracts.
KEY POINTS
1. Introduction
Herefordshire Clinical Commissioning Group (HCCG) are required to be negotiated and agreed with all providers. The most significant contracts for HCCG are Wye Valley Trust and 2G Foundation Trust. The CCG, with the support of Staffordshire and Lancashire Commissioning Support Services (CSU) are in the process of directly negotiating the these main CCG healthcare contracts The other contracts HCCG are party to are negotiated by other CCGs outside Herefordshire, who will act as host commissioner and negotiate these contracts on behalf of Herefordshire CCG. The CCG will also act as host on the above contracts for other CCGs.
Where a contract does not exist, providers are able to invoice the CCG under the remit of ‘non contracted activity.(NCA)’ so that providers are able to invoice the CCG for legitimate costs associated with treating a patient who is registered with a Herefordshire GP.
Contracts are required to be signed by 28 February 2014.
2. Contract Status as at 24/02/14
2.1 Wye Valley Trust
The CCG has had a number of contractual meetings with Wye Valley Trust. The next meeting is timetabled for 25 February 2014. The key issues to resolve cover both the acute and community elements of the contract, as the Trust are pursuing additional funding for price changes and are currently negotiating around local contract pricing agreements. The Trust has identified a shortfall in funding associated with Community Services, and following an open book accounting exercise, it is agreed that a funding gap does exist, discussions are still ongoing to
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agree exactly the level of the gap and to mitigate this exposure for both the CCG and WVT.
Negotiations are ongoing around the CCG’s required QIPP target of £3.4m (Acute and Community)
The national date set for contract sign off is the 28th February. Both the Trust and the CCG continue to work closely together to enable a fair contract to be agreed so that this deadline date is met.
2.2 2gether Mental Health Trust
Negotiations are close to reaching agreement. The 2gether Mental Health Trust has reluctantly accepted 1.8% deflation against 2013/14 contract values. The CCG has put forward to the Trust a contractual QIPP target and both organisations are working together to re-design services and the Trust are continuing to work with the CCG in repatriating Out Of County patient placements.
The following service benefits have been agreed as part of agreeing a longer term agreement
Improved target for Dementia Improved target for IAPT The CCG is proposing penalties for underachieve and performance payments for over achievements.
In addition, working on additional QiPP in respect of: Repatriation Review of Community Team structures Improvement in Crisis Intervention and reduction of inpatient stay (also linked to RAID)
2.3 West Midlands Ambulance Trust
An offer has been received from the West Midlands Ambulance Trust and appears to be in line with CCG expectations. A key issue for the CCG is the non- achievement of the RED1 target, and as being part of a commissioning consortium the contractual levers incentivise the Ambulance Trust to achieve the target in rural locations. The CCG is not content with signing the contract as the target has not been met in Herefordshire even though it is achieved across West Midlands Commissioner.
2.4 Worcestershire Hospital Trust
The CCG is yet to receive an offer from Worcestershire Hospital Trust. The CSU continue to chase this with neighboring CCGs who have the responsibility for
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negotiating this contract.
3. Overall position
The CCG has set the 2014/15 financial plan based upon 2013/14 out-turn and have then applied deflation rates, demographic growth and non-demographic growth as per national planning assumptions. It is expected that overall there will be enough planned resources to mitigate any contract risk that may arise whilst agreeing 2014/15 health care contracts, but risks are still materializing.
RECOMMENDATION TO THE Governing Body
Governing body should note that there remains key financial risk until contracts are agreed and signed off with key Providers.
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Governing body – Item 9
CCG Governing body
Tuesday 4th March
Tuesday 25th February 2014 Assurance Framework - Performance and Risk Register Subject: Report Presented By: Head of Business Delivery
PURPOSE OF THE REPORT: To provide the governing body with updated performance report and strategic risk register reviewed at Quality and Patient Safety and Finance and Performance Resources Committees.
KEY POINTS: This report highlights current performance across the CCG’s priority areas; against the NHS Constitution requirements, provides an assessment against the National CCG Assurance Framework and also specifies provider KPI performance and corrective actions in place.
The report is split into 3 sections, firstly CCGS core performance dashboard focusing on those key measures identified in 13/14 as providing an indication of success against the CCGs key work areas
Secondly the National Assurance framework - the individual domain ratings have not changed since last month with performance against the NHS Constitution being red rated. The last domain assessing organisation development will remain amber red until all the authorisation conditions are lifted.
Thirdly additional information on specific provider performance related to any key metrics.
Appendix A-E provide the detailed performance information and detail.
Contained in the report are details of any potential areas of concern and where appropriate additional commentary or improvements actions being undertaken by the provider and commissioners. Key areas where current performance has been identified as potentially underperforming are:
A&E 4-hr waits 62 day cancer waiting times Ambulance Category A Red 1 response times Mixed Sex Accommodation Never Event IAPTS Dementia
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Governing body – Item 9
Friends & Family Test 52 Week wait breach
Attachment 1: is the CCGs current strategic risk register up to January 2014. Based on risk methodology adopted by the CCG the top 5 risks identified on the risk register, which will also be highlighted on the board assurance dashboard, after mitigating and planned corrective actions are: Financial and future sustainability of key acute provider Wye Valley Trust. Financial Pressures faced by strategic partners across Herefordshire, in particular reduction in funding /allocation to other public sector agencies e.g. local authority. Pressures on the Urgent Care system, which are increasing in light of correct performance and quality issues within the system. Patient Safety/Quality Assurance (including infection control) - Failure to have robust systems, processes, capacity, understanding and skills to identify/prevent potential or significant harm or abuse to vulnerable adult or child, resulting serious neglect, injury or death of vulnerable person. Capacity challenges relating to the fact that potentially Herefordshire lacks sufficient resources and clinical capacity to support the delivery of its key strategic objectives and work programmes. The format of the assurance report has changed as the January Audit Committee recommended that going forward that for greater clarity the reports revert to the separation of the performance report and assurance elements. Therefore as a step towards this this report contains the CSU Performance report and the CCGs corporate risk register, to further assist in this development the internal auditors are undertaking a review of the GBAF and risk processes that will also inform future iterations of these reports.
RECOMMENDATION TO THE COMMITTEES The governing body is asked to note the report and make any recommendations for further actions to mitigate risk.
CONTEXT & IMPLICATIONS: Financial Potential financial penalties can be applied to providers for poor performance
Legal Health and Social Care Act 2008 Children Act 1989, 2004 Mental Capacity Act 2005 Mental Health Act 1983, 2007 Risk and Assurance Processes for identify risk are inherent in the quality (Risk Register/BAF) assurance framework and CCGs risk process. Any risks identified will be placed on the corporate risk
register HR/Personnel No issues identified
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Governing body – Item 9 Equality & Diversity Promotes equality and diversity
Strategic Objectives Meets the strategic objectives in relation to Governance and Quality
Healthcare/National Policy Meets the requirements of national policy in relation to quality (e.g. CQC/Annual Health Check)
Partners/Other Directorates NHSCB Area Team Local Authority Providers of commissioned services CQC Carbon Impact/Sustainability N/A
Other Significant Issues N/A
GOVERNANCE Process/Committee approval with date(s) (as appropriate)
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Governing body – Item 9 Contents
Section Page
Introduction 4
Section 1: The CCG’s Core Performance Dashboard 4
Section 2: National Assurance Framework 6 2.1 Are local people getting good quality of care? 6 2.2 Are Health Outcomes Improving for Local People? 7 2.3 Quality Premium 7 2.4 NHS Constitution 8 2.5 Financial Requirements 9 2.6 Authorisation Conditions 9
Section 3: Provider Performance 9 3.1 Overall Performance 9 3.2 KPI Review 10 3.3 Finance 13 3.4 CQUINs 13 3.5 Contract Fines 13 3.6 Contract Round 2014/15 14
Appendix A - Quality of Care Assessment 15
Appendix B - HCCG Outcomes Indicators 16
Appendix C - NHS Constitution 18
Appendix D - HCCG Financial Requirements 19
Appendix E - Quality Premium 20
Appendix F - Key Performance Indicators 21
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Governing body – Item 9 Introduction
The performance report is split in to three parts as follows:
Section 1: The CCG’s Core Performance Dashboard
Section 2: National Assurance Framework for CCGs in regard to the NHS Constitution; Financial Requirements and Authorisation conditions
Section 3: Provider performance with specific details around key performance indicators, contract levers and corrective action plans
The main body report of the report will focus on performance issues on an exception basis and only provide high level summaries of each performance category. The appendices contain the full detail of the indicators as follows:
Appendix Contents Lead Committee Main Reporting Driver A Quality of Care Quality & Patient Safety B Outcomes Framework Quality & Patient Safety C NHS Constitution Finance & Performance CCG Assurance Framework D Financial Requirements Finance & Performance E Quality Premium Finance & Performance F Key Performance Indicators Finance & Performance Provider Performance
Section 1: The CCG’s Core Performance Dashboard
These dashboard indicators have been selected from the CCG’s own ‘Business Plan’ for the year (e.g 13/14 plan on pgae) with additional key performance indicators and provides a snapshot on what are considered to be the key local health and commissioning performance issues for the CCG.
February Monitoring
Latest Performance Year to Date
Plan / Plan / % against Year End Direction Forecast CCG Dashboard Strategic Objective Month Actual Variance Actual Variance Target Target plan Target of Travel Outturn Reduction in number of community episodes/spells with Leading local health Dec 29 23 -6 296 265 -31 90% <391 LoS >30 days system Reduction in the average LoS of community Leading local health Dec 11.87 11.10 -0.77 12.84 12.24 -0.6 95% <13 episodes/spells (excludes zero LoS) system Leading local health Delayed discharges as a percentage of admissions Dec <=2% 1.69% 0.31% <=2% 1.96% 0.04% <=2% system Leading local health QIPP Delivery Jan system Achieve green finance rating as part of Assurance Leading local health Jan Framework system Leading local health Remove all authorisation red conditions by March 14 Jan system Leading local health Plan for flourishing and sustainable future for WVT Jan system
Dementia diagnosis (activity against plan) Planned Care Jan 1,233 1,114 -119 1,233 1,114 -119 90.35% 1,257
Receiving psychological therapies (activity against plan) Planned Care Jan 152 130 -22 1,520 750 -770 49.34% 1,820
Elective FFCEs (activity against plan) Planned Care Dec 1,728 1,524 -204 15,938 16,397 459 102.88% 21,641
First out patient attendances (activity against plan) Planned Care Dec 3,472 3,960 488 35,437 37,848 2,411 106.80% 47,143
Maximum 18 week wait RTT - incomplete Planned Care Dec 92.00% 96.59% 4.59% 92.00% 96.59% 4.59% 92.00%
C Diff Planned Care Dec 5 3 -2 41 37 -4 90.24% 55
MRSA Planned Care Dec 0 1 1 0 2 2 0
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Governing body – Item 9
Plan / Plan / % against Year End Direction Forecast CCG Dashboard Strategic Objective Month Actual Variance Actual Variance Target Target plan Target of Travel Outturn *Reduction in referrals for dermatology; gastro and Preventing ill-health Dec 388 385 -3 4053 4250 197 104.86% <5% cardiology
Reduction in admissions for people with a LTC Preventing ill-health Nov 811 758 -53 6288 5930 -358 94.31% <1.2%
Reduction in re-admissions for people with a LTC Preventing ill-health Nov 158 129 -29 1137 963 -174 84.70% <1.2%
Reduction in LoS for people with a LTC (Total Bed Days) Preventing ill-health Nov 3038 2421 -617 25491 23989 -1502 94.11% <1.2%
Friends and Family - combined score Preventing ill-health Dec 71 55 -16 71
*Reduction in non-elective admissions (Wye Valley, Urgent Care Nov 798 829 31 6708 6378 -330 95.08% -1.2% Adults Only, Excludes maternity)
Non-elective FFCEs (activity against plan) Urgent Care Dec 1,286 1,419 133 11304 11428 124 101.10% 15,154
A&E attendances (activity against plan) Urgent Care Jan 3,853 4,075 222 40,369 44,459 4090 110.13% 54,574
A&E waiting times (max 4 hours) Urgent Care Jan 95.00% 90.77% -4.23% 95.00% 92.18% -2.82% 95.00%
Minimise A&E turnaround (over 30 minutes) Urgent Care Jan 0 30 -30 0 629 629 0
Maximum 2 week prior to first outpatient appointment for Urgent Care Dec 93.00% 93.81% 0.81% 93.00% 95.15% 2.15% 93.00% suspected cancer Figures in bold italics are unvalidated/provisional/via external sources *Referrals & non-elective data subject to further analysis to reconcile current data to original forecast/Unify return
Key: Colour Direction of Travel Forecast Outturn Green Improving position/performance Forecast to achieve or exceed target Amber Maintaining position/performance Potential that target will not be achieved Red Worsening position/performance Forecast NOT to achieve target
Key issues to note here are:
Dementia data for January confirmed at 1114, remaining well below target, with anticipated in year improvements from investment due to take effect. Numbers receiving psychological therapies (IAPT) remained below target in December, however did show an encouraging increase in numbers from previous months. The part year funding agreed with 2gether will achieve expected performance of 7-8% (previous year 6%). This performance is below the plan for 2013/14 (12.5%), but there is an expectation that the full year impact of the investment will achieve 15% in 2014/15. The position for CDIFF was maintained in December. Three cases were recorded to the CCG which is below the plan of 5. Overall the CCG has had 37 cases out of an annual target of 55. The Wye Valley Friends and Family test combined score for December was 55, compared to 66 in November. This remains below the target of 71. The A&E score fell from 54 to 50, however the Inpatient fell significantly from 78 to 60. The average November combined score for England (without Independent Sector Providers) was 64. A&E attendances (all Wye Valley attendances, Herefordshire and non-Herefordshire residents) showed an over-performance again in December with 222 more patients seen than the forecast trajectory. Year to date now showing 2,633 more attendances than expected. Activity/finance for Herefordshire residents (at all acute A&E providers) continues to reporting below trajectory. A&E waiting times (95% 4-hour wait target) performance reported continued pressures throughout January. This resulted in failure against the target for the month with the reported outturn of 90.77%. Whilst attendances were above trajectory, this is not thought to be the primary contributing factor to the level of 4 hour breaches and more as a result of the bed capacity and flow of patients through the trust. This assumption is that this target will not be met at year end, predicted to be 92%. Referrals for dermatology/gastro/cardiology were in line with the planned trajectory, however remain above the reduction target year to date.
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Governing body – Item 9
Section 2: National Assurance Framework
Overall performance against the Framework’s balanced score card for all the domains is as follows: The Quality and Patient Safety Committee has specific accountability for reviewing the first and third of these domains which are detailed in appendices A and B. Performance against these domains is currently assessed as follows:
Rating Lead Amber Amber Direction Domain Green Red Committee Green Red of Travel Are local people getting good QPS quality of care? Is the CCG promoting the NHS F&P Constitution? Are health outcomes improving QPS for local people? Is the CCG delivering against F&P financial requirements? Are the authorisation F&P conditions being met?
This performance is reviewed at the quarterly checkpoint meetings with the Area Team together with the domains covering Quality of Care and NHS Outcomes. The next review is due to take place in April.
2.1 Are local people getting good quality of care?
Appendix A contains the detailed assessments against the relevant providers. These measures are used by the Area Team for quarterly monitoring of the CCG. The assessment is based on the provisional Quarter 3 information to date.
A green rating for this domain can only be achieved if positive answers are given to all areas of the domain. The CCG is not able to do this because: Concerns remain around the pressures at Wye Valley in terms of capacity and activity management which led to action by the TDA. The CCG and WVT continue working to address and resolve. The Friends and Family test score for WVT fell in December. The overall score was 55, down from 66. The inpatient score for December was 60, the A&E score was 50 (on a scale of -100 to 100). The England average overall score was 64. The response rate for WVT remained below the England average. WVT remains identified as a negative outlier on SHMI or HSMR WVT has unclosed serious incidents.
The overall HCCG assessment for the Quality of Care domain for Quarter 3 remains at Amber Red due to the current quality concerns it has with its providers as a result of the pressures at Wye Valley Trust and assurances around mitigation.
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Governing body – Item 9 2.2 Are Health Outcomes Improving for Local People?
Appendix B sets out all the NHS Health Outcomes. In order to get a green assessment all relevant indicators need to be on track for achievement of the Quality Premium. The domain is currently assessed as an amber green as not all indicators are statistically on track for achievement, however, Herefordshire performs well when benchmarked with other CCGs. These indicators are: IAPTS Dementia Friends and Family Test
As reported earlier, investment has been agreed with 2G in relation to IAPTS, with December performance showing early signs of improvement.
For Dementia, the figures for January are not yet available, however it is expected to remain well behind target. Investment has been agreed with an enhanced service starting 1st January 2014. This will improve performance but is forecast to remain below plan for 2013/14. Once data is available to evidence the impact of the new service it will be reported.
As reported above, the Friends and Family test results did fall in December, and continued to perform below expectations year to date. The Quality Premium payment however will be based on comparative performance from the first quarter this year to the first quarter in 2014/15.
2.3 Quality Premium Appendix E contains the detail relating to the performance and potential Quality Premium payment. A number of the domains and indicators are outcome based and as such the supporting data are proxy measures and give a provisional view.
The measures currently at risk are: Domain 2 & 3 – Enhancing Quality of Life & Helping people recover Domain 4 – Positive Experience of Care Domain 5 – Treating People in a Safe Environment Local Measure 2 – Reduction in Referrals for Dermatology/ Gastroenterology/ Cardiology Local Measure 3 – Dementia – number of people diagnosed
The associated constitution indicators currently at risk are: A&E Waits Cancer Waits – 62 days Category A Red 1 Ambulance Calls
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Governing body – Item 9
2.4 NHS Constitution
Appendix C contains the detail for performance against the requirements of the NHS constitution. A green or amber green rating can only be achieved if less than 2 indicators are rated red. The CCG is assessed as a red overall as two or more indicators are rated red as their performance has been below the standard over two consecutive quarters.
Those indicators rated red are:
4 hr A&E waits January data identifies continued pressures at Wye Valley, with a result of 90.77% of patients being seen within 4 hours (based on WV data). Exception reports continue to be submitted to NHS England on a weekly basis where performance falls below 85% on a single day or 90% for a week
62 day cancer waits (referral to treatment) The December cancer data (74.4%) confirmed that performance remains well below the 85% target, recording 78.6% year to date. It is expected that this measure will not be passed for 2013/14.
Red One Ambulance responses within 8 minutes December performance for Red One Ambulance responses remained well below the 75% target at 63.6%. An audit is being carried out to better understand the Herefordshire activity and case-mix and how the service is responding to questions around the poor performance for Herefordshire.
Mixed Sex Accommodation There were 2 more confirmed MSA breaches December, taking the year to date total to 17 at Wye Valley. Provisionally there have been none reported in January. Measures have been taken by Wye Valley in configurations, to minimise potential future breaches.
Cancelled Operations The Q3 outturn for cancelled operations is awaited to determine whether the causes of the Q2 poor performance have been addressed. This data is not collected on a commissioner basis and cannot be mapped to CCGs.
52 Week Wait breach A breach at North Bristol NHS Trust has been reported. Investigations are ongoing to establish the reasons, however early indications are that it was due to patient choice. A treatment date was offered in December, however the patient declined and a subsequent date has been arranged for February.
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Governing body – Item 9
2.5 Financial Requirements
Appendix D contains the detailed assessment on how sustainable the CCG’s financial plan is. The month 10 position on the individual indicators shows an improvement to that reported in last month’s assessment, with the Activity Trends ratings moving from Amber Red to Amber Green. The overall assessment criteria has yet to be defined, however in line with month 9, and the review of key financial metrics with the Area Team the position remains rated as amber green.
The Financial Update and Budget report also provides further information with reference to this domain.
2.6 Authorisation Conditions
The CCG is subject to a separate process for discharging its authorisation conditions. The Assurance Framework provides, in the quarterly checkpoint, an opportunity to review rectification plans and test progress. The authorisation domain does not have any formal assessment criteria and the rating will be based on the number of conditions outstanding.
Having focussed on the two remaining conditions relating to patient experience the CCG submission to remove these was supported by the Area Team. The regional review panel met in January 2014 to consider and determine the outcome, and official confirmation has been received that the conditions have been lifted.
Section 3: Provider Performance
3.1 Overall Performance
3.1.1 Wye Valley NHS Trust
The key KPIs that are not been met are as follows:
• A&E 4hr wait target • Cancer waits (breast and 62 day wait) • Ambulance hand-overs • CDiff
3.1.2 2Gether FT The dementia and IAPT targets will not be met in 2013/14. There are issues with the provision of financial information including the financial matrices and analysis of NCAs. These are in dispute now, with HCCG CFO writing to 2g to query. The dementia contract variation has been sent with IAPT to follow shortly.
3.1.3 West Midlands Ambulance Service The red 1 ambulance performance has been a significant issue due to the press reports regarding the level of fines and reinvestment. The total level of fines attributable to the CCG are low, more emphasis is given to agree a plan that improves RED 1 performance. This was reviewed by SMT on 10th February. Further information has been requested from WMAS and a review carried out with DF and JS around the contract baseline and investment for 14/15.
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Governing body – Item 9 3.2 KPI Review The KPIs are outlined in Appendix F. The data has been based on the weekly return submitted to the CCG 7th February 2014. The majority of KPIs cover the 9 month period April to December 2013.
3.2.1 Wye Valley KPIs Causing Concern
CDiff Infections As previously reported the number of CDiff infections reported were improving, WVT had previously been subject to a contract notice. One case was reported in December and the performance remains amber rated. Currently there have been 12 cases (year to date) out of a full year target of 15. Whilst, the other providers are mirroring a similar performance to WVT, the achievement of this target will be very tight especially with winter pressures.
Cancer Breast symptomatic 2 week wait time – The CCG has received data for April-December which is below target 88.6% vs. 93.0%. The activity below shows the number of patients seen within each time frame between April 2013 and December 2013. This performance measure has been subject to a contract notice with WVT. The CCG are aware from the CMB that WVT have added additional clinics including in the evening. WVT have quoted that a common reason for missing the target is patient choice. Row Labels Seen Within 14 days Seen 15 To 16 days Seen 17 To 21 days Seen 22 To 28 days Seen After 28 days RLQ Exhibited (non-cancer) breast symptoms - cancer not initially suspected 427 12 25 14 5 RRK Exhibited (non-cancer) breast symptoms - cancer not initially suspected 0 1 0 0 0 RTE Exhibited (non-cancer) breast symptoms - cancer not initially suspected 3 0 0 0 0 RWP Exhibited (non-cancer) breast symptoms - cancer not initially suspected 11 0 0 0 0 RNZ Exhibited (non-cancer) breast symptoms - cancer not initially suspected 1 0 0 0 0 Grand Total 442 13 25 14 5 NB RLQ is Wye Valley NHS Trust.
The data for December is displayed below and shows some a drop in performance to 85.5%. Row Labels Seen Within 14 days Seen 15 To 16 days Seen 17 To 21 days Seen 22 To 28 days Seen After 28 days RLQ Exhibited (non-cancer) breast symptoms - cancer not initially suspected 59 4 4 1 1 Grand Total 59 4 4 1 1
The CCG’s Cancer 62 days wait target – The overall target is not being met largely due to the two providers not achieving the target. Both Wye Valley and Gloucester recorded poor performance in December at 70.3% and 62.5% respectively. The specialties that are causing concern at WVT are primarily Urology and to a lesser degree Breast. Overall it is unlikely that this target will be achieved.
The CCG are aware that Wye Valley has sought assistance from the NHS cancer intensive support team (IST) to audit cancer procedures and processes to help address the poorly performing cancer waiting times. Details of the findings and recommendations are yet to be published.
Diagnostic Tests WVT performance has slipped below target in December. A contract notice has been issued for an action plan and assurance of improved performance. In addition, the CSU is has identified data quality issues which WVT have been asked to review.
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Governing body – Item 9
A&E 4 hour waits This target remains the key concern. The poor performance in December continued into January recording 90.77% against the 95% target. This continues to be monitored and reviewed by the Urgent Care Working Group. Many actions have been taken to mitigate the pressures, with WVT service reconfiguration with Clinical Assessment Unit, additional CCG investment, Primecare GP in A&E etc. The CCG is predicting an under-performance of this measure. The expected percentage level of achievement for the year is 92%.
RTT The early indications of system pressures (emergency admissions and the theatre issues) at WVT in October, have continued into November. The performance for November indicated failure of admitted care in the following specialties: ENT, Ophthalmology, Other and Trauma & Orthopaedics.
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Governing body – Item 9 WVT have stated that the end position will deliver the 92% performance in admitted care however it expects to fail T&O. The CCG has negotiated a year end deal with WVT and it is likely that the waiting list will move out from 150 cases to 220 cases. This will need to be picked up in 2014/15. WVT is still benchmarking well against other providers.
52 week wait There have been nine breaches so far this year, one of which was from WVT.
Ambulance handovers Handovers over 15 minutes are still being exceeded and fines imposed.
Breast feeding target Number of new mothers initiated breast feeding – The provider did not achieve the target in 2012/13 78.1% v a target of 85%. Current performance has improved although is still below target at 75.45% YTD.
Breast feeding Prevalence of breast feeding 6 to 8 weeks after birth – Performance is higher than last year although performance is still below the national target (46.3% vs 60%). As at November this is still below target at 48.1%.
Never events No further cases reported this month. To date, three cases have been confirmed by Wye Valley to the CCG. Two cases were retained objects, the third was a medication error.
3.2.2 Mental Health – 2Gether The CCG have agreed developments for both IAPT and Dementia. Services will be operational from the beginning of January 2014. Outcomes of the
IAPT The target for IAPT is 12.5% in 2013/14. Due to slippage in enhanced service 2g forecast outturn will be at 7-8%. The full year in 2014/15 is planned at 15%. The CCG are looking at other CBT therapies that are given as part of the expert in order to establish whether this activity can be counted. 2g are assessing this with WVT.
Dementia The dementia diagnosis target is 40% of prevalence. Again and mainly to due to a delayed start the expected year end performance is expected to be c35%. Next year (2014/15) this will rise to 40%.
There have been a number of issues identified with the provision of quality data and financial information. These are being addressed through the contract negotiations for 14/15.
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Governing body – Item 9
3.2.3 West Midlands Ambulance Service The ambulance performance has been an issue both in terms of over-performance (financial) and targets not been met. The over performance is probably due to two factors. Firstly under buying activity and the impact of 111. The performance on calls has been poor however this is not replicated in other CCG areas. The red 1 performance has been poor through-out the period, and continued to report below target in December.
The consolidated performance now means that the Ambulance Service will be running into fines. WMAS have been in the press indicating that there is £3m at risk. The CCGs estimate of these suggest that they are likely to be less i.e. £0.7m for 7 months. A letter has been sent to the provider concerning the application of fines. The relevant extract is as follows: “….. if WMAS board has developed a plan for re-investment of WMAS fines to meet performance we would welcome sight of the initiatives proposed, including lead times and costs to end March 2014. Any agreement to reinvestment of fines to date would not prejudice CCGs of fine levies for the remainder of this financial year, or after.” All possible contract levers are being explored, around potential fines and remedial action plans, however some of the constraints are widely reported in terms of the regional West Midlands contract and impacts on Herefordshire. The financial over-performance of the contract has been of major concern. The CCG is seeing over-performance of c15% in calls. The CCG have requested a report to be taken to SMT and this will be provided to the meeting on 3 February 2014. The key areas that it will address depending on the availability of information will be as follows: Understanding the reasons for the reasons for the financial over-performance, an analysis of calls by Geography, age, source of call, category of call and clinical condition.
3.2.4 Call to Balloon Monitoring Following previous discussions at QPS, efforts have continued to obtain data to evidence the performance of the pathway. Some very high level figures have been received directly from the Worcestershire Cardiology Consultant, as follows: For the calendar year 2013, there were 49 PPCI patients at WRH with HR postcodes. 33 patients were admitted directly (not interhospital transfers) and excluding a couple for incomplete date, these patients had an average call to balloon time of 122 minutes (range 72 – 193, 5 patients >150 minutes). Further avenues are being explored to obtain more detailed information and analysis.
3.3 Finance The detailed financial picture is included in the CFO’s report, however, the headline issues are included below.
Wye Valley The CCG and WVT have verbally agreed a year end deal. The total sum agreed was £105m. Awaiting formal agreement from Wye Valley.
3.4 CQUINs No further report.
3.5 Contract Fines The CCG have agreed as part of the year end settlement that these will be shown as a variation out of the contract and reinvestment agreed through QPR/FPR will be added back in. The total value agreed with WVT was £500,000.
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Governing body – Item 9 3.6 Contract Round 2014/15 Initial contract meetings have taken place for the two main providers.
WVT - The key issues will be: Agreeing the Community Contract Value Agreeing the activity and finance schedule – key issues growth, waiting lists Local pricing including CAU Impact of other commissioners e.g. Public Health Sexual Health budget In year Schedule being developed for the review of contract specifications
2g – The key issues will be: The transfer of zero priced services The impact of the Local Authority reduction of 20% of the contract value Agreeing information requirements In year Schedule being developed for the review of contract specifications
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Governing body – Item 9 Appendix A – Quality of Care Assessment
Quality of Care Assessment - CCG Assurance Framework 2013/2014 Are local people getting good quality care? Review Period: *Q4 2013/14 - 1st January 2014 - 7th February 2013 Indicator Outcome Providers: WVNHST 2GNHSFT Has the local provider been subject to enforcement action by the CQC? No No Has local provider been flagged as a 'quality compliance risk' by Monitor and/or are requirements in place N/A No around breached of provider licence conditions? Has local provider been subject to enforcement action by the NHS TDA based on 'quality' risk? Yes N/A Does feedback from the Friends and Family test (or any other patient feedback) indicate any causes for Yes No concern? Has the provider been identified as a 'negative outlier' on SHMI or HSMR? Yes N/A Do provider level indicators from the National Quality Dashboard show that: MRSA bacteraemia cases are above zero No No The provider has reported more C Diff cases than trajectory No No MSA breaches are above zero No No Does the provider currently have any unclosed serious incidents? Yes No Has the provider experienced any Never Events during the last quarter? No No
Clinical Commissioning Group: Clinical Governance Does the CCG have any outstanding conditions of authorisation in place on clinical governance No Has the CCG self-assessed and identified any risks associated with the following: Concerns around quality issues discussed regularly by the CCG governing body No Concerns around the arrangements in place to pro-actively identify early warnings of a failing service No Concerns around the arrangements in place to deal with and learn from serious incidents and never events No Concerns around being an active participant in its Quality Surveillance Group No EPRR If there was an emergency event in the last quarter, has the CCG self-assessed and identified any areas of N/A concern on the arrangements in place for dealing with such an event? Winterbourne View Has the CCG self-assessed and identified any risk to progress against its Winterbourne View action plan? No Overall Assessment The CCG has all 'No' reponses. No The CCG has 1 or more 'Yes' responses, but action plan in place to successfully mitigate patient risk No The CCG has 1 or more 'Yes' responses, and no action plan in place/plan does not successfully mitigate Yes patient risk The CCG has enforcement action being undertaken by the CQC, Monitor or TDA and the CCG is not No engaged in proportionate action planning to address patient risk.
Green - all no responses Amber/Green - 1 or more 'yes' responses but action plan in place that successfully mitigates patient risk Amber/Red - One or more yes responses and no action plan in place/plan does not successfully mitigate patient risk Red - Enforcement action is being undertaken by the CQC, Monitor or TDA and the CCG is not engaged in proportionate action planning to address patient risk. N/A = Not Applicable
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Governing body – Item 9 Appendix B – HCCG Outcomes Indicators Domain 1 Preventing people from dying prematurely RAG Frequency Status Target Baseline Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Rating
g g ANNUAL LIVE 1,925 (f)
Potential years of life lost (PYLL) from causes considered amenable to Indicators C1.1 Overarchin healthcare 2,655(m) Reducing premature mortality from the major causes of death C1.2 Under 75 mortality rate from cardiovascular disease ANNUAL LIVE 72.03 C1.6 Under 75 mortality rate from respiratory disease ANNUAL LIVE 18.09
C1.7 ment Under 75 mortality rate from liver disease ANNUAL LIVE 13.64
C1.9 Improve Under 75 mortality rate from cancer ANNUAL LIVE 108.58
Domain 2 Enhancing quality of life for people with long term conditions RAG Frequency Status Target Baseline Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Rating
BI- Health-related quality of life for people with long-term conditions IN DEV
ANNUALLY Indicators
C2.1 Overarching
BI- People feeling supported to manage their condition IN DEV C2.2 ANNUALLY Improving functional ability in people with long term conditions Reducing Time spent in hospital by people with long term conditions Unplanned hospitalisation for chronic ambulatory care sensitive
Areas MONTHLY LIVE <600 657.9 55.85 65.39 51.77 64.03 43.59 51.08 69.48 48.36 C2.6 conditions (adults) Unplanned hospitalisation for asthma, diabetes and epilepsy in under Improvement Improvement MONTHLY <350 360.5 26.17 36.6 26.17 39.26 15.7 34.03 31.41 36.64 C2.7 19s
Domain 3 Helping people to recover from episodes of ill health or following injury RAG Frequency Status Target Baseline Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Rating Emergency admissions for acute conditions that should not usually MONTHLY LIVE <1,000 1,066 85.45 72.47 76.79 74.09 81.12 74.63 83.28 81.66 C3.1 require hospital admission
Indicators Emergency readmissions within 30 days of discharge from hospital MONTHLY LIVE <6% 6.55% 6.65% 6.79% 6.22% 6.36% 6.13% 6.46% 6.53% 6.38% C3.2 Overarching
Improving outcomes from planned treatments C3.3 Increased health gain as assessed by patients for elective procedures MONTHLY LIVE a) Hip replacement 0.46 N/A N/A b) Knee replacement 0.33 N/A N/A c) Groin hernia 0.11 N/A N/A d) Varicose veins
Areas Preventing lower respiratory tract infections (LRTI) in children from becoming serious Emergency admissions for children with Lower Respiratory Tract
Improvement Improvement MONTHLY LIVE C3.4 Infections (LRTI) People who have had a stroke who: Herefordshire CCG – Assurance Framework 17
Governing body – Item 9
Domain 4 Ensuring that people have a positive experience of care
RAG Frequency Status Target Baseline Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Rating Patient experience of primary or hospital care Patient experience of primary care i) GP Services ii) GP Out of Hours BI- LIVE C4.1 services ANNUALLY
C4.2 Patient experience of hospital care ANNUAL Indicators Overarching 43 48 53 C4.3 Friends and family test for inpatient care and A&E TBD IN DEV 71 70 45 50 40 57 66 55
Domain 5 Treating and caring for people in a safe environment and protecting them from avoidable harm RAG Frequency Status Target Baseline Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Rating
C5.3 Cumulative Incidents of healthcare associated infection MRSA MONTHLY LIVE 0 7 0 0 0 0 0 1 1 2 2 ment Areas Cumulative Incidents of healthcare associated infection C difficile MONTHLY LIVE 55 59 6 16 19 20 22 26 28 34 37 C5.4 Improve
Domain 6 Others RAG Frequency Status Target Baseline Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Rating
IAPT Coverage - performance against plan Quarterly 1820 871 -60 -59 -110 -82 -109 -78 -104 -72 -74 -22
Areas ement ement C6.1 Improv
Reduction in non-elective admissions (achieved through such initiatives Monthly -1.2% 9,978 695 829 747 816 817 769 876 829 C6.2 as Hospital at Home) Reduction in 1st OPD referrals for Dermatology; Gastro and Cardiology Monthly -5.0% 6,008 508 480 430 632 482 489 438 406 385 C6.3 (achieved through such initiatives as E Consultation) Dementia - Percentage of people diagnosed with dementia. Monthly 40% 35% 32.59% 34.59% 34.82% 35.46% C6.4
Herefordshire CCG – Assurance Framework 18
Governing body – Item 9 Appendix C – Expected Rights and Pledges from the NHS Constitution
Lower YTD/Current Direction Target Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Threshhold Position of Travel Referral To Treatment waiting times for non-urgent consultant-led treatment No data Admitted patients to start treatment within a maximum of 18 weeks from referral 90% 85% 94.09% 92.43% 89.90% 93.25% 93.25% available No data Non-admitted patients to start treatment within a maximum of 18 weeks from referral 95% 90% 99.19% 99.50% 99.55% 99.42% 99.42% available Patients on incomplete non-emergency pathways (yet to start treatment) should have been No data 92% 87% 97.04% 96.85% 96.93% 96.59% 96.59% waiting no more than 18 weeks from referral available No data Zero tolerance of over 52 week waiters 0 10 0 0 0 1 9 available Diagnostic test waiting times Patients waiting for a diagnostic test should have been waiting no more than 6 weeks from No data 99% 94% 99.74% 99.62% 99.24% 99.24% 99.11% referral available A&E Waits
Patients should be admitted, transferred or discharged within 4hours of their arrival at an A&E 95% 90% 83.40% 95.04% 95.41% 89.45% 90.77% 92.18% department Lower Direction Cancer waits – 2week wait Target Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Rating Threshhold of Travel Maximum two-week wait for first outpatient appointment for patients referred urgently with No data 93% 88% 93.50% 94.12% 94.94% 93.81% 95.15% suspected cancer by a GP available Maximum two-week wait for first outpatient appointment for patients referred urgently with No data 93% 88% 86.21% 88.33% 93.33% 85.51% 88.58% breast symptoms (where cancer was not initially suspected) available Cancer waits – 31 days No data Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers 96% 91% 98.75% 98.00% 98.75% 100.00% 99.05% available No data Maximum 31-day wait for subsequent treatment where that treatment is surgery 94% 89% 88.24% 100.00% 100.00% 100.00% 94.74% available Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug No data 98% 93% 100.00% 100.00% 100.00% 100.00% 100% regimen available Maximum 31-day wait for subsequent treatment where the treatment is a course of No data 94% 89% 100.00% 100.00% 92.31% 100.00% 99.39% radiotherapy available Lower Direction Cancer waits – 62 days Target Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Rating Threshhold of Travel Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for No data 85% 80% 82.50% 82.26% 81.82% 74.42% 78.61% cancer available Maximum 62-day wait from referral from an NHS screening service to first definitive treatment No data 90% 85% 60.00% 100.00% 100.00% 100.00% 96.92% for all cancers available Maximum 62-day wait for first definitive treatment following a consultant's decision to upgrade No op No op No data 100.00% 100.00% 100.00% 100.00% 100% the priority of the patient (all cancers) – no operational standard set standard standard available Category A ambulance calls
Category A calls resulting in an emergency response arriving within 8minutes – Red 1 75% 70% 88.20% 76.20% 65.00% 63.60% 62.50% 65.80%
Category A calls resulting in an emergency response arriving within 8minutes – Red 2 75% 70% 77.10% 73.90% 74.70% 72.20% 76.30% 75.70%
Category A calls resulting in an ambulance arriving at the scene within 19 minutes 95% 90% 95.10% 94.50% 95.90% 93.50% 94.30% 94.80% Lower Direction Mixed Sex Accommodation Breaches Target Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Rating Threshhold of Travel Minimise breaches 0 >10 0 15 0 2 0 17
Cancelled Operations
All patients who have operations cancelled, on or after the day of admission (including the day Not attributable to a No data of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the 4 13 22 CCG available patient's treatment to be funded at the time and hospital of the patient's choice.
Mental Health
Care Programme Approach (CPA): The proportion of people under adult mental illness No data specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient 95% 90% 100% 100% 100% 95.24% 99.53% available care during the period
Additional measures NHS Commissioning Board has specified for 2013/14 (but not part of Assurance Framework scorecard).
Direction Target Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Rating of Travel A&E Waits
No waits from decision to admit to admission (trolley waits) over 12 hours 0 0 0 0 3 0 3
Cancelled Operations No data No urgent operation to be cancelled for a 2nd time 0 0 0 0 0 0 available Ambulance Patient Handovers
All handovers between ambulance and A & E must take place within 15 minutes and crews should be ready to accept new calls within a further 15 minutes. Financial penalties, in both 0 83 40 51 50 29 569 cases, for delays over 30 minutes and over an hour. 30-60 mins
All handovers between ambulance and A & E must take place within 15 minutes and crews should be ready to accept new calls within a further 15 minutes. Financial penalties, in both 0 15 8 2 7 1 60 cases, for delays over 30 minutes and over an hour. Over 1 Hour Herefordshire CCG – Assurance Framework 19
Governing body – Item 9 Appendix D – HCCG Financial Requirements
CCG Assurance Framework - Financial Primary or Ratings secondary Green Amber Green Amber Red Red Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Requirements indicator 1 Underlying recurrent surplus Primary >=2% 1%-1.99% 0%-0.99% <0% 2 Surplus - year to date performance Primary >=1% >=0.8% >=0.5% <0.1% 3 Surplus - full year forecast Primary >=1% >=0.8% >=0.5% <0.1% 4 Management of 2% NR funds within agreed processes Secondary Yes No 5 QIPP - year to date delivery Primary >=95% of plan >=80% of plan >=50% of plan <50% of plan 6 QIPP - full year forecast Primary >=95% of plan >=80% of plan >=50% of plan <50% of plan 7 Activity trends - year to date Secondary <101% of plan <102% of plan <103% of plan >104% of plan 8 Activity trends - full year forecast Secondary <101% of plan <102% of plan <103% of plan >104% of plan 9 Running costs Primary <=RCA >RCA Indicator Indicator Clear identification of risks against financial delivery Indicator met partially met - partially met - Indicator not 10 Primary and mitigations in full limited material met uncovered risk uncovered risk
11 Internal and External Audit Opinion Supporting TBC TBC TBC TBC 12 Balance Sheet Indicators Supporting TBC TBC TBC TBC
Overall rating To be defined, however an overall rating can only be achieved if all primary indicators are individually rated green. 2 or more red primary indicators would lead to an overall red rating.
Herefordshire CCG – Assurance Framework 20
Governing body – Item 9
Appendix E – Quality Premium
Population Payment per Patient Total Achievable 182,000 £ 5.00 £ 910,000.00
Percentage of Measure Eligible quality Measures Name quality premium Value Achieved premium funding Notes Based on provisional public health data indications are that this measure is achievable. Further analysis Preventing people from required as proxy measures are Domain 1 dying prematurely 12.5% £ 113,750.00 Yes £ 113,750.00 indicative only. Based on provisional proxy measures and 12/13 data provided by CSU the indications are that this measure may be achievable. Herefordshire performs well when benchmarked against CSU peers. Further analysis Enhancing Quality of life. required as actual data will not be Domain 2 & 3 Helping people recover. 25.0% £ 227,500.00 ? £ - available until 2014. Positive experience of Friends and Family Test well below Domain 4 care 12.5% £ 113,750.00 No £ - required target. 2 reported cases of MRSA. 1 deemed to be unavoidable as not hospital Treating people in a safe acquired but measure specifies any Domain 5 environment 12.5% £ 113,750.00 No £ - MRSA cases assigned to the CCG. Data analysis showing 6% reduction year to date. Cohort of patients are Wye Valley, non-elective admissions, excluding Reduction in non-elective maternity, adults only (18 and over) – Local Measure 1 admissions 12.5% £ 113,750.00 Yes £ 113,750.00 from SUS data Reduction in referrals for Dermatology/Gastro Data analysis showing a 4.5% increase Local Measure 2 /Cardiology 12.5% £ 113,750.00 No £ - in activity year to date. Provisional data analysis showing that Dementia - number of year to date performance is 9.5% Local Measure 3 people diagnosed 12.5% £ 113,750.00 No £ - below target. Total 100.0% £ 910,000.00 £ 227,500.00
Adjustment to Quality premium Constitution Measure achieved funding funding Notes Referral to treatment times (18 weeks) Y £ - YTD 92.43% against 90% target A&E Waits N 25% £ 56,875.00 YTD 92.67% against 95% target Cancer waits - 62 days N 25% £ 56,875.00 YTD 78.86% against 85% target Category A Red 1 ambulance calls N 25% £ 56,875.00 YTD 66.9% against 75% target Total Adjustment 75% £ 170,625.00
Revised Total £ 56,875.00
It will be a pre-qualifying criterion for any payment that a CCG manages within its total resources envelope for 2013/14 and does not exceed the agreed level of surplus drawdown The National Health Service (clinical commissioning groups - Payments in Respect of Quality) Regulations 2013
Herefordshire CCG – Assurance Framework 21
Governing body – Item 9 Appendix F – Key Performance Indicators
Headline 13/14 Perf Lower Definition Responsible Org Oct-13 Nov-13 Dec-13 Jan-14 YTD measures Target Threshold No data NHS Herefordshire CCG 0 N/A 0 1 0 2 MRSA bacteraemia infections - The accountable cases of MRSA available No data bloodstream infections occurring in their responsible population at the Wye Valley 0 N/A 0 0 0 0 available end of each month. No data 2G 0 N/A 0 0 0 0 HCAI measure available No data (MRSA & CDI) NHS Herefordshire CCG 55 N/A 2 6 3 37 available CDIFF infections - The accountable cases of C. Diff infections occurring in No data Wye Valley 15 N/A 1 3 1 12 their responsible population at the end of each month. available No data 2G 0 N/A 0 0 0 0 available No data NHS Herefordshire CCG 88% 94.12 94.94 93.81 95.15 All Cancer 2 available The percentage of patients urgently referred with suspected cancer by No data week wait Wye Valley (HCCG) 93% N/A 94.31 94.84 93.73 95.16 their GP who were first seen within 14 calendar days within a period available referrals No data Gloucester Hospitals N/A 100 100 100 100 available No data NHS Herefordshire CCG 88% 88.33 93.33 85.51 88.58 All breast available The percentage of patients urgently referred for evaluation/investigation symptomatic 2 No data of “breast symptoms” where cancer is not initially suspected who were Wye Valley (HCCG) 93% N/A 87.72 93.02 85.51 88.41 week wait available first seen within 14 calendar days during the period. No data referrals Gloucester Hospitals N/A No activity No activity No activity 100 available No data NHS Herefordshire CCG 91% 98 98.75 100 99.05 available The percentage of patients receiving first definitive treatment within one No data month (31-days) of a cancer diagnosis (measured from ‘date of decision Wye Valley (HCCG) 96% N/A 97.37 98.15 100 99.42 available to treat’) No data Gloucester Hospitals N/A 100 100 100 100 available No data NHS Herefordshire CCG 89% 100 100 100 94.74 available Surgery - Maximum 31-day wait for subsequent treatment where that No data Wye Valley (HCCG) 94% N/A 100 100 100 95.77 treatment is surgery available 31 day Cancer No data Gloucester Hospitals N/A 100 100 100 100 Waits available No data NHS Herefordshire CCG 93% 100 100 100 100 Anti Cancer Drugs - The percentage of patients receiving first definitive available treatment within one month (31-days) of a cancer diagnosis (measured Wye Valley (HCCG) 98% N/A 100 100 100 No data 100 available from ‘date of decision to treat’) No data Gloucester Hospitals N/A 100 100 100 100 available No data Radiotherapy Treatment Course - The percentage of patients receiving NHS Herefordshire CCG 89% 100 92.31 100 99.39 available subsequent treatment for cancer within 31-days where that treatment is 94% No data Gloucester Hospitals N/A 100 100 100 100 a Radiotherapy Treatment Course available No data NHS Herefordshire CCG 80% 82.26 81.82 74.42 78.61 available The percentage of patients receiving first definitive treatment for cancer No data Wye Valley (HCCG) 85% N/A 80.00 80.00 70.31 77.53 within 62 days of an urgent GP referral for suspected cancer. available No data Gloucester Hospitals N/A 92.31 57.14 62.50 78 available No data NHS Herefordshire CCG 85% 100 100 100 96.92 NHS Cancer Screening - The percentage of patients receiving first available No data 62 day Cancer definitive treatment for cancer within 62-days of referral from an NHS Wye Valley (HCCG) 90% N/A 100 100 100 98.33 Waits available Cancer Screening Service. No data Gloucester Hospitals N/A No activity No activity No activity 100 available No data NHS Herefordshire CCG 100 100 100 100 Consultant Upgrade of Status - The percentage of patients receiving first No No available No data definitive treatment for cancer within 62-days of a consultant decision to Wye Valley (HCCG) Operational Operational 100 100 100 100 available upgrade their priority status. Criteria set Criteria set No data Gloucester Hospitals No activity No activity No activity available No data NHS Herefordshire CCG 85% 92.43 89.9 93.25 93.25 The percentage of admitted pathways within 18 weeks for admitted available 90% patients whose clocks stopped during the period on an adjusted basis No data Wye Valley N/A 92 89.72 92.82 92.82 available No data NHS Herefordshire CCG 90% 99.5 99.55 99.42 99.42 The percentage of non-admitted pathways within 18 weeks for non- available 95% No data admitted patients whose clocks stopped during the period Wye Valley N/A 99.83 99.87 99.74 99.74 available No data The percentage of incomplete pathways within 18 weeks for patients on NHS Herefordshire CCG 87% 96.85 96.93 96.59 96.59 RTT - 18 week 92% available No data waits for incomplete pathways at the end of the period Wye Valley N/A 97.47 97.69 97.3 97.3 treatment available No data NHS Herefordshire CCG >10 0 0 1 9 Referral To Treatment - Zero tolerance of over 52 week waiters 0 Breaches available No data Wye Valley N/A 0 0 0 1 available No data NHS Herefordshire CCG 14 32 16 16 available Referral To Treatment - The number of patients waiting over 34 weeks for No data Wye Valley N/A N/A 2 17 7 7 treatment (Apr - Jun = +40 wks ) available No data Non-WVT Trusts 12 15 9 9 available
Diagnostic Waits The percentage of patients waiting 6 weeks or more for a diagnostic test No data NHS Herefordshire CCG 99% 94% 99.62 99.24 96.38 98.77 and Tests (15 key diagnostic tests) at the end of the period available
Herefordshire CCG – Assurance Framework 22
Governing body – Item 9
Headline 13/14 Perf Lower Definition Responsible Org Oct-13 Nov-13 Dec-13 Jan-14 YTD measures Target Threshold
Number of general & acute (G&A) elective admissions Finished First No data NHS Herefordshire CCG 21,641 157 -114 -204 459 Consultant Episodes (FFCEs) available
Number of non-elective FFCEs in general & acute (G&A) specialties in a No data NHS Herefordshire CCG 15,154 65 -49 133 124 month Variance available Acute Activity against plan First outpatient attendances (consultant-led) following GP referral in No data NHS Herefordshire CCG 47,143 339 -8 488 2411 general and acute specialties available
The number of attendances at A&E NHS Herefordshire CCG 54,574 492 285 665 222 4090
No data NHS Herefordshire CCG 0 13 22 All patients who have operations cancelled to be offered another binding available Cancelled date within 28 days. Wye Valley 0 Breaches 0 13 No data 22 Operations available No data No urgent operation to be cancelled for a 2nd time Wye Valley 0 0 0 0 0 available No data No data NHS Herefordshire CCG N/A 6.53% 6.38% 7.68% Emergency The percentage of all readmissions that are an emergency that occur available available <6% Readmissions within 30 days of any previous discharge No data No data Wye Valley N/A 6.54% 6.24% 7.64% available available No data NHS Herefordshire CCG 15 0 2 17 available The number of breaches of mixed-sex accommodation (MSA) - sleeping No data MSA breaches Wye Valley 0 0 15 0 2 17 accommodation available No data 2G 0 0 0 0 available Category A calls resulting in an emergency response arriving within 8 NHS Herefordshire CCG 75% 70% 76.20 65.00 63.60 62.50 65.80% minutes – Red 1 Ambulance Category A calls resulting in an emergency response arriving within 8 quality - Cat A NHS Herefordshire CCG 75% 70% 73.90 74.70 72.20 76.30 75.70% minutes – Red 2 response times Category A calls resulting in an ambulance arriving at the scene within 19 NHS Herefordshire CCG 95% 90% 94.50 95.90 93.50 94.30 94.80% minutes All handovers between ambulance and A & E must take place within 15 minutes and crews should be ready to accept new calls within a further 15 0 0 40 51 50 29 569 minutes. Financial penalties, in both cases, for delays over 30 minutes Ambulance and over an hour. 30-60 mins NHS Herefordshire (Wye Handovers All handovers between ambulance and A & E must take place within 15 valley) minutes and crews should be ready to accept new calls within a further 15 0 0 8 2 7 1 60 minutes. Financial penalties, in both cases, for delays over 30 minutes and over an hour. Over 1 Hour Number of A&E attendances where the patient spent 4 hours or less in Wye Valley 95.00% 90% 95.04 95.41 89.45 90.77 92.18 A&E from arrival to transfer, admission or discharge. No waits from decision to admit to admission (trolley waits) over 12 Wye Valley 0 0 0 0 3 0 3 hours A&E No data No data The percentage of unplanned follow-up attendances within 7 days of NHS Herefordshire CCG N/A 8.86% 7.39% 8.31% Attendances available available discharge from A&E for the original attendance, including if referred back Less than 5% No data No data Wye Valley N/A 7.97% 6.58% 7.37% by another health professional. available available Left department without being seen - The percentage of attendances No data No data where the patient left without being seen (LWBS) by a clinical decision Wye Valley Less than 5% N/A 3.18% 2.29% 2.77% available available maker No data No data No data Unplanned hospitalisation for chronic ambulatory care sensitive NHS Herefordshire CCG N/A 69.48 48.36 conditions (adults) - The proportion of persons aged over 18 with chronic available available available <600 conditions admitted to hospital as an emergency admission - rate per No data No data No data Wye Valley N/A 66.07 44.27 100,000 pop. available available available
No data No data No data Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s NHS Herefordshire CCG N/A 31.41 36.64 A&E Quality - Total number of emergency admissions for people under 19 (0 – 18 available available available <350 Indicators - All years) where asthma, diabetes or epilepsy was the primary diagnosis - No data No data No data Wye Valley N/A 28.79 34.03 Providers rate per 100,000 pop. available available available
Emergency admissions for acute conditions that should not usually No data No data No data NHS Herefordshire CCG N/A 83.28 81.66 require hospital admission - Emergency admissions to hospital of persons available available available with acute conditions (ear/nose/throat infections, kidney/urinary tract <1,000 No data No data No data infections, heart failure) usually managed in primary care - rate per Wye Valley N/A 78.42 77.87 100,000 pop. available available available No data No data Wye Valley N/A 95.28 95.22 95.22 VTE Risk The percentage of all adult inpatients who have had a VTE risk available available 95.00% assessment assessment on admission. No data No data 2G N/A 100 100 100 available available Achieve No data Wye Valley N/A 3.43 2.82 1.69 1.96 Delayed Delayed Transfers of Care - Provider measure is the number of days <= 3.5% available Transfers of Care delayed as a proportion of a count of acute activity or beds. Achieve <= No data 2G N/A 2.65 5.30 1.90 2.00 7.5% available
No. of Health Health visitor numbers as a subset of the all Hospital and Community 35.4 FTE by No data Wye Valley N/A 33.74 WTE 34.12 WTE 34.28 WTE 34.12 WTE Visitors Health Services (HCHS) workforce by FTE Mar 2013 available
No data The percentage of people who have had a stroke who spend at least 90% NHS Herefordshire CCG N/A 100 93.75 100 95.21 80% available No data of their time in hospital on a stroke unit Wye Valley N/A 100 88.00 100 94.83 available Stroke indicator No data NHS Herefordshire CCG N/A 57.89 52.38 52.00 63.64 The percentage of people at high risk of Stroke who experience a TIA are available 60% No data assessed and treated within 24 hours Wye Valley N/A 60.00 50.00 55.56 63.44 available
Herefordshire CCG – Assurance Framework 23
Governing body – Item 9 Headline 13/14 Perf Lower Definition Responsible Org Oct-13 Nov-13 Dec-13 Jan-14 YTD measures Target Threshold The percentage of women in the relevant PCT population who have seen Maternity 12 a midwife or a maternity healthcare professional, for health and social No data 90.00% N/A 93.20 94.59 96.88 93.75 weeks care assessment of needs, risks and choices by 12 weeks and 6 days of available pregnancy.
No data Number of women known not to have been smokers at time of delivery 85.00% N/A 78.57 85.71 87.41 85.91 available Smoking at the Data Quality Validation - STATUS RECORDED - Good performance is also Time of Delivery No data typified by achievement of the required data quality standard. Coverage >=95% N/A 100.00 100.00 100.00 100.00 available of at least 95%. No data Number of new mothers known to have initiated breastfeeding 85.00% N/A 85.06 80.12 80.42 75.45 Wye Valley available Breastfeeding Data Quality Validation - STATUS RECORDED - Good performance is also Initiation No data typified by achievement of the required data quality standard. Coverage >=95% N/A 100.00 100.00 100.00 100.00 available of at least 95%. Prevalence of breastfeeding at 6-8 wks after birth - The number of infants recorded as being totally or patially breastfed at the 6-8 week check >=60% N/A 57.96 45.00 45.16 45.39 47.87 Breastfeeding at during the quarter. 6-8 weeks Coverage of breastfeeding at 6-8 wks after birth - Good performance is also typified by achievement of the required data quality standard. >=95% N/A 100.00 100.00 99.35 99.29 99.59 Coverage of at least 95%.
The percentage of people eligible for the NHS Health Check programme No data TBC N/A 978 1116 744 10425 Coverage of NHS who have been offered an NHS Health Check available Health Checks The percentage of people eligible for the programme who have received No data NHS Herefordshire TBC N/A 557 538 347 4835 an NHS Health Check. available (Public Health) Number of clients of NHS Stop Smoking Services who report that they are Smoking No data No data not smoking four weeks after setting a quit date - cumulative position TBC N/A 29 11 246 Quitters available available and variance of performance against plan. Immunisation rate for children aged 1 who have been immunised for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus influenza type b (Hib) - 95.00% N/A 94.41 98.62 96.50 94.51 95.55 (DTaP/IPV/Hib)
Immunisation rate for children aged 2 who have been immunised for 95.00% N/A 89.73 97.44 95.10 94.38 93.74 Pneumococcal infection (PCV) - (PCV) Immunisation rate for children aged 2 who have completed immunisation Childhood for Haemophilus influenza type b (Hib), meningitis C (MenC) - NHS Herefordshire (Wye 90.00% N/A 89.04 95.51 93.71 91.01 92.13 Immunisation (Hib/MenC) Valley) Immunisation rate for children aged 2 who have been immunised for 95.00% N/A 89.73 98.72 93.71 93.82 92.27 measles, mumps and rubella (MMR) - (MMR)
Immunisation rate for children aged 5 who have been immunised for 95.00% N/A 88.00 95.86 83.92 82.93 88.75 Diphtheria, Tetanus, Polio, Pertussis (DTaP/IPV) Immunisation rate for children aged 5 who have been immunised for 95.00% N/A 86.67 96.55 83.92 83.54 92.27 measles, mumps and rubella (MMR) No data The number of new cases of psychosis served by early intervention teams 22 N/A 2 2 1 19 available
The proportion of admissions to the Trust’s acute ward that were No data 95% N/A 100 100 100 96.27 Access to Mental gatekept by the crisis resolution home treatment teams available Health services The proportion of people under adult mental illness specialties on CPA No data who were followed up within 7 days of discharge from psychiatric in- 95% 90.00% 100 100 95.24 99.53 available patient care during the quarter (QA). 2Gether The proportion of people who have depression and/or anxiety disorders >=12.5% by N/A 3.18% 3.73% 4.27% 5.17% 5.17% who receive psychological therapies. Cumulative Mar 2014
The proportion of people who have depression and/or anxiety disorders 1820 by Mar N/A -104 -72 -74 -22 -770 IAPT Services who receive psychological therapies. Variance against plan- cumulative 2014
The number of people who have completed treatment having attended >=45% by Mar N/A 50.00% 47.69% 50.00% 50.00% 42.52 at least two treatment contacts and are moving to recovery 2014
Herefordshire CCG – Assurance Framework 24
Item 09 Strategic Risk Register January.xls
Herefordshire CCG Corporate Risk Register
Rating before Rating after Rating after Mitigation Mitigation Section 1: Assurance Framework - Strategic Risks (Identified March 2013) (Gross) (net) Actions (target)
Consequence Consequence / Impact Likelihood Rating Consequence / Impact Likelihood Rating Target Dates Key Consequence Likelihood TARGET Score Risk Risk No. Date Risk Description Existing Controls in Place Corrective Action/Action Plan (including Risk
Identified costs) Owner
Financial
Organisational
URGENT CARE URGENT
key link to work work key to link
PLANNEDCARE
Risk Type - Legal - RiskType
Direction of Travel of Direction
IMPROVING HEALTH IMPROVING
SYSTEMLEADERSHIP
Reputational (inc Political) (inc Reputational
Risk Type - People/Quality - RiskType
Amend/ Reviewed(date) Amend/
programme/objective/goals Delivery of Service Delivery of Objectives
SR001 01/10/2012 Developing a Capacity - Transitional nature of NHS 4 4 16 Recruitment plan has been completed. 4 2 8 Continued review of resource requirements will 30/02/2014 4 1 4 Chief 05/02/2014 high-performing reforms, results in stretched capacity Interim capacity has been sourced to be undertaken, particularly with regard to key Officer ↔ CCG and capability resulting non-delivery of provide additional senior management programmes of work, and additional resources service improvements and financial support to CCG. being sourced to provider cover for CFO, during efficiencies (including robust Revised OD Plan now developed and financial planning process until new chief officer monitoring of contracts and quality being implemented; and staff and takes up post. Additional Communications and outcomes) ; and inappropriate clinical leads objectives being set and project managers to be put in place by end of pressures on staff. Risk exacerbated will be reviewed annually. February; Additional resource to support key as further clarity around additional Additional capacity has been sourced to transformation working now in place e.g. Better responsibilities for CCGs increases, support key strategic projects i.e. Care fund and to support the NHS planning for example additional responsibilities Clinical Modelling and Cobic. Regular round. New Chief Officer now in post. regarding emergency planning and dialogue with AT to establish clarity y y y y y primary care now have to absorbed around responsibilities, in particular within £25 per head running costs. emergency planning, is in place. Direction associated with capacity and capability removed. New Accountable Officer will in post from 3rd Feb 2014. Review of CSU performance in relationship to Communications and engagement has resulted in additional capacity being agreed and post now be advertised - Jan 2014. To support development of 5 yr. plan - CSU providing project manager (within CSU offer) and an interim Joint Better Care
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Consequence Consequence / Impact Likelihood Rating Consequence / Impact Likelihood Rating Target Dates Key Consequence Likelihood TARGET Score Risk Risk No. Date Risk Description Existing Controls in Place Corrective Action/Action Plan (including Risk
Identified costs) Owner
Financial
Organisational
URGENT CARE URGENT
key link to work work key to link
PLANNEDCARE
Risk Type - Legal - RiskType
Direction of Travel of Direction
IMPROVING HEALTH IMPROVING
SYSTEMLEADERSHIP
Reputational (inc Political) (inc Reputational
Risk Type - People/Quality - RiskType
Amend/ Reviewed(date) Amend/
programme/objective/goals Delivery of Service Delivery of Objectives
SR002 01/10/2012 Developing a Failure of the CSU to deliver 4 4 16 The CSU have now recruitment to over 4 3 12 Internal stakeholders have expressed concerns 28/02/2014 4 2 8 Head of 05/02/2014 high performing commissioning support services to the 90 per cent of local embedded posts regarding's quality of products being delivered; Busines ↔ CCG standard required- will result in CCG and began delivering support from the and non-delivery of key IT infrastructure s unable to carry out key business as 1st April formally. Relationship developments and information and intelligence Delivery/ usual activities e.g. monitor key Management arrangements in place; flows, including roll-out of risk stratification tool. Head of contracts and providers and SLA is in place and will be monitored on Following CSU SLA meeting remedial actions Commer successful delivery of key change a monthly basis against a key set of have been put in place and assurances have cial initiatives (e.g. virtual wards) - measurable. Reports and updates been given that there will be improved co- Develop resulting in CCG unable to deliver its provided formally to the FPR committee. ordination. CSU authorised to recruit to full-time ment aims and objectives, and having to If serious underperformance remedial engagement post to be embedded in procure additional support from actions will escalated and requested via Herefordshire. Assurances also being sought on elsewhere resulting in further financial Staffordshire's CSU Delivery Director. solutions/work around to national challenges e.g. risk - as well reputational damage for Additional Capacity in relation to new IG rules and SBS roll-out; new risk y y y y y y y y y the CCG with its key partners and Communications Support and Project stratification guidance from DoH should now member practices management support for planning round alleviate some of risk stratification challenges. being sourced due to be place by National lead provider framework process now February; former alongside patient being run by NHS England - framework will be experience and engagements support live for 2015. C; CCG will maintaining CSU considered to be underperforming. services for 14/15 but more detailed and meaningful performance measures will be agreed. Concerned also raised around Communications support; appointment made to full-time embedded communications post, CSU merger with CSU Central Midlands should strengthen offering around communications and transformation.
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Consequence Consequence / Impact Likelihood Rating Consequence / Impact Likelihood Rating Target Dates Key Consequence Likelihood TARGET Score Risk Risk No. Date Risk Description Existing Controls in Place Corrective Action/Action Plan (including Risk
Identified costs) Owner
Financial
Organisational
URGENT CARE URGENT
key link to work work key to link
PLANNEDCARE
Risk Type - Legal - RiskType
Direction of Travel of Direction
IMPROVING HEALTH IMPROVING
SYSTEMLEADERSHIP
Reputational (inc Political) (inc Reputational
Risk Type - People/Quality - RiskType
Amend/ Reviewed(date) Amend/
programme/objective/goals Delivery of Service Delivery of Objectives
SR003 01/10/2012 Delivery QIPP Health and Social Care 5 4 20 Continued development of CCG Clinical 5 3 15 Recognised that more work needs to be done to 28/02/2014 5 2 10 CFO 16/11/2013 Targets & Commissioners and Providers are not Commissioning strategy and plans has ensure this alignment happens, building on ↓ fostering aligned on delivering key financial involved and will continue involve key relationships and mechanisms in place due to integrated challenges clinicians and stakeholder e.g. Clinical current financial challenges in the system. This working across * Non-delivery of Adult Social Care Strategy group - key liaison meetings includes more proactive involvement in WVT the whole system Cost Improvement Plan established e.g., QIPP Operational futures programme (and associated * Lack of delivery resulting in financial group meets monthly, regular meetings programmes) and driving forward of the HWBB over-performance between DASS and Chief Officer and work streams. Further clarity from ITF work to * Efficiencies adversely impacting on CCG engaging actively in Health and establish joint commissioning arrangements and quality and outcomes for patients and Wellbeing Board, new Leaders meeting plans to be undertaken between December to public between CCG/WVT and LA established. March, aligned with NHS Planning * Non-delivery whole system Financial Plan will be shared and developments. This will include 14/15 QIPP improvements and care pathways* worked through as part of the yearly plans. Transfer of s256 monies dependent on Financially unsustainable Health and contract rounds. a new joint assurances around scheme delivery. Further Social Care system commissioning board to be established multi-agency workshops in place for Janaury and y y y y y y y to review and align work of the LA/CCG March (arrangements agreed by HWBB). ITF/BCF task and finance group considering how future joint commissioning arrangements could work, and establishing process for clear joint commissioning plan. S256 agreed, but final transfer of monies still to be undertaken. Further multi-agency workshops in place for Janaury and March.
SR004 01/10/2012 Delivery QIPP Health and Social Care 5 4 20 Continued development of CCG Clinical 5 3 15 Recognised that more work needs to be done to 28/02/2013 5 2 10 Chief 16/11/2013 Targets & Commissioners and Providers are not Commissioning strategy and plans has ensure this alignment happens, building on Officer ↔ fostering aligned on addressing key quality and involved and will continue involve key relationships and mechanisms in place due to integrated improvement challenges clinicians and stakeholder e.g. Clinical current financial challenges in the system. This working across * poor patient experience because of Strategy group - key liaison meetings includes more proactive involvement in WVT the whole system service disruption & incomplete established e.g., QIPP Operational futures programme (and associated service redesign group meets monthly, regular meetings programmes) and driving forward of the HWBB * Non-realisation of QIPP, CIP between DASS and Chief Officer and work streams. Further clarity from ITF work to savings CCG engaging actively in Health and establish joint commissioning arrangements and y y y y y y y y * Quality benefits not achieved Wellbeing Board, new Leaders meeting plans to be undertaken between December to * Cost and savings simply between CCG/WVT and LA established. March, aligned with NHS Planning moved/shunted through system Key clinical engagement events in place developments. This will include 14/15 QIPP * Financially unstable Health and to ensure Clinical engagement into plans. Transfer of s256 monies dependent on Social Care system Clinical Modelling work and assurances around scheme delivery. *non-delivery of health improvements development plans. Multi-agency e.g. preventative work around alcohol workshops in place for Janaury
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Consequence Consequence / Impact Likelihood Rating Consequence / Impact Likelihood Rating Target Dates Key Consequence Likelihood TARGET Score Risk Risk No. Date Risk Description Existing Controls in Place Corrective Action/Action Plan (including Risk
Identified costs) Owner
Financial
Organisational
URGENT CARE URGENT
key link to work work key to link
PLANNEDCARE
Risk Type - Legal - RiskType
Direction of Travel of Direction
IMPROVING HEALTH IMPROVING
SYSTEMLEADERSHIP
Reputational (inc Political) (inc Reputational
Risk Type - People/Quality - RiskType
Amend/ Reviewed(date) Amend/
programme/objective/goals Delivery of Service Delivery of Objectives
SR005 01/10/2012 Map of Medicine The non delivery of care pathways, 4 3 12 CCG STIG board established to monitor, 4 2 8 Full establishment of PMO; clear prioritisation of 01/04/2014 4 1 4 Head of 16/11/2013 has been identified as a risk in non- and develop CCGs Clinical Outcomes pathways implementation plan in place, pathways COST ↔ delivery of QIPP and cross and Service transformation programme. monitored, developed and agreed by STIG as Herefordshire; will result in non- CCG PMO and PM approach being part of the CCG strategy. Benefits tracked and delivery of financial savings and developed to monitor and review success of pathways monitored - several increased financial pressures and delivery. Engagement of Map of pathways now developed just require quality challenges - long term in the Medicine to support pathway embedding). Supported by dedicated education Herefordshire System. implementation; and resources being programme for GPs and Practice Nurses. reprioritised to focus on key pathway. y y y y y Clear plan and PID in place and engagement with Clinicians integral to work. Clear process in place for sign off of pathways in place
SR006 01/10/2012 Developing Clinicians across Herefordshire are 4 4 16 Key forums established including 4 3 12 Continued development of engagement 28/02/2014 4 2 8 Clinical 28/01/2014 Primary strategy, not engaged in service redesign, Clinical Strategy Group (CSG) and GP mechanism including GP newsletter and GP Lead ↔ all key COST transformation and clinical Parliament. CCG is clearly clinically led, Parliament; establishment of wider Clinical (Chair) programmes, commissioning developments, with GPs on board and additional GP network and forums (e.g. for Ots, Physio and WVT Futures resulting in key plans, strategies and appointments as Project leads. Frequent Nurses), and ensuring feedback loops and programme, and projects not being owned and practice visits by Chair of CCG also in mechanisms in place. In light of feedback from enhanced quality delivered by clinical community in place, used to inform strategy authorisation further survey being taken with assurance Herefordshire and significant development of CCG. Opth community Clinicians to consider best engagement framework, transformational change and and Dentists also now engaged. mechanisms. CSG to become oversight group demonstrating improvements not happening (risk Regular newsletter in place and Clinical for clinical modelling work. Success of clinical has increased in light of authorisation Cabinet and primary care group, along engagement to be monitored by CCG survey. leadership feedback) with education and training days in Continued liaison with Clinical Chair of CCG and y y y y y y y place. Clinical engagement on Clinical Medical Directors . Map of Medicine launched. Modelling work key and these have Education programme now active and well been put in place for December, attended. Scheduled practice visits in diary. successful events held in January. LIS Primary Care Strategy development in in place to enable improved conjunction with Area Team. Transparency and engagement of member practices visibility around decision-making process also needs to be improved to ensure clarity around rationale for decisions - plans being developed to improve this, including improved use of GP ParliamentCSG and clinicains significantly involved in Janaury with Clincal modelling and strategy work.
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Consequence Consequence / Impact Likelihood Rating Consequence / Impact Likelihood Rating Target Dates Key Consequence Likelihood TARGET Score Risk Risk No. Date Risk Description Existing Controls in Place Corrective Action/Action Plan (including Risk
Identified costs) Owner
Financial
Organisational
URGENT CARE URGENT
key link to work work key to link
PLANNEDCARE
Risk Type - Legal - RiskType
Direction of Travel of Direction
IMPROVING HEALTH IMPROVING
SYSTEMLEADERSHIP
Reputational (inc Political) (inc Reputational
Risk Type - People/Quality - RiskType
Amend/ Reviewed(date) Amend/
programme/objective/goals Delivery of Service Delivery of Objectives
SR007 01/10/2012 Develop a high- Failure to pass the authorisation 5 4 20 Improvement plan in place developed in 5 2 10 Plan in place for removal of remaining conditions 30/12/2014 4 1 4 Chief 25/01/2014 performing CCG process or significant proportion of response to PWC review, reformed OD in December. Regular liaison and input from Officer ↔ controls/caveats put in place will result Plan developed. Improvement plan Area Team being sought to support final in reviewed and monitored by Chief submission. Confirmed conditions now removed * CCG not fully operational Officer. External quarterly reviews by an dteh CCG is fully authorised. * Full delegation of monies and NHS England area team. As at October responsibilities does not happen 2013 - only 2 conditions remain focused * Negative Reputational impact – on patient experience, all directions y y y pathfinder status lost removed. Clear plan in place for * Engagement of Clinicians weakens removal of conditions. * Poorer outcomes for patients
SR008 01/10/2012 Wye Valley Trust Financial and future sustainability of 5 4 20 CCG active member of WVT Futures 5 3 15 Recognised this still a significant risk for 30/01/2014 5 3 15 Chief 20/11/2013 Futures key acute provider Wye Valley Trust programme - member of oversight Herefordshire, the CCG has enhanced plans to Officer ↔ programme, and future configuration destabilises board and project board. QIPP savings engage and involve key stakeholders in this and Clinical Modelling Herefordshire health economy and and plans agreed with CCG as part of work, including key clinical forums and ensuring Chief and sustainable inhibits delivery of CCG Clinical contract, and will be monitored. Further NHS England/TDA part of project team and Finance health and social Strategy development and delivery of Clinical board. Intended first outcomes from Clinical Officer care system strategy and associated programme Modelling work available to wider stakeholders in aimed to identify key areas/specialities January. Consideration to a robust y y y y y that the CCG believed should be Communications an public involvement plan for commissioned within Herefordshire. future work programmes stemming from initial More detailed modelling to be analysis will also be developed in undertaken on impact of reconfiguration December/January changes and redesign of services. Clinicians and managers from all providers continue to be engaged in development of pathways. The CCG is actively engaged via the Operation
Item 09 Strategic Risk Register January.xls 5 of 10 26/02/2014 Item 09 Strategic Risk Register January.xls
Consequence Consequence / Impact Likelihood Rating Consequence / Impact Likelihood Rating Target Dates Key Consequence Likelihood TARGET Score Risk Risk No. Date Risk Description Existing Controls in Place Corrective Action/Action Plan (including Risk
Identified costs) Owner
Financial
Organisational
URGENT CARE URGENT
key link to work work key to link
PLANNEDCARE
Risk Type - Legal - RiskType
Direction of Travel of Direction
IMPROVING HEALTH IMPROVING
SYSTEMLEADERSHIP
Reputational (inc Political) (inc Reputational
Risk Type - People/Quality - RiskType
Amend/ Reviewed(date) Amend/
programme/objective/goals Delivery of Service Delivery of Objectives
SR025 01/04/2013 Delivery of The scale of the Financial 5 4 20 Delegation to the Finance Performance 5 4 20 1. Major risks identified are being actively 4 4 16 Deputy 17/09/2013 Financial QIPP challenge in 2013/14 is significant. and Resources Committee for monitored. CFO ↓ savings and The 2013/14 revenue budget paper monitoring of monthly financial position. 2. QIPPs/demand management initiatives are in sustainable presented to the CCG Board in Presentation of the financial position to place and are being monitored through the PMO health and social the CCG Board . Reporting to NHS approach. April identified the risks that the acre system England on a monthly basis through the 3. Further Work programmes are developing CCG were aware of ( including ISFE ledger system and off line further action plans and are monitoring QIPP specialised services risk and the reporting. Assurance meetings with the schemes. 4. HCCG are actively engaged in the baseline mapping issues that are Area Team. Engagement of HCCG in monitoring of the QIPP programme 5.The CFO emerging) . These risks were demand management and admission requested that any slippage within the 2% non identified in excess of planned avoidance schemes. Involvement of recurrent transformational monies should offset budgets for 2013/14. Audit Committee in assurance on potential specialised commissioning cost financial systems. Detailed monthly pressures as identified at the HCCG Board in financial management packs produced. April. Monthly position reviewed with HCCG y y y y budget managers. Monitoring of action plans by financial management and across the Clinical Outcomes Service and Transformation team.
SR009 01/10/2012 Enhanced Safeguarding - Failure to have robust 5 4 20 Robust NHS line of accountability & 5 3 15 Allocated designated and named professionals 30/12/2013 5 2 10 Board 16/11/2013 Quality systems, processes, capacity, governance for Safeguarding Children to provide support for staff. Improvement Board Nurse ↓ assurance understanding and skills to and Adults. in place with improvement plan - 6 monthly DFE process and identify/prevent potential or significant Local Safeguarding Children and Adults review positive - safeguarding adults board development of harm or abuse to vulnerable adult or Board have with multi agency protocols undergoing improvements. LA reorganisation culture of child, resulting serious neglect, injury easily accessible via link, assurance has placed spot light on safe guarding. openness and or death of vulnerable person - risk processes in both Boards. transparency has increased in light of local authority CCG Safeguarding Polices and inspection score protocols in place. Internal Audit report y y y y y of significant assurance for safeguarding adults. Safeguarding dashboards for 2g and Wye Valley Trust track performance. Engagement with safeguardig boards
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Consequence Consequence / Impact Likelihood Rating Consequence / Impact Likelihood Rating Target Dates Key Consequence Likelihood TARGET Score Risk Risk No. Date Risk Description Existing Controls in Place Corrective Action/Action Plan (including Risk
Identified costs) Owner
Financial
Organisational
URGENT CARE URGENT
key link to work work key to link
PLANNEDCARE
Risk Type - Legal - RiskType
Direction of Travel of Direction
IMPROVING HEALTH IMPROVING
SYSTEMLEADERSHIP
Reputational (inc Political) (inc Reputational
Risk Type - People/Quality - RiskType
Amend/ Reviewed(date) Amend/
programme/objective/goals Delivery of Service Delivery of Objectives
SR010 07/10/2012 y y y y y Delivery of QIPP Changes made by Health and Social 3 3 9 Key meetings and summits regularly 3 3 9 Joint working opportunities being sought, On-going 3 2 6 Chief 16/09/2013 savings and Care Commissioners and Providers in held between key senior staff and regional networks being established and Officer ↓ delivering a surrounding counties and countries clinicians; Collaborative Commissioning Herefordshire actively engaged and active sustainable impact negatively on Herefordshire agreements agreed between participation in cross border groups. Further health and social and are not aligned on addressing neighbouring and associate CCGs. summits planned with neighbouring CCGs in care system key improvement and financial Meeting to seek collaborative working August and September. Better arrangements for challenges resulting in: opportunities have been held with patients registered with Welsh GPs agreed by * poor patient experience because of neighbouring CCGs. Conditions relating Bevan Health Board. service disruption & incomplete to collaboration lifted by NHS England service redesign * Non-realisation of QIPP, CIP savings * Quality benefits not achieved * Cost and savings simply moved/shunted through system SR011 01/10/2012 y y y y y Demonstrating Service changes made by providers 4 4 16 Collaborative project processes in place, 4 3 12 Outcomes of the MIU suspension of 24/7 on-going 4 2 8 Chief 20/11/2013 clinical do not appropriately involve and communications plans in place, regular services, have resulted in concerns raised that Officer ↓↓ leadership commissioners and patients and meetings with key leads in providers, actions in place where not robust enough to commissioning result in deterioration of services - use of provider forums and contract minimise risks. Reviews of process around this the best resulting in poorer quality services meetings, communications and service change are in motion and improved available care for and negative reputational impact for consultation protocols reinforced with communication channels have been put in place. Herefordshire CCG providers CCG have reiterated formally the process that residents providers are required to follow re: decisions around service changes. Urgent review plans and strategies now being consulted on and involving stakeholders. Regular meetings established with key providers to ensure future service change are discussed in line with Contractual requirements, will also include future role of community hospitals.
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Consequence Consequence / Impact Likelihood Rating Consequence / Impact Likelihood Rating Target Dates Key Consequence Likelihood TARGET Score Risk Risk No. Date Risk Description Existing Controls in Place Corrective Action/Action Plan (including Risk
Identified costs) Owner
Financial
Organisational
URGENT CARE URGENT
key link to work work key to link
PLANNEDCARE
Risk Type - Legal - RiskType
Direction of Travel of Direction
IMPROVING HEALTH IMPROVING
SYSTEMLEADERSHIP
Reputational (inc Political) (inc Reputational
Risk Type - People/Quality - RiskType
Amend/ Reviewed(date) Amend/
programme/objective/goals Delivery of Service Delivery of Objectives
SR012 08/10/2012 y y y y y High Performing Inheritance and legacy of PCT from 5 4 20 Feedback from authorisation raised this 4 2 8 Continual robust monitoring and discussion 30/02/2014 4 1 4 Chief 27/01/2014 CCG financial, quality and statutory as significant risk re: understanding of being undertaken to ensure further legacy issues Finance ↔ perspective is not understood or new financial inheritance and Legacy do not arise. Key outstanding issues relate Officer & responsibilities are assigned to CCGs documents, and transitional largely to property and retrospective CHC claims Head of not originally envisaged resulting risk arrangements in place, several this is being worked through with NHS Property Commer of key statutory responsibilities not members of CCG staff moving to CCG, Services. cial properly being undertaken and all duties have been mapped and lead Develop putting patients put at risk, and officers identified. Quality legacy hand ment additional financial pressures document and meeting undertaken and completed. Corrective Actions completed for last quarter -has seen conditions removed by NHS England - actions completed include development of recovery plan and due diligence performed. Continued review and monitor being undertaken to ensure any issues that arise are acted on quickly, this has included outstanding CHC cases and lack of clarity around property costs/leases. Review of specialised commissioning allocations also undertaken and completed
SR014 01/10/2012 y y Patient and Role of CCG is not understood by 4 4 16 Communications and Engagement 4 2 8 CSU developing strategy document and 30/01/2014 4 1 4 Head of 15/01/2014 Public Herefordshire residents and Group established, PPI events held and implementation plan. . Further systemisation of Busines ↓ Engagement, stakeholders combined with rising central to service redesign work, CSU processes happening, continued promotion of s enabling patients public expectations results in CCG products being developed; Membership membership scheme and review and refresh of Delivery/ to take seen as a ineffectual organisation, scheme being rolled out and website engagement plans. Web site due further Board responsibilities with residents an stakeholders feeling updated. Media plan in place and development Membership scheme actively Nurse for themselves uninvolved and not consulted on key increased media profile. promoted. Enhanced Communication plan for health changes and service redesign key strategic programmes being developed. projects Appointment to Communications post has happened, more resources being put in place for engagement; events planned with patient and voluntary groups in March and April. Protocols being established with HVOSS and Health watch. SR016 01/10/2012 y y y y Commissioning Diversity of providers and market is 4 2 8 AQP being rolled out, options and 4 2 8 PWC/Cobic secured as partners for OBC work - 30/01/2014 4 1 4 Head of 10/02/2014 the best limited in Herefordshire, limiting dialogues with neighbouring counties procurement process intended to develop market Commer ↔ available care for choice for CCG and patients, and providers being explored, track for uregent care. Joint Market Management work cial Herefordshire inhibiting who and how the CCGs record of looking alternative providers with Adult Social Care to begin in 2014/15. Develop residents goes to market e.g. 2gethr demonstrated success ment
SR017 01/10/2012 y y y y y y y Demonstrating Commissioning decisions are not 4 3 12 Joint INA in place, robust governance 4 2 8 Benefits and evaluation processes to be 28/02/2014 4 1 4 Chief 10/01/2013 Clinical based on robust evidence and and PMO processes being strengthened embedded in CCG and clinical modelling work Officer ↓ leadership, analysis; resulting in unsustainable to ensure decision made are properly will improve intelligence base for decision- reducing change and poor and inefficient considered and involve all stakeholders. making. Further work to understand data flows variations in improvements Clear benefits tracking process being and suitable proxy measures for outcomes and primary care put in place and strengthened. New improved benchmarking are required this has governance structure now in place and been requested from CSU to support planning 'approved' by NHS England. round
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Consequence Consequence / Impact Likelihood Rating Consequence / Impact Likelihood Rating Target Dates Key Consequence Likelihood TARGET Score Risk Risk No. Date Risk Description Existing Controls in Place Corrective Action/Action Plan (including Risk
Identified costs) Owner
Financial
Organisational
URGENT CARE URGENT
key link to work work key to link
PLANNEDCARE
Risk Type - Legal - RiskType
Direction of Travel of Direction
IMPROVING HEALTH IMPROVING
SYSTEMLEADERSHIP
Reputational (inc Political) (inc Reputational
Risk Type - People/Quality - RiskType
Amend/ Reviewed(date) Amend/
programme/objective/goals Delivery of Service Delivery of Objectives
SR018 01/10/2012 Enhanced Quality Assurance - Failure to have 5 4 20 Quality Assurance framework in place 5 3 15 All Quality processes mapped and reviewed 31/03/2014 5 2 10 Board 13/012014 Quality robust systems, processes, capacity, and being embedded across CCG Quality framework and strategy documents in Nurse ↓ Assurance - understanding and skills to QPS committee established and in place draft Patient Safety identify/prevent potential or significant reviewing quality issues Good practice from other CCGs being adopted and quality issues or failures , resulting All Quality systems being refreshed including improved data streams from CSU. y y y y y y y Safeguarding serious neglect, injury or death of Accountability and governance lines Submission to quarterly review with positive patients and residents in established in line with feedback - awaiting final reporting. Internal audit Herefordshire - (risk has increased in recommendations from best practice completed with positive assurance light of authorisation feedback)
SR019 1.11.11 ye ye ye ye ye ye Enhanced Patient Safety - Infection Prevention 5 4 20 Infection prevention and control 5 3 15 Continued monitoring including assurance visits. 31/03/2014 5 2 10 Board 13/01/2014 s s s s s s Quality and Control: Poor Infection monitoring of practice through IPC Contractual levers utilised for adverse events. Nurse ↓ Assurance - prevention and control practices committees, HCAI forum, assurance HCAI forum established and engagement with Patient Safety leading to increased Clostridium visits, audit. Area Team HCAI forum demonstrated and difficult, MRSA and other Health care RCA on all governance deaths and Safeguarding associated infections which in turn cases of MRSA bacteraemia leads to increased morbidity and Mandatory training for all staff - included y mortality. in contracts/ job descriptions, monitoring of training. Action plans related to all concerns raised, RCA lessons learnt and compliance with health and social care act standards. Community management algorithm developed across the health economy
SR021 01/12/2013 y y y y y y High Performing Weak governance arrangements will 4 3 12 Constitution and governance framework 4 3 12 Conflict of interest policy reviewed, self- 30/01/2014 4 1 4 Head of 08/01/2014 CCG lead to CCG Board not receiving the agreed, all committee in place and up assessment of governing body effectiveness Busines ↓ assurance required on delivery of key and running, terms of reference clear for undertaken (November 2013). s objectives and outcomes and CCG all; governance review completed and Delivery unable to uphold its value of an open new committee structure in place. and transparent culture Conflict of interest policy in place. Anti- fraud and corruption training undertaken by board, and declaration of interests y register maintained. In light of November board this risk remains at 12 - due to the need to clarify Conflicts of interest processes
SR022 y y y Urgent Care Continued pressures on Urgent Care 5 4 20 Urgent Care Recovery Plan now 5 3 15 Implementation of plan and monitoring of its 01/04/2014 5 3 15 Board 13/01/2014 Improvements/re system result in wider capacity issues developed and Urgent Care board in delivery. Ongoing review of measures taken Nurse ↔ covery, across Herefordshire, leading to place - meeting monthly. Members through urgent care working group though sustainable poorer quality of care for patients i.e. include key commissioners, local system wide performance remains weak. Further health and social impact on electives and increase in authority and provider review required. care system 4hr breaches (In 2012/13 Wye Valley Trust (WVT ) failed to achieve the 95 % standard in year. Furthermore, other measures are similarly concerning, and WVT reported a cluster of 12 hour breaches in the final quarter of 12/13)
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Consequence Consequence / Impact Likelihood Rating Consequence / Impact Likelihood Rating Target Dates Key Consequence Likelihood TARGET Score Risk Risk No. Date Risk Description Existing Controls in Place Corrective Action/Action Plan (including Risk
Identified costs) Owner
Financial
Organisational
URGENT CARE URGENT
key link to work work key to link
PLANNEDCARE
Risk Type - Legal - RiskType
Direction of Travel of Direction
IMPROVING HEALTH IMPROVING
SYSTEMLEADERSHIP
Reputational (inc Political) (inc Reputational
Risk Type - People/Quality - RiskType
Amend/ Reviewed(date) Amend/
programme/objective/goals Delivery of Service Delivery of Objectives
SR023 y y y Urgent Care Implementation of NHS 111 is not fully 5 4 20 NHS 111 Board and project team meets 5 3 15 External review of step in arrangements 01/04/2014 5 2 10 Board 16/11/2013 Improvements/re successful and results in poor patient regularly, regional project team now providing significant assurance. Daily sit-rep Nurse ↓ covery, experience and unresponsive out of significantly involved to ensure smooth monitoring provided, on-going local and regional sustainable hours service putting patients implementation. Active participation in Clinical Governance participation and clinical health and social potentially of risk of accessing regional CG process, engagement with modelling to inform Herefordshire's review and re- care system appropriate care clinical modelling for future configuration procurement of urgent care services and regional commissioning group. WMAS step in signed off by Board
SR24 30/07/2013 y y y Primary Care Lack of clarity around accountability 4 3 12 Significant gap in controls c urgently 4 3 12 Primary Care Development Plan, alongside 30/03/2014 4 2 8 Primary 07/01/2014 Development for primary care improvements and Primary Care Development group and further clarity being sought from NHS England on Care ↔ developments, in NHS system, Area team network meetings responsibilities of CCG vs. Area team working Clinical results in piecemeal with CCG on Primary Care Plan., as part of NHS Lead developments/engagements and lack planning process. CCGs PC plan is currently of engagement of primary care being consulted on and reviewed alongside practitioners in CCG improvement NHSE proposals. plans and pathway developments resulting in non-delivery of CCGs work, and impact on CCGs reputation
Item 09 Strategic Risk Register January.xls 10 of 10 26/02/2014 Governing body – Item 10
Governing Body
4 March 2014
SUBJECT Month 10 Finance Report
PRESENTED BY Jill Sinclair, Chief Finance Officer
PURPOSE OF THE REPORT
This report is the financial report for the period up to Month 8 (April to January 2014)
KEY POINTS
At Month 10 Herefordshire CCG is reporting that it is achieving its planned year to date and forecast surplus position 2013/14 remaining risks identified within report The report covers the year end settlement reached with WVT An update on devolvement of the former Herefordshire PCT closing balances As at Month 10 QIPP year to date delivery of annual plan and is on track to deliver the full year QIPP target An update on the 2% non-recurrent reserve and section 256 monies
RECOMMENDATION TO THE COMMITTEE
Note the Month 10 reported financial position, the risk identified at Month 10 and that this risk needs to be managed through to the year end to ensure that agreed financial targets are delivered Note the risks identified at paragraph 2.2 of this report and to note that the year end agreement with Wye Valley Trust is reflected within the month 10 position Note the use of the 2% non recurrent monies in 2013/14 as identified within this report Note the update on the non-recurrent Section 256 monies Note the QIPP year to date delivery Note the feedback on the revised Recovery Plan Note that the CCG continues to declare a 0.5% forecast surplus Note that the Finance Team will continue undertaking a forensic review of all expenditure areas through to the year end Advise on any further actions that should be undertaken
Herefordshire CCG – Month 10 Finance Report Page 1 of 3
Governing body – Item 10
CONTEXT & IMPLICATIONS
Financial A balanced revenue budget has been set for 2013/2014 which delivers 0.5% surplus at circa £1m, a minimum of 0.5% contingency reserve and a 2% recurrent resource earmarked for non- recurrent expenditure.
This Financial Report highlights identified risks at Month 10. It is recognised that as further data becomes available that further risk may emerge in year.
At Month 10 the CCG continues to report year to date and forecast achievement of the planned surplus.
Legal Health and Social Care Act 2012
Risk and Assurance Statutory financial duties planned to be achieved (Risk Register/BAF) this year will require robust in year management. QIPP delivery is critical for achievement of financial balance.
The Board is requested to note the risks identified at Month 10 within the report.
HR/Personnel Resources underpinning QIPP delivery
Equality & Diversity Considered as part of the report
Strategic Objectives Medium Term Financial Strategy
Healthcare/National Policy Everyone Counts Planning 2013/14
(e.g. CQC/Annual Health Check)
Partners/Other Directorates All Directorates, Wye Valley NHS Trust, 2Gether Foundation Trust, GPS across Herefordshire, Herefordshire Local Authority
Carbon Impact/Sustainability Considered as part of the report
Other Significant Issues Highlighted in the report
Herefordshire CCG – Month 10 Finance Report Page 2 of 3
Governing body – Item 10
GOVERNANCE
Process/Committee approval Finance and Performance Committee 25 February with date(s) (as appropriate) 2014
Herefordshire CCG – Month 10 Finance Report Page 3 of 3
Governing body – Item 10
CCG Month 10 Finance Report (April to January 2014)
1. Introduction
This report covers the period from April to January 2014 .The report covers: Year to date financial position and key risks identified Allocations update Month 10 QIPP update Update on the non-recurrent reserve Section 256 monies Recovery Plan feedback
2. Financial position as at Month 10
2.1 Summary
At Month 10 Herefordshire CCG is achieving its planned year to date and forecast surplus position see table below:
Year to Date Surplus/(Deficit) Forecast Outturn Surplus/(Deficit) Actual Ytd Plan Ytd FOT Plan FOT Actual
(£’000) (£’000) (£’000) (£’000) 851 851 1,021 1,021
2.2 Key risks identified at Month 10
Risks not in financial position:
Continuing care commissioning and other CCG legacy balances – As per recent guidance received on legacy balances, it is expected that the historical PCT balances relating to the CCG portfolio such as the continuing care restitution cases provision will be available for the CCG to make payments against. These balances will be held by NHS England, however the CCG will be able to authorise payments relating to these balances and charge the expenditure to a balance sheet code, thus ensuring a neutral effect to the CCG in 2013/14. As part of month nine processes, the finance team are identifying 2012/13 expenditure and are re-allocating as per the latest guidance.
1 HCCG – Finance Update Governing body – Item 10
Wye Valley Trust (WVT). A forecast outturn position of £2.2m after taking into account contract fines circa £500k has been agreed with
WVT attached to which are a number of conditions. In addition additional funds have been agreed to support measures in connection with the Trust’s implementation of measures associated with the Rapid Response Review (RRR), winter pressures and emergency threshold reserve for Virtual Ward and Hospital at Home staffing.
Property Services Ltd and Community Health Partnerships Ltd will require funding from commissioners to meet a proportion of the costs they incur in managing and holding those elements of the PCT estate which have transferred to them. In terms of financial reporting, it is anticipated that the budget mapped to the CCG will cover these pressures. At Month 10, PropCo have revised their costs to the CCG, meaning a £314k Forecast year-end underspend.
Commissioning additional nursing home beds in recent weeks to alleviate emergency pressures at WVT.
2 HCCG – Finance Update Governing body – Item 10
2.3 Allocations
The table below details the CCG’s Revenue allocations as at 31st January 2014: Herefordshire CCG
Revenue Resource Limit Allocations Summary
2013/14 2013/14 2013/14 Allocation narrative Opening Opening Opening Rev RL (Rec) Rev RL (N/R) Rev RL £ £ £
Recurring Resource Limit Notified RL 204,218,000 204,218,000 Running Costs 4,570,000 4,570,000 70% Non Elective (1,800,000) (1,800,000) 70% Non Elective 1,800,000 1,800,000 Notified Resource Limit 208,788,000 0 208,788,000
Month 4 Allocations Return of 12/13 Surplus 181,000 181,000 Opthalmics 97,000 97,000 SCT topslice error 466,000 466,000 Anticoagulation LWs & INR Strips 322,000 322,000 Sub-Total 885,000 181,000 1,066,000
Month 5 Allocations 0 0 0 Month 6 Allocations SCT topslice return funding 734,377 734,377 Wye Valley Dental (656,909) (656,909) Sub-Total 77,468 0 77,468
Month 7 Allocations
Month 8 Allocations Winter Pressures 769,000 769,000 Sub-Total 0 769,000 769,000
Month 9 Allocations
Sub-Total 0 0 0
Total 209,750,468 950,000 210,700,468
No allocations were received in month 10.
Anticipated Allocations & Income
These are CCG income sources which are currently outside the formal allocations: GP IT allocation adjustment £482k (top sliced 10%) – invoiced Local Area Team 5th September. This transaction was settled early October and is included in the Month 10 position. 3 HCCG – Finance Update Governing body – Item 10
GP IT CSU contribution £30k invoiced and accounted for in Month 10 position.
£368k Public Health LA in respect of overheads (zero based services) confirmed as being received on a monthly basis – confirmed at Month 5 to be received monthly. This is in Month 10 position and is being received at £30k monthly.
2.4 Forecast Outturn
The CCG’s summary forecast outturn position is detailed at Appendix A. (As at the end of Month 10).
The main detailed expenditure areas reflected in the Month 10 position are:
NHS Providers £912k forecast overspend
The main areas of over/underspend are highlighted below:
WMAS forecast has been increased by £36k to show over-performance of £693k. This accounts for the sustained level of over- performance incurred to date and the potential impact of further increases in the forthcoming winter months. The forecast also includes an additional £75k in respect of an estimate of PCI charges for 2013-14 and £14k capacity management charges.
Out of county providers £322k forecast underspend – Favourable movement of £73k from the previously reported forecast position. The main over performing areas are as follows: Worcester Acute Forecast outturn £199k due to emergency activity as per trust Month 9 monitoring, Choice £183k to cover the impact of increased elective work , Royal Orthopaedic £81k due to over performance on elective activity and Shrewsbury & Telford over performance of £50k. These over spending areas are however offset by a number of areas currently under-performing, these are mainly identified as Robert Jones & Agnes Hunt, Sandwell & West Birmingham, North Bristol and University Hospitals Birmingham, which now shows a forecast underspend of £359k, mainly due to the validation and removal of critical care costs originally assigned to the CCG at month 7.
Wye Valley Trust Forecast £428k Over Performance – This includes, as reported at section 2.2, a forecast outturn position of £2.2m investment in Virtual Wards, reinvestment of contract fines circa £500k and resolution of outstanding contract variations. It reflects the outturn position agreed with WVT in connection with the Trust’s implementation of measures associated with the Rapid Response Review (RRR) and winter pressures. There are a number of conditions attached to the Outturn position.
4 HCCG – Finance Update Governing body – Item 10
Other NHS Providers – £111k forecast overspend. This relates mainly to the forecast over performance of AQP offset by underperformance at minor providers.
Non-NHS £995k forecast overspend
This is the reported position for Continuing Healthcare (CHC) and special placements and Non NHS lines taken together as per Appendix A.
The main area of overspend in the Non-NHS budgets remains Special Placements, with a forecast overspend of £849k.
Prescribing £1.4m forecast overspend
Based on an initial assessment of Month 08 Prescribing data with the Medicines Management Team together with the problems encountered in practices with Scriptswitch linking to EMIS, which are now resolved, the risk assessed is a £1.4m forecast year end overspend. This is static from the Month 07 reported position. This Forecast does not mirror exactly the PPA forecast of £1.023m as there are known errors in the profiling of the Forecast by PPA, which are anticipated to be rectified in time for Month 09 Actual PPA data reports. It is recognised that there is a potential for further risks around PPA forecasts. The Medicines Management Team are analysing the PPA Forecasts including any anticipated further savings on Category M drugs.
Out of Hours £10k forecast overspend
The Out of Hours forecast overspend of £10k is due to an overspend on the Out of Hours service provided by Primecare as a result of arrangements to support urgent care pressures and a potential contract variation dispute for the call handling element of the service which is no longer provided. This is offset by a forecast underspend on the NHS 111 contract which is due to a reduction in WMAS step in costs and Worcester CCGs now joining the regional commissioning arrangements with WMAS resulting in a greater spread of costs. The CCG have had confirmation from regional commissioners that the cost at month 10 is final, unless there are any material moves before the year end which will be notified as they occur.
CCG Development Costs £552k forecast underspend
The CCG is currently forecasting an underspend of £552k for 2013/14 at Month 10. As reported previously it is forecast that the contingency will remain uncommitted throughout the remainder of the financial year.
Local Enhanced Services break-even
The Local Enhanced Services budget areas are showing no variance at Month 10 and no anticipated adverse forecast outturn.
5 HCCG – Finance Update Governing body – Item 10
Other Budgets £294k forecast underspend
Overall other budgets are under spent by £294k a favourable movement of £15k from previous reported position. There has been no movement on Internal Mental Health services at £94k forecast Overspend.
Reserves and National Planning requirements
At Month 10 the CCG has used £212,674 of the 0.5% national contingency to offset risks emerging at month 10 to ensure delivery of the 0.5% £1,021,087 surplus.
Use of reserves to date has been authorised by the Acting Chief Officer and Deputy Chief Finance Officer.
2.5 Specialised Services
The Specialised Services position remains unchanged from the position reported at month seven.
The Finance Board report update in early June requested that the Board approve any adverse impact from the Specialised Services mapping against slippage from the 2% recurrent reserve held for non recurrent investment. This was approved in principle and the negative Specialised Services budget is offset against the 2% reserves within the forecast outturn position as approved at the CCG Board meeting on 5 November 2013.
2.6 CCG Running costs
The CCG has a running cost envelope of £25 per head of population. The CCG has held a contingency of £200k throughout 2013/14. The totality of the running costs budget is needed for the future full year costs of posts with some part year costs in 2013/14 (as some of the CCG posts were appointed during 2013/14), also to allow for the future effect of pay-scale increments .
2.7 QIPP
The CCG as part of its financial plan in 13/14 requires £8.1m of QIPP savings. At Month 10 the CCG is forecasting that it will achieve its QIPP target of £8.1m and a year to date performance as at month 10 of £6,783k, 83.7% achievement which is on target.
2.8 Non recurrent reserve
At the June Board meeting it was requested that a monthly position statement on the planned 2% schemes should be included within the finance report. The
6 HCCG – Finance Update Governing body – Item 10
table below reflects the position at Month 10 which shows these funds as now fully committed:
Month 10 Plan Committed Slippage £’000 £’000 £’000 Total 4,084 4,084 0
The Board approved at the November Board meeting the utilisation of the non-recurrent reserve as highlighted in the above table.
The Board has requested that if there is any further slippage identified from the above table that further schemes to address the urgent care access issues should be considered as a priority against such slippage.
Key to the successful delivery of the CCG led transformational programmes in 2013/14 is ensuring that the non-recurrent Section 256 monies are utilised to give optimal outcomes and delivery success for Herefordshire residents and to ensure that these monies are transparently utilised to assist and underpin the delivery of the service transformation led by the CCG.
2.9 Section 256 Monies
The Section 256 allocation for 2013/14 is £3.151m. This is an increase of circa £800k from the monies allocated in 2012/13. This funding is allocated by NHS England to local authorities with monies held by Area Teams. Monies will be released by Area Teams once the local authority has agreed with its local health partners how funding is best used to support adult social care services which also has a health benefit.
Meetings have been held with Local Authority colleagues and spending plans for these monies was agreed at November’s Health & Well Being Board as follows.
1. Dedicated support to virtual wards (domiciliary care as well as reablement / enablement and equipment)
2. Rapid Access to Assessment and Care & Emergency Respite and Interim Residential and Nursing Capacity) this includes both,
urgent short term domiciliary care (within 2 hours for up to 72 hours) to enable treatment at home access to 2 weeks of assessment, care and enablement/reablement (domiciliary, residential and nursing) to enable both admission avoidance and earlier discharge
7 HCCG – Finance Update Governing body – Item 10
3. Integrated health and social care hub (health and social care hub)
4. Maintain Community Equipment investment levels
The monitoring of the planned implementation of the above schemes is on- going.
2.10 Budgets and Authorisation Limits
The updated paper on authorisation limits (Scheme of Delegation (SoD)) was approved at Finance & Performance Committee on 26th November subject to minor changes and taken to the January Audit Committee for final review. Audit Committee approved this with one minor amendment recommended.
CSU have been tasked with the operational implementation of the SoD.
3. Cash, BPPC and Statement of Financial Position
On a quarterly basis it is proposed that the CCG will formally report to the Board on the cash position, balance sheet and the better practice payments code and on a monthly basis to the Finance & Performance Committee
3.1. Recovery Plan
As reported to the Committee in July the CCG submitted its recovery plan in mid May to show achievement of the key national financial metrics by the end of 2014/15. A further updated recovery plan was submitted on 30th September 2013 to NHS England and the CCG has received verbal feedback and is currently awaiting official feedback which is likely now to be after the planning submissions.
4. Recommendations
4.1 HCCG Governing Body is requested to note the financial position reported for Month 10 and the emerging in year risks highlighted in this report.
4.2 HCCG Governing Body is requested to note the risks identified at paragraph 2.2 of this report and to note the agreement made regarding a forecast outturn position with Wye Valley Trust.
4.3 HCCG Governing Body is asked to note the update on the 2% non- recurrent transformational monies
4.4 HCCG Governing Body is asked to note the use of non recurrent Section 256 monies.
4.5 HCCG Governing Body is asked to note the QIPP year to date delivery.
8 HCCG – Finance Update Governing body – Item 10 4.6 HCCG Governing Body is to note the likely timing of feedback on the revised Recovery Plan.
4.7 HCCG Governing Body is asked to note that the CCG continues to declare a 0.5% forecast surplus and that there is on going work across the CCG to ensure that this position is maintained throughout the remaining months of this financial year.
4.8 HCCG Governing Body is asked to note that the Finance team will continue to undertake a forensic review of all expenditure through to year end.
4.9 HCCG Governing Body is asked to advise on any further actions that should be undertaken.
Jill Sinclair Chief Finance Officer 24/02/14
9 HCCG – Finance Update Herefordshire CCG 2013/14 Financial Summary Month 10
2013/14 2013/14 2013/14 Revised Revised Revised Forecast 2013/14 Budget to Spend to Variance Opening Opening Opening Recurrent N/Recurrent Budget Outturn Forecast date date as at Budget (Rec) Budget (N/R) Budget Budget Budget Expenditure Variance Month 10 Month 10 Month 10 £ £ £ £ £ £ £ £ £ £ £ RESOURCES 1 Initial Resource Limit 208,788,000 208,788,000 208,788,000 0 208,788,000 208,788,000 0 173,990,000 173,990,000 0 Revised Initial Resource Limit 0 962,468 950,000 1,912,468 1,912,468 0 1,593,723 1,593,723 0
2 Anticipated Allocations 2,502,201 181,000 2,683,201 0 0 0 0 0 0 0 0
3 Total Resource Limit 211,290,201 181,000 211,471,201 209,750,468 950,000 210,700,468 210,700,468 0 175,583,723 175,583,723 0
EXPENDITURE 4 NHS 141,883,552 181,000 142,064,552 140,916,277 4,111,000 145,027,277 145,939,161 (911,884) 120,856,064 121,615,969 (759,905) 5 Non NHS 5,139,827 0 5,139,827 5,043,183 0 5,043,183 4,927,197 115,986 4,202,652 4,105,997 96,655 6 CHC & Special Placements 15,783,344 0 15,783,344 15,879,988 0 15,879,988 16,991,376 (1,111,388) 13,233,323 14,159,481 (926,158) 7 Prescribing 23,616,904 0 23,616,904 23,616,904 0 23,616,904 24,993,021 (1,376,116) 19,680,753 20,827,517 (1,146,764) 8 Out of Hours 3,948,884 0 3,948,884 3,948,884 0 3,948,884 3,958,838 (9,954) 3,290,737 3,299,032 (8,295) 9 CCG Development Costs 6,070,183 0 6,070,183 6,051,183 0 6,051,183 5,499,462 551,721 5,042,653 4,582,885 459,768 10 Local Enhanced Services 1,706,908 0 1,706,908 1,828,908 0 1,828,908 1,828,908 0 1,524,090 1,524,090 0 11 Other Budget Lines 2,975,871 0 2,975,871 2,993,871 0 2,993,871 2,699,260 294,610 2,494,892 2,249,384 245,508 12 Reserves 0 0 0 0 National Planning Requirements 7,147,609 7,147,609 7,147,609 (1,280,000) 5,867,609 2,512,761 3,354,848 4,889,674 2,093,967 2,795,707 Emergency Threshold 1,800,000 1,800,000 1,800,000 (1,800,000) 0 0 0 0 0 0 Specialist services Topslice (2,386,802) (2,386,802) (864,425) 0 (864,425) (864,425) 0 (720,354) (720,354) (0) Adj. to ensure neutrality of topslice 2,386,802 2,386,802 0 0 0 0 0 0 0 Other Reserves (inc. Investments) 1,217,120 0 1,217,120 1,388,087 (81,000) 1,307,087 1,193,822 113,265 1,089,239 994,851 94,388
13 Total Commissioning Budget 211,290,201 181,000 211,471,201 209,750,468 950,000 210,700,468 209,679,381 1,021,087 175,583,723 174,732,819 850,905
14 Budgeted Surplus/(Deficit) 0 0 0 0 0 0 1,021,087 1,021,087 (0) 850,905 850,905
Q:\HCCG\1. Committees\2. CCG Governing Body\2014 Governing Body\04 4 March 2014\Business March\Item 10 - HCCG Mth 10 Summary.xls March 4th 2014
Quality & Patient Safety report
David Farnsworth Executive Lead Nurse Contents
1) Purpose 2) Assurance questions and responses 3) Rapid Response Review 4) Supporting Information • Provider performance • WVT • 2gether • Other providers • Patient Experience • Safeguarding • Additional considerations
• Medicines Optimisation • CQC review of MHA • SI reporting • WMQRS work programme 14/15 Feb-14 • CQUIN 2 Purpose
1) To update Governing Body on the Rapid Response Review 2) To promote Governing Body discussion on key assurance questions 3) To update Governing Body on performance across a range of quality indicators
Feb-14 3 Assurance Gaps - WVT • Review of SI learning has identified pockets of poor compliance with governance systems and • Out of date ward reporting systems (shields) • Poor uptake of care bundles • Limited incident reporting • Patient experience programme • Maternal patient experience • Appraisal performance • Clarity on staffing levels detail • Excess avoidable mortality • Executive personnel changes Actions • Board to Board focus on quality • Unannounced targeted assurance visit scheduled (informed by gaps in SI learning) • Mortality • Refreshed executive steering group • Mapping assurances against NHSE guidance • Developed shared clinical improvement group • Increased assurance sought via CQRF on • Patient experience programme • Maternal patient experience • Staff development programme • Nurse staffing levels Feb-14 4 Assurance Gaps – Other providers
2Gether NHSFT • Increased risks in suicide prevention WMAS • Red 1 Performance NHS111 • High 999 dispositions Actions
• Engagement with Public Health • Seeking to increase local contracting levers for WMAS performance / exploring local pathway impacts • Referral to regional 111 committee
Feb-14 5 Supporting Information
• As discussed at Quality & Patient Safety sub- committee
Feb-14 6 Provider performance
Feb-14 7 Rapid Response Review • Monthly Oversight Group – NHS England, Trust Development Authority and CCG • Action plan - Key exceptions reviewed 1 • Progress in day surgery unit including SOP revised in conjunction with staff, executive led training with staff involved in the patient pathway, daily status and monitoring to assure implementation of SOP through reporting and exec review. Assurance reports to go via quality committee to Board • CAU to be fully staffed by March 2014. Recruiting nurse practitioners. CAU Project Group in place. GPs working at trust positive re assessment of patients and peer feedback. Physician time out to do training. • Bed reconfiguration planned to stream GP patients outside of A&E • Visits by TDA quality manager confirmed revised SOP, staff engagement and implementation and closure of Fred Bulmer Unit to inpatients • WVT confirmed day surgery to be closed to inpatient admissions from 17.02.14 but recognising if inpatients are placed due to pressures there are systems in place to maintain patient safety • Workstreams for non-elective care reviewed oversight group. • Challenges discussed re primary care and social care. CCG highlighted application for Challenge Fund to implement community 7 day working – applications to be Feb-14 reviewed by LAT/NHSE. 8
Rapid Response Review • Action plan - Key exceptions reviewed 2 • ED workforce strategy under development • Implementing ECIST learning / clinician attendance at masterclasses • WVT highlighted need for Local Education Training Board / Committee engagement re future workforce requirements ,CCG engaged in planning Pressure on physician recruitment • System wide mortality meeting to be refreshed. Planned joint committee bi-monthly starting March 2014. • Discussions re mortality reduction and SHMI report. Mortality Group meeting yesterday. Coding reviews to include nursing inputs into process. Areas of focus: hydration / fluid balance, GP education, NEWS scores in community, bed moves, care bundle effectiveness • Staffing – 21 days of safer care nursing tool just completed. 20 overseas nurses recruited (Local tests & induction undertaken). • Positive progress reported with safety culture survey 500 responses.
Feb-14 9
WVT – Key exceptions
Patient Safety • 5 category 3 pressure ulcers in December (no change from November) – Noted significant reduction in category 4 ulcers from 10 in April 2013 to Zero since September 2013. • Slight increase in the number of falls (all) to 65 in December from 61 in November • Infection prevention and Control training performance remains low at 70% over the past 2 months (Note increased vacancies in IPC Team) Assurances
• Pressure ulcers & Falls - Action plan in response to RRR/CQC. Assurance visits confirmed safety shields visible in clinical areas. • Trust Development Authority specialist IPC lead to support Trust recruitment to substantive IPC role
Feb-14 10
WVT – Key exceptions
Patient Experience • FFT inpatient score and response rate declined in December – Noted WVT have historically been in the highest quartile for response rates • FFT response rate for A&E fell below the >15% threshold in December • 2 Mixed Sex Accommodation (MSA) breaches were reported in December both on the Day Surgery Unit Assurances • RRR actions focussed on programme of improving patient experience. • NHSE patient experience team supporting WVT development and Healthwatch locally engaged in identifying shared assurances • CQRF request for focus on patient experience work in March • CQRF received refreshed WVT protocol for DSU and are sighted on 3 stage implementation plans to support WVT commitment to zero further MSA sleeping breaches Feb-14 11
WVT – Key exceptions
Clinical Effectiveness • Emergency readmission 30 days following discharge provision figure increase to 7.29% above the 6% threshold – Noted WVT are achieving lowest re-admission rate in WM region • Elective C-Section rate above 9% threshold @ 18.30% for December compared with 10.91% November • Trust appraisal rate remains below performance @ 59.30% Assurances • Contract monitoring of readmission performance – CQRF to seek additional assurances • RCOG review of maternity performance. Action plan to report to CQRF and further assurances to be sought to patient education work • Appointment of substantive HR director. Early indication of further improvement in reporting systems and increase in performance. Further
Feb-14review at CQRF 12
WVT – Additional considerations
• WVT board paper on nurse staffing levels – Noted WVT are indicating planned compliance with ward level staffing levels reporting by April 2014 – Additional financial risks – Recruitment risks • A&E 4 hr Standard • 12 hour breaches Assurances
• Further assurances on detail of plans for staffing levels required – CQRF to request • 12 Breach RCA reports submitted following extension – QPS to receive collated learning report in March 2014 • See Performance framework for A&E 4hr actions
Feb-14 13
2Gether NHSFT– Key exceptions
• 1 serious incident reported in December under the category of suspected suicide • Decrease in delays of transfer of care to 1.90% in December from 5.30% November. Threshold is <7.5% well below limits • Slight increase in proportion of people who have depression and/or anxiety disorders who receive psychological therapies to 4.27% in – However despite this increase performance remains well below the planned target of >12.5% • Limited effectiveness of provider incident reporting systems • Limited management of risk within clinical teams – Both issues identified via 2G own governance committee
Feb-14 14 Assurances
• CCG attendance at 2G internal governance committee – Significant internal scrutiny and challenge including NED – Internal Governance committee sighted on recovery plans • Contracting team sighted on recovery trajectory for IAPT – Additional commissioning in plan • Review of suicide prevention work via internal governance meeting – CCG to engage with Public Health to support further assurances
Feb-14 15 Other Providers – Key exceptions
• NHS 111 – Service remains stable. Call reviews continue with continued improvement in quality. Identified that Herefordshire dispositions to 999 are much higher than other West Midland areas (15%) despite national pathways. WMAS looking why this might be. • Nuffield – Two vacancies – one Hospital Manager, current senior management team reduced. Recruitment in progress • Primecare- Delay in urgent triage calls - urgent triage received when doctors on home visits not being picked up. • WMAS – Red 1 Herefordshire performance December = 63.6%. External review in progress into lack of performance consistency • Shaw Healthcare – CQRF scheduled 25th February 2014 • Blanchworth – Seeking improvements in governance of MIU.
Feb-14 16 Assurances
• NHS 111 – NHS 111 Board meeting monthly and sighted on key issues. Higher 999 dispositions referred to regional group for review. • Nuffield – Quality monitoring via local contracting meeting and reporting from lead commissioner CQRF monthly • Primecare- Contracting meeting received assurance that calls are now clinically supported via Birmingham call centre • WMAS – Local engagement with WMAS to identify pressures from local pathways (transfers to Birmingham). Contract team exploring opportunities for levers with lead commissioners. Additional contracting in plan. • Shaw Healthcare – CQRF scheduled 25th February 2014 • Blanchworth – Refresh of provider / commissioner meetings and requirements placed to support MIU development.
Feb-14 17 Patient Experience
• Media reports related to the new Clinical Assessment Unit opening at Wye Valley, and the proposal of 7 day service provision • Positive experiences were report relating to primary care and access at Market and Ledbury Surgery • 2 complaints received into the CCG highlighting concerns around orthopaedic clinic and pain clinic
Feb-14 18 Feb-14 19 Safeguarding
• School Nursing Update – Reported to Safeguarding Childrens Board – The public health team is reviewing all of the contracts for public health services that were novated to the local authority on 1st April 2013 under public health transition arrangements – No written service specification and no data reporting or contract management arrangements in place, Public health informed and took advice from local children’s and safeguarding leads and – The provider implemented a recovery plan – Regular monthly contract monitoring meetings established – Interim service specification agreed – The service no longer has vacancies, internal processes have been reviewed and improved and a greater use of skill mix is being explored. – The next steps include “rebalancing” the work that the School Nursing Service does during the coming year across all four levels including community, universal, universal plus, whilst maintaining an appropriate level of input to meet local need at the universal partnership plus level. Feb 14 20 Additional considerations
• CQC review of Mental Health Act – The purpose of the visit to check compliance with the Mental Health Act and Code of Practice in respect of how well assessment processes are joined up across the various parts of the care pathway in Hereford and how well the relevant partners contribute to outcomes of care for people who use services. – Report issued to the mental health provider trust although it is recognised that other organisations are responsible for some of the actions detailed within – Action plan in place – Monitored via 2Gether governance committee
• West Midlands Quality Review Service work programme 14/15 – New format – available review of care standards and/or pathways – Up to 2 pathway reviews available – Request for suggestions for reviews
Feb 14 21
Additional considerations
• Medicines Optimisation – Never Event – The incorrect prescribing of methotrexate on a daily regime. QPS is asked to note that robust assurance has been requested to prevent recurrence. – CQUINS – MOG supported the proposal that CQUINS in relation to medicines should be included within the 14/15 contracts for WVT and 2gether with WVT CQUIN on outpatient Electronic Discharge Summary. – Record of requests made to providers for emergency supply of medicines – WVT A&E, GPEAC and OOHs services together with the 27 community pharmacists will record the number of requests for emergency supplies of medicines. – Herefordshire CCG Stakeholder draft good practice guidance on managing medicines in care homes. – Herefordshire CCG registered as a NICE stakeholder and submitted comments 16 December 2013 on suggestions to improve the draft guidance. – 2gether have highlighted concerns that patients and clinicians do not have access to the required level of specialist pharmacist input in Herefordshire (Zero priced service)
Feb 14 22
Additional considerations - CQUIN
• 2.5% of total income relate to CQUINS delivery 2gether NHS Foundation Trust • Nationally mandated - 0.375% ⁻ Friends & Family Test, ⁻ NHS safety thermometer ⁻ Improving physical healthcare to reduce premature mortality in people with server mental illness (SMI) • Remainder for local priorities: - Improve the experience of service users who make the transition from children and young people's services to adult services - Antipsychotic prescribing within community based setting and 3 monthly review - Falls prevention and bone health staff training - Use of falls pathway and risk assessment tool
Feb 14 23
Additional considerations - CQUIN
Wye Valley NHS Trust • Nationally mandated - 0.375% ⁻ Friends & Family Test, ⁻ NHS safety thermometer ⁻ Dementia & Delirium • Remainder for local priorities: (awaiting final agreement and numbers) – Development of personalised self-management plans to support transition of young people with LTC to adult pathway – Embedding E-Consultation as a clinical assessment service – Embedding of selected care bundles to ensure the provision of consistent effective clinical care – Demonstration of improvement in services acting upon the ‘Childs voice’ – Reduction in all falls Community Hospital and Intermediate Care setting – Improve the experience of maternity services users by increasing the supernumerary time of experienced midwives on the delivery suite – Completion and timeliness of issue of EDS from Outpatient units
Feb 14 24 CCG Governing Body
4th March 2014
Advanced Care Planning for all Patients in Nursing and SUBJECT Residential Homes
Alison Talbot-Smith PRESENTED BY Fiona Nikitik
PURPOSE OF THE REPORT
To seek final approval from the Governing Body for the Anticipatory/Advanced Care Planning for Patients in Nursing & Residential Care
To seek approval for the GP Provider Service Specification
KEY POINTS
The aim of this work is to: Establish an Education Programme for Advanced Care Planning (ACP) and End of Life (EOL) Care across Nursing and Residential Care settings and Primary Care clinicians Deliver Anticipatory Care Planning that is “above GMS/PMS”, across nursing and residential care settings Maximise the benefit and reduce the risk associated with medicines through pharmacist review in the patients’ own home.
RECOMMENDATION TO THE COMMITTEE
To approve the GP Provider Service Specification for the delivery of the service and advise on future steps To approve the reallocation of funds to this project
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CONTEXT & IMPLICATIONS
Financial £210,000 reallocation of current funds
Legal NHS constitution
Risk and Assurance (Risk Register/BAF)
HR/Personnel Recruitment of an Educational Lead for Advanced Care Planning Countywide
Equality & Diversity Equal Opportunities / Equitable delivery of a CCG commissioned service countywide
Strategic Objectives To support the Urgent Care Delivery Plan
Healthcare/National Policy GMS Contract 2014/2015
(e.g. CQC/Annual Health Check) CQC compliance
Partners/Other Directorates N/A
Carbon Impact/Sustainability N/A
Other Significant Issues N/A
GOVERNANCE
Process/Committee approval STIG 7th December 2013 with date(s) (as appropriate)
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1. INTRODUCTION
The Herefordshire Clinical Commissioning Group (HCCG) has a statutory responsibility to ensure, and maintain, both value for money and clinically effective care. With this in mind, the HCCG undertook a review of the Nursing Home GP pilot which was originally started in 2008. The business case was presented to STIG sub-committee in December 20131 and approved. However, the committee requested that a Service Specification be drafted for approval b the Governing Body and this is set out below.
2. CONTEXT
The Nursing Home GP scheme was originally set up in 2008 to predominantly meet the need of city practices who were overwhelmed with the needs of patients being cared for in Nursing Homes. Whilst it has been successful and has met its’ initial goal, a lot of the work undertaken by the Nursing Home GP is now duplicated in other CCG initiatives and pilots.
Additionally, many of the functions of the Nursing Home GP are within the GMS contract and therefore, the responsibility of the patient’s registered GP. Consequently, following this, and previous, reviews and the decision to stop this pilot (as it was not considered good value for money), recommendations were made that a replacement scheme be devised and established.
The recommendations for a replacement scheme were made in December 2013 to STIG. The committee approved the business case which gave detail to the allocation of the current budget of £210k for this project and mandated that a Service Specification be written for the GP Provider element of the project. Medication review by pharmacist projects locally have highlighted the added benefits of pharmacist intervention in optimising the actual use of medicines and patient compliance, reducing the risk associated with medicines, which have historically run alongside the care home GP pilot.
3. AIMS and OBJECTIVES
The overall aim of this project is to ensure that all patients living in Nursing or Residential Homes have an Anticipatory or Advanced Care Plan Care completed (ACP)1. To support this vision, the CCG has identified four key actions to ensure this vision is achieved:
3.1 Patients who are in Nursing or Residential Homes at lower risk level (than used to identify patients in the virtual wards or the upcoming 2014 GMS enhanced service) to have a medical review undertaken by their GP on admission. Additionally, the GP will ensure an ACP is put in place, with appropriate input from the nursing or residential home staff. The ACP will be reviewed annually to ensure it is contemporaneous. If a Nursing or Residential Home contact Primecare (OOH), ring 999, or have to admit a patient as an emergency, then the ACP will be reviewed within two weeks of discharge or notification of the phone call.
1 HCCG STIG Minutes 19th November 2013 & 17th December 2013 1 For this paper ACP means an advanced or anticipatory care plan. These consider issues such as decision to admit, Whether to treat actively in the event of clinical deterioration, DNAR, and carers crisis planning 11
3.2 To employ a Lead in Education for Advanced/Anticipatory Care Planning (ACP) and End of Life (EOL) Care on a sessional basis.
3.3 To establish a countywide education programme to support Advanced/Anticipatory Care Planning for Patients over 75, those at risk of emergency admission, and those at or approaching End of Life. This will cover all sectors and will be overseen and at least partly delivered by the professional Lead for ACP. It will focus on primary care professionals and nursing/residential home staff, but also link and in some circumstances provide education to partners such as WMAS, third sector organisations, LA staff.
3.4 To commission a pharmacist led medication review service in domiciliary care settings including care homes, for patients highlighted as high risk. This will improve patient safety relating to medication issues, support them remaining in their own homes for longer, and has previously demonstrated a high return on investment. This is described in Appendix 4. It should be noted that this includes a focus on patient use and compliance with medication, rather than medical issues relating to prescriptions
4. INTERACTION WITH OTHER SCHEMES/INITIATIVES
For the purposes of this Business Case, it is assumed that the patient’s own GP will undertake GMS responsibilities which include: Clinically focused Medicine Reviews, QOF work, End of Life care, Palliative Care and continue with the MDT meeting held monthly with DNs, Macmillan Nurses and other Allied Health Professionals. Anything over and above these elements of work is considered not to be GMS/PMS.
This proposal also recognises the related CCG initiatives/schemes with which it interacts, namely Virtual Wards, the recently announced 2014 GMS enhanced service for emergency admissions, and GP input into the RAAC:
Virtual wards – which cover 0.33% of the population. o This equates to 252 adult “beds” across the city and 608 across the county - although there will be more than one patient admitted to each bed per annum. Not all will be resident in nursing/residential homes o The nursing/residential home scheme is targeted at patients who are at a lower risk level than those in virtual wards. There may be instances when a patient in this scheme achieve a higher level of risk and are entered into the virtual ward as well The 2014 GMS enhanced service for unplanned admissions (see http://bma.org.uk/news-views-analysis/general-practice-contract/unplanned- admissions-2014). o This will cover 2% of the adult population (18 and over plus any children with complex needs). This equates to 1,174 adults across the city and 2,794 across the county as a whole. It is not yet clear from national guidance how long patients stay in the service, not how often they are reviewed. Not all will be resident in nursing/residential homes
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o It is anticipated that the nursing/residential home scheme will again be targeted at a lower level of risk than in the new GMS enhanced service, although further detail is awaited nationally. GP involvement in the RAAC. In the RAAC people are usually placed for social care, rather than medical reasons. This is for a period of less than two weeks, and at a maximum for 6 weeks. Due to this short length of stay they would not be eligible for this proposed scheme
To maximise the seamlessness and effectiveness of anticipatory care planning and advanced care planning interventions across the residential/nursing home population, and to prevent duplication of payment, it is proposed that we consider these schemes as a continuum (see Figure 1).
Increasing
Risk
Figure 1. Risk stratification of the Nursing and Residential home population
(n.b. this relates to the nursing and residential home population only. Not all patients in the Enhanced Service or Virtual Wards will be resident in nursing or residential homes.)
Key points for the nursing/residential home population are:
The whole nursing/residential home population would be “registered” with the proposal described in this paper, for the length of their stay in the nursing/residential home. Those developing a higher risk of emergency admission would be moved up into the GMS enhanced service, according to national guidance. When their risk level falls they will be “dropped down” to the scheme described in this paper.
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Those with an even higher risk would be entered into the virtual ward, as per local guidance. When their risk level falls they will be “dropped down” to either the enhanced service or the scheme described in this paper.
We propose that:
Practices would receive the “basic payment” of £77 per patient per annum for all patients in nursing home/residential homes, with all registered in this scheme For nursing/residential home residents then entered into the GMS Enhanced Service, practices receive an additional payment to “top-up” to the enhanced service payment. This would be for the period patients are in the enhanced service, in order to reflect the additional work for practices For nursing/residential home residents then entered into Patients receive a further additional payment for patients entered into the Virtual Ward – to “top-up” to the virtual ward payment for the period patients are in the enhanced service, in order to reflect the additional work for practices (VW payment is equivalent to £150 per VW bed per annum)
This requires the following actions:
1. Alignment of Anticipatory and Advanced care plan templates across all three schemes/levels of risk 2. Alignment of payment amount across all three schemes/levels of risk – this requires further detail to be made available nationally on the details of the enhanced service scheme (such as frequency of reviews) and on payment structure.
3. EXPECTED BENEFITS – WHY IS THIS VALUE FOR MONEY?
We have an increasing number of patients with complex co-morbidities and dementia living in nursing and residential homes.
Improving patient experience and reducing inappropriate emergency admissions requires a co- ordinated approach to:
Embed ACPs into the care of vulnerable patients in nursing and residential homes Ensure the wider system is both knowledgeable and confident in acting upon such care plans, and understands and is educated about the wider end of life context Utilise a multi-disciplinary workforce (such as pharmacists) to support the patient focused components of these activities, enabling primary care to focus on medical issues. This will optimise the benefits of medicines and reduce associated risks of medicines use in higher risk patients in line with local formulary arrangements which has been shown to optimise cost effective use of medicines.( Appendix 4)
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4. RESOURCES REQUIRED
It is anticipated that current resources used for the Nursing Home GP pilot will be reallocated as per Table 1.
For core element 1, the post for an educational Lead has been advertised in January 2014 and the successful candidate will be employed as soon as possible in order to establish an education programme for commencement in April 2014.
For core element 2, Practices will be required to submit a list of patients from their Practice list who currently reside in a Nursing or Residential Home. Therefore, Remuneration to Practices will be based on per capita of patients in Nursing or Residential Care on a quarterly basis. Claims will be submitted to the CCG Finance department and approved for payment based on previous submission of registered patients residing in Nursing or Residential Care.
For core element 3, it is anticipated that there will be no cost incurred to the CCG other than a £13,000 administration cost, but also met through:
GP attendance at GP education days – already funded through the LIS Practice Nurse attendance at the Practice Nurse education days – already funded through the LIS Residential and Nursing Home CQC requirements to educate and maintain competencies amongst their staff
For core element 4, the Pharmacist led Domiciliary medication review element to remain within the financial envelope of £10k and transferred for 14/15 to CCG Medicines Management Reserve and the service will be managed by the Medicines Optimisation Team.
Core Element of Business Case by Finance for 14/15 Cost pa
1. Lead for Education for ACP £38,376 (£300 per session, for 2 sessions per week, including 23% ‘on’ costs)
2. Remuneration to GP Practices for completing/reviewing ACP based £77 per patient on total number beds (total = 2043) for Nursing / Residential Homes and patients’ usual GP. Total £157,311
3. Establishing a Countywide Education Programme £13,000
4. Pharmacist medication led review in domiciliary setting £10,000
TOTAL £209,687
Table 1 – Cost of Implementation
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Finances for medication review undertaken by community pharmacist will be as per national financial arrangements and claimed through national community pharmacy contract or for independent community pharmacist work through the CCG. Travel remuneration will be applied Application to NHS England will be made to facilitate community pharmacist led domiciliary Medicines Use Review to enable these to be undertaken without the need for individual patient permissions as per current national arrangements to enable community pharmacists to participate.
5. Service Specification for Anticipatory Care Planning
The service specification is attached to this paper for approval by the Governing Board.
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Herefordshire CCG – Governing Body Page 17 of 9
HEREFORDSHIRE CLINICAL COMMISSIONING GROUP SERVICE SPECIFICATION 2013/14 NHS STANDARD CONTRACT PARTICULARS
Service Specification No. Service Anticipatory Care Planning Commissioner Lead Provider Lead Period Date of Review
1. Population Needs
1.1 National/local context and evidence base
We have an increasing number of patients with complex co-morbidities including dementia living in nursing and residential homes.
Improving patient experience and reducing inappropriate emergency admissions requires a co-ordinated approach to:
Embed Anticipatory Care Plans (ACPs) into the care of vulnerable patients in nursing and residential homes Ensure the wider system is both knowledgeable and confident in acting upon such care plans, and understands and is educated about the wider End of Life context
Utilise a multi-disciplinary workforce (such as pharmacists) to support the patient focused components of these activities, enabling primary care to focus on medical issues. This will optimise the benefits of medicines and reduce associated risks of medicines use in higher risk patients in line with local formulary arrangements which has been shown to optimise cost effective use of medicines.
This project will be commenced in advance of the Direct Enhanced Service for People over 75 years. It is uncertain what the DES will contain in detail and it was felt that this project should start on the 1st April 2014 prior to publication of the DES. However, it is vital that the DES and this service specification should be aligned and complement each other once the DES is published. Therefore a review will be necessary during the financial year.
It is anticipated that this service be delivered by the GPs within each practice. Alternatively it could be provided by a single GP Provider who will then have responsibility for ensuring all elements of the service are delivered.
2. Outcomes
2.1 NHS Outcomes Framework Domains & Indicators
Domain 1 Preventing people from dying prematurely √ Domain 2 Enhancing quality of life for people with long-term conditions √
HEREFORDSHIRE CLINICAL COMMISSIONING GROUP SERVICE SPECIFICATION 2013/14 NHS STANDARD CONTRACT PARTICULARS
Domain 3 Helping people to recover from episodes of ill-health or √ following injury Domain 4 Ensuring people have a positive experience of care √ Domain 5 Treating and caring for people in safe environment and √ protecting them from avoidable harm
2.2 Local defined outcomes
The aim of this service specification is to ensure : Ensure all Nursing and Residential Home Patients to be given the opportunity to discuss plans for End of Life Care and agree an Anticipatory Care Plan with their GP (with the inclusion of family / carers) including defining the patients’ preferred place of death Result in a reduction in A&E attendances and non-elective admissions Result in a reduction in Post Mortems Ensure that all GPs participate in an evidenced-based, structured countywide education programme for Anticipatory Care Planning Alignment of Anticipatory Care Plan templates across settings and services with development of a standardised template for countywide use Compliance with CQC Quality Indicators and Measures GPs refer eligible patients to receive domiciliary pharmacist led medication reviews and consider any follow up recommendations and READ code accordingly on the patient’s electronic record
3. Scope
3.1 Aims and objectives of service
The overall aim of this project is to:
ensure that all patients living in Nursing or Residential Homes have a robust Anticipatory Care Plan Care completed and updated as appropriate improve patient experience by identifying needs earlier and ensure that End of Life care is the best it can be for the frail and elderly and for people who are expected to die.
Objectives
The GP Provider will ensure that:
Patients who are in long term placements in Nursing or Residential Homes at lower risk level (than used to identify patients in the virtual wards or the upcoming GMS Enhanced Service) to have a medical review undertaken by their GP on admission to a Nursing or Residential Home. A catch up programme is embedded for patients already placed in a Nursing or Residential Home and should be part of the annual review, unless circumstances dictate an ACP is required sooner (see bullet point below). Additionally, the GP will ensure an ACP is put in place, with appropriate input from the nursing or
HEREFORDSHIRE CLINICAL COMMISSIONING GROUP SERVICE SPECIFICATION 2013/14 NHS STANDARD CONTRACT PARTICULARS
residential home staff and the patient’s relatives/carers. Additionally input into the ACP could be from the Virtual Ward or Hospital at Home Community Matron, depending on the patients’ level of need. Ensure that the patient’s ACP is reviewed annually to ensure it is contemporaneous. If a Nursing or Residential Home contact Primecare (OOH) or ring 999 recurrently (more than twice a year), then the GP should be made aware (within 24 hours if a weekday or 72 hours if a weekend) and the patient’s ACP be reviewed within two weeks. If a patient is admitted as an emergency, then the patient’s ACP will be reviewed within two weeks of discharge by the GP. The standardised template for ACP for countywide use (developed by the CCG and be compatible with the Practices patients system of choice) is used. The template will include (but not be limited to) management of patients in the event of acute deterioration and issues regarding End of Life care. Compliance against these objectives is audited annually and work with the CCG to identify and resolve any issues in their implementation. Ensure appropriate input into the development of ACPs from Nursing and Residential care home staff and other specialist services allied to this aspect of care, e.g. Memory Clinic GP providing this service to participate in a countywide education programme to support Advanced/Anticipatory Care Planning and ensure that all Practitioners are skilled in the development of ACPs and their implementation. The education programme will cover all sectors and will be overseen and at least partly delivered by the GP Professional Lead for ACP. It will focus on primary care professionals and nursing/residential home staff, but also link and in some circumstances provide education to partners such as WMAS, third sector organisations, Local Authority staff. Liaison with (and work in partnership) Nursing and Residential Homes, Out of Hours service, West Midlands Ambulance Service and hospital providers to ensure real time sharing of care plans and contribute towards ensuring a mechanism to facilitate their implementation. Patients can receive a Pharmacist led medication review in a domiciliary care setting, which includes Nursing and Residential Homes, if highlighted as ‘high risk’ of poor compliance with drug regimes where patients self medicate, by implementing the findings through prescribing and care plans. This will improve patient safety relating to medication issues, support them remaining in their own homes for longer, and has previously demonstrated a high return on investment. It should be noted that this includes a focus on patient use and compliance with medication, rather than medical issues relating to prescriptions. GPs will use a CCG template referral form, receive outcomes and should consider any recommendations of the review. A READ code domiciliary pharmacist led medication review should be recorded for data purposes.
3.2 Service description/care pathway All patients in Nursing and Residential Homes to have a record of an Anticipatory Care Plan which is updated annually or following any urgent hospital admission.
3.3 Population covered All Nursing and Residential Home Patients registered with a GP Practice in Herefordshire
HEREFORDSHIRE CLINICAL COMMISSIONING GROUP SERVICE SPECIFICATION 2013/14 NHS STANDARD CONTRACT PARTICULARS
3.4 Any acceptance and exclusion criteria and thresholds Any patient identified as moved away (out of county) from the Nursing and Residential Home
3.5 Interdependence with other services/providers To ensure development of ACPs are implemented in a holistic way, there is an interdependence with other groups and organisations to ensure ACPs are shared and implemented successfully in an integrated way to the benefit of the patient and to avoid duplication, such as: Nursing & Residential Homes Social Care / Local Authority Wye Valley Trust eg Virtual Ward staff, District Nursing Service West Midlands Ambulance Service Palliative Care Providers eg St Michael’s Hospice Out of Hours Service, eg Primecare 24 GP Practices and Walk in Centre Mental Health, eg 2Gether, Memory Clinic Public & Patient Involvement Groups, eg Healthwatch Voluntary Groups, eg Macmillan RAAC (Rapid Access to Assessment and Care) Medicines Optimisation Team (for ensuring that Domiciliary Pharmacist Reviews are undertaken) Other Specialist Services as identified during the roll out of this programme 4. Applicable Service Standards
4.1 Applicable national standards (eg NICE) All national guidance eg
4.2 Applicable standards set out in Guidance and/or issued by a competent body (eg Royal Colleges) See guidance as appropriate
4.3 Applicable local standards To be devised by GP Education Lead
5. Applicable quality requirements and CQUIN goals
5.1 Applicable quality requirements (See Schedule 4 Parts A-D)
CQC Monitoring requirements
DoH Directed Enhanced Service for the Over 75 (still awaiting detail and how to incorporate the directives into this Specification)
5.2 Applicable CQUIN goals (See Schedule 4 Part E)
Not applicable
6. Location of Provider Premises
HEREFORDSHIRE CLINICAL COMMISSIONING GROUP SERVICE SPECIFICATION 2013/14 NHS STANDARD CONTRACT PARTICULARS
The Provider’s Premises are located at:
All 24 GP practices within Herefordshire All Nursing and Residential Homes within Herefordshire
7. Individual Service User Placement
Not applicable
Payment Arrangements:
As specified in the main contract
Anticipated Activity
Approximately 2043 patients
HEREFORDSHIRE CLINICAL COMMISSIONING GROUP SERVICE SPECIFICATION 2013/14 NHS STANDARD CONTRACT PARTICULARS
SCHEDULE 4
A. Local Quality Requirements
Quality Requirement Threshold Method of Measurement Consequence of Breach (Key Performance Indicator) Practices to hold a register of all Nursing and Residential Home Patients 1. All Nursing and Residential Home Patients to have an Year 1 75% Practices to record on patients electronic Anticipatory Care Plan Year 2 100% record that an ACP has been completed Evidence of an ACP in records held at Nursing & Residential Homes
2a. Participate in a countywide Education Programme for Contribute to devising an Education Advanced Care Planning and include: Programme and ensuring attendance by all Year 1 75% GPs Year 2 100% 2b. Contribute to establishing a countywide Care Plan Help develop necessary paperwork and and documentation for implementation throughout the documentation for ACP and monitor Nursing and Residential Homes compliance of its’ use through annual audit Record the number of Post Mortems Record and review the reason for Post 3. Monitor the number of Post Mortems for two years Mortem and if felt unnecessary to for all Nursing and Residential Home Patients in ? investigate why it was required and if any partnership with the CCG training needs identified either within the Nursing or Residential Home, GP Practice or key stakeholder, eg WMAS
HEREFORDSHIRE CLINICAL COMMISSIONING GROUP SERVICE SPECIFICATION 2013/14 NHS STANDARD CONTRACT PARTICULARS
Practices/Nursing & Residential Homes to record all non-elective attendances and admissions to Accident & Emergency and participate in the audit of this data and submit results to CCG for analysis and reporting 4. Audit ACP against attendance & non-elective Each organisation to internally review their admission to Accident and Emergency from Nursing or data and identify any training needs or Residential Home for non-elective reason areas of improvement and action plan to be devised and submitted to the CCG for approval Include a Root Cause Analysis as part of the post-admission review of the ACP for submission to the CCG and help mitigate risk in the future Documented clinical medication review on 5. GP to undertake a clinical medication review on 100% both Practices’ electronic record and admission of all Patients in Nursing and Residential Home Nursing/Residential Patient record To liaise with the CCG IM&T group as 6. To participate in the exploration of a full mobile necessary solution to enable access to the Patient’s electronic To submit bids where applicable for IM&T record held within the Practice development monies with assistance from the Finance team 7. Establish a Stakeholder Group to enable review of Service in a structured way and include representatives from: 100% HCCG Nursing & Residential Homes 24 GP Practices (& all GPs)
HEREFORDSHIRE CLINICAL COMMISSIONING GROUP SERVICE SPECIFICATION 2013/14 NHS STANDARD CONTRACT PARTICULARS
Walk in Centre West Midlands Ambulance Service Primecare/Out of Hours Service Voluntary Organisations e.g. Health Watch, Herefordshire Carers Local Authority WVT 2Gether 8. Refer patients for pharmacist led domiciliary medication review targeting those patients at risk of Numbers of referrals and outcomes from medicines related incidents in line with national MUR pharmacist led domiciliary medication review groups: patients taking high risk medicines NSAIDs, anti- coags, diuretics, antiplatelets, recent discharge from hospital, certain respiratory medicines and other 100% Number of READ CODE Domiciliary Pharmacist patients where a referral is through to be appropriate to led medication review assist with concordance and support day to day management of medicines.
2013/14 NHS STANDARD CONTRACT PARTICULARS
SCHEDULE 6 – CONTRACT MANAGEMENT, REPORTING AND INFORMATION REQUIREMENT
Reporting Period Format of Report Timing and Method for Application delivery of Report National Requirements Reported Centrally 1. As specified in the list of As set out in relevant As set out in relevant As set out in relevant All assessed mandated collections Guidance Guidance Guidance published on the HSCIC website to be found at http://www.hscic.gov.uk/datac ollections as applicable to the Provider and the Services 2. PROMS As set out in relevant As set out in relevant As set out in relevant All Guidance Guidance Guidance 3. NDTMS As set out in NTA Guidance As set out in NTA Guidance As set out in NTA Guidance SM National Requirements Reported Locally
1. Monthly Activity Report Monthly Using SUS data, where All applicable 2. Service Quality Performance Monthly Submit to Co-ordinating Report, detailing performance Commissioner within 10 against Operational Standards, Operational Days of the end of National Quality Requirements, the month to which it relates. Local Quality Requirements, Never Events, including,
Particulars 2013/14 NHS Standard Contract
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without limitation:
2.1 details of any thresholds All that have been breached and any Never Events that have occurred;
2.2 details of all requirements satisfied; All
2.3 details of, and reasons for, any failure to meet All requirements and;
2.4 the outcome of all Root Cause Analyses and A audits performed pursuant to Service Condition 20 (Venous Thromboembolism). 3. CQUIN Performance Report and N/A details of progress towards satisfying any Quality Incentive Scheme Indicators, including details of all Quality Incentive Scheme Indicators satisfied or not satisfied 4. Monthly report on performance Monthly All against the HCAI Reduction Plan 5. Complaints monitoring report, All setting out numbers of complaints received and including analysis of key themes
Particulars 2013/14 NHS Standard Contract
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in content of complaints
6. Report against performance of In accordance with relevant In accordance with relevant In accordance with relevant All Service Development and SDIP SDIP SDIP Improvement Plan (SDIP) 7. Cancer Registration dataset As set out in relevant As set out in relevant As set out in relevant CR reporting (ISN): report on Guidance Guidance Guidance R staging data in accordance with Guidance 8. Monthly summary report of all Monthly All incidents requiring reporting 9. Data Quality Improvement In accordance with relevant In accordance with relevant In accordance with relevant All Plan: report of progress against DQIP DQIP DQIP milestones 10. Report and provide monthly Monthly As set out in relevant As set out in relevant A data and detailed information Guidance Guidance A+E relating to violence-related AM injury resulting in treatment U being sought from Staff in A&E departments, urgent care and walk-in centres, and from ambulance services paramedics (where the casualties do not require A&E department, urgent care and walk-in centre attendance), to the local community safety partnership and the relevant police force, in accordance with applicable Guidance (College of Emergency Medicine Clinical Guidance Information Sharing to Reduce Community Violence
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(July 2009))
11. Report on outcome of reviews 6 monthly (or more All and evaluations in relation to frequently if and as Staff numbers and skill mix in required by the Co- accordance with General ordinating Commissioner Condition 5.2 (Staff) from time to time) Local Requirements Reported Locally
Insert as agreed locally 12. Quarterly review of number and % of Quarterly patients with a completed ACP
13. Compliance with ACP – Audit Annually undertaken
14. GPs to participate in an education Quarterly programme for ACP 15. Number of referrals for pharmacist Quarterly led medication review in targeted groups. Numbers of patients received medication review through READ coding.
Particulars 2013/14 NHS Standard Contract
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Particulars 2013/14 NHS Standard Contract
Governing body – Item 13
Governing Body
Tuesday 4th March 2014
SUBJECT Local Incentive Scheme (LIS)
Alison Talbot-Smith, Consultant in Public Health and PRESENTED BY Head of Clinical Outcomes and Service Transformation
PURPOSE OF THE REPORT
The purpose of the report is to: 1. Note the current performance of the LIS scheme;
2. Consider whether the CCG should offer revisions to aspects of the LIS that are no longer achievable due to circumstances outside practices control.
KEY POINTS
1. Background
1.1. The Senior Management Team have received periodic reports on the LIS schemes. Following the SMT 17 February 2014 it was agreed that the Governing Body should review the performance and decide where schemes that have slipped should be reallocated.
1.2. The LIS scheme was offered to all member practices plus Primecare for certain elements. All practices and Primecare have agreed to participate.
1.3. The total value of the scheme is £256,405.
1.4. Within the LIS the two key financial value components are Neighbourhood Teams and Virtual Wards. These 2 elements amount to £109,443 or 43% of the value.
1.5. A part payment has been made to all practices, equal 25% of the full value of the LIS, in recognition that a number of the schemes didn’t start until later than originally envisaged.
2. Financial Position 2.1. The table below indicates the annual, current performance and forecast performance.
Herefordshire CCG –LIS Page 1 of 4
Governing body – Item 13
Expenditure Evidenced payments as at 31 December 2013 CCG Lead Plan Forecast Variance to date £ £ £ £ Meet Annually with CCG Mike Emery 25,000 6,000 25,000 0 Rapid Decision making Respond within 72 hrs Mike Emery 25,000 10,000 21,000 (4,000) Host Primary Care Workers & Dementia CMB - 2G 24,000 0 24,000 0 Community Workers Attendance of Qrtly Educational Events Jacinta / Sarah / Saran 18,241 6,059 13,500 (4,741) Attendance of Qrtly Practice Nurse Educ. Event Cate Lamport 18,241 6,619 13,500 (4,741) E-Consultation Jacinta / Sarah 18,241 17,626 17,626 (615) Audit Crispin Fisher 18,241 0 18,241 0
Participation in Neighbourhood Teams by practice Marie Hardy 18,241 12,910 12,910 (5,331) Participation in Virtual Wards by practice Marie Hardy 91,203 0 0 (91,203) Diebetes Pathway 0 0 900 900 Tissue Viability 0 0 520 520
TOTAL 256,405 59,215 147,197 (109,208)
2.2. As agreed by STIG and SMT, underspend has been used to fund clinical input to specific pathway development work, in Diabetes and Tissue Viability.
2.3. Overall the LIS programme is forecast to under-spend by c£109,000.
2.4. The key area that is forecast to under-spend is Virtual Wards. The main reason for this is because the scheme started as a pilot with just the 8 city practices. Whilst there is an intension to roll out to the county areas it is unlikely that this will be managed within the contract period and whether they will achieve the occupancy criteria.
2.5. The occupancy criteria that define payment levels originally set for the this scheme is as follows:
Occupancy Between 80% Occupancy above 95% and 95% 75% of £0.50 per head of 100% of £0.50 per head practice population of practice population
1.1. From the pilot sites it is clear that practices are struggling to meet the lower occupancy rate, with no practices currently achieving the lower threshold required for payment.
1.2. To date we have 120 patients currently in Virtual wards bed – against a commissioned bed capacity of 253 beds. This gives an “average” current bed occupancy of 47%, with a slow but ongoing upward trajectory. (n.b. 88 patients have already been discharged from virtual ward beds).
1.3. The main reasons why practices are struggling to achieve the occupancy criteria are:
Herefordshire CCG –LIS Page 2 of 4
Governing body – Item 13
Delayed start; Manual processes are required for risk stratification, due to national s251 issues which have prevented the use of a risk stratification tool). Practices are using a manual process for identifying patients with community matrons. This is time consuming, and has also limited the “pool” of identified patients available to practices
1.4. From the above it is clear that there have been a number of significant reasons outside the control of practices which are likely to lead to a significant under- performance of the criteria set.
1.5. It should also be noted that practice engagement in the Virtual Wards is very strong – this was evidenced at the November GP parliament, through feedback from practises, and from feedback from WVT community matrons and staff.
1.6. For this reason we propose adjusting the for payment to:
First three months (October to December 2013) – give 50% of payment to reflect engagement, involvement and workload of primary care in recruiting patients and managing them within virtual wards
From January 2014 onwards – add additional lower thresholds to trigger payments, but continue to incentivise increasing the bed occupancy Occupancy between Occupancy Occupancy between Occupancy above 40% and 60% between 60% and 8% and 95% 95% 80% 50% of £0.50 per 60% of £0.50 per 75% of £0.50 per 100% of £0.50 per head of practice head of practice head of practice head of practice population population population population
1.7. The county practices in the Neighbourhood team element are also underperforming . Reasons for this are less clear, and require further analysis before any recommendations can be made to Governing Body.
RECOMMENDATION TO Governing Body
The Governing body are asked to consider a revision to the payment criteria for Virtual Wards given that practices are unable to earn the incentive payments for reasons primarily outside their control.
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Governing body – Item 13
CONTEXT & IMPLICATIONS
Financial The proposals are within the original approved budget.
Legal The LIS is being varied and will need agreeing with practices.
Risk and Assurance None (Risk Register/BAF)
HR/Personnel None
Equality & Diversity None
Strategic Objectives Achievement for key CCG objectives including the development of Virtual wards and Neighbourhood Teams.
Healthcare/National Policy None
(e.g. CQC/Annual Health Check)
Partners/Other Directorates None
Carbon Impact/Sustainability N/A
Other Significant Issues N/A
GOVERNANCE
Process/Committee approval Governing Body with date(s) (as appropriate)
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Quality and Patient Safety Committee st Tuesday 21 January 2014 1030 – 1330 18a Brockington, Hafod Road, Hereford, HR1 1SH
Minutes
Agenda Item
1. Welcome and Introductions Members: Dr Ian Tait - Chair David Farnsworth Susan Little Dr Richard Williams Lynne Renton
Named Deputies: Alison Rogers (for Dr Alison Talbot-Smith)
In Attendance: Emma Sneed Marcus Farr Bob Parker Christine Price Gillian Pearson (Minutes) 2. Apologies Jill Sinclair Mike Emery 3. Minutes of the last meeting The minutes of the last meeting were agreed as an accurate representation of the meeting.
4. Actions To review the on-going actions from previous meetings.
QPS Action Log December 2013.doc
RW asked if call to needle time could be looked into. MF advised that WMAS have been asked to provide this data. Action: DF to speak with Quality colleagues at Worcester and ask them to pursue WMAS data on call to needle time. 5. WVT
5.1 WVT Dashboard
DF took the group through the dashboard highlighting key areas within the attachment 5.1 on the agenda. Discussions were held around the following areas:
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Increase in >AD+2 – been picked up with ES who is well sighted on this work. Initially earlier in year there have been changes in the reporting processes. We are now close to trajectory on these figures. ES also looked at additional primary care education. IT asked what a reasonable benchmark is nationally. DF advised national directive is zero tolerance. There are always exceptions though so there are no national lowest safe level set. If there is any further rise in these figures then ES to come to next QPS to advise what is being done about these.
MRSA – This was unavoidable due to nature of patient. IT queried needle exchange policy. A discussion was held around the needle exchange policy. The Committee was informed that this is dealt with by Public Health and that DASH are also very proactive regarding this. It was agreed that does need to be monitored.
PALs: contacts to the CCG have raised slightly but with no themes coming from these complaints. CP informed the Committee that they went to WVT last week and the majority of feedback was positive. DF advised the Committee that he was meeting with MC to discuss how we further promote and enhance the sense of purpose of the staff and promote that success within WVT. Action: DF to feedback to the Committee outcome of meeting with MC to discuss staff wellbeing.
There has been a decline in the numbers of staff who have had Infection Prevention and Control training. This is partly due to new staff coming in and is also partly representative on workload. WVT have been asked to look at their recovery from this. 6. 2gether
6.1 U18 Report
DF took the Committee through the U18 report. 2g have declined to log this as a SI as this is not reflective of a failure on 2g’s part and is not identified in the national reporting schedule. The national system is under resourced in terms of availability of tier 4 beds and national resolution of this is very difficult. This individual did require admission to a mental health bed and 2g didn’t have an appropriate bed within Herefordshire. LR advised that this was a LAC and is a transfer of patient for the LA. Action: RHT to triangulate U18 report with the LA for their views on this. To include looking at what access did 2G have to LAC system within CAMHS and were they pro-active enough before admission. A discussion was held around specialised commissioning and the Committee were informed that PR continues to raise issues within the specialised commissioning meeting. It was confirmed that if these incidents aren’t reported as SI’s then they aren’t tracked. Action: DF to raise with quality leads within area to agree whether U18 admissions to adult acute psychiatric unit is developed as a local SI so that they can be tracked.
DF advised that SW has begun to collate an issues log for 2g and that he will invite her to the February QPS meeting to present this issues log and an exception report from this log. Action: DF to invite SW to February QPS to present 2g action log and exception report.
LR advised the Committee that she had asked the CQC to carry out a mental health act report yet the CCG have never received this finalised report. Action: LR to request finalised mental health act report by the CQC from 2g.
DF advised the Committee that KPI’s are being discussed at the moment with 2g. It was agreed that the following KPI’s could be considered for inclusion: Speed of review of patients that have taken overdoses Question to be included around performance of crisis resolution There are some issues around 2g having propped up WVT providing acute response services for
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patients presenting in A&E. This results in 2g having less ability to respond within the community. A paper is being prepared by 2g looking into how they are to address this issue. IT asked whether we are at the point with the new dementia pathway where diagnosis is made earlier. He was informed that ATS is focussed on this work but that this pathway hasn’t currently been finalised yet.
DF advised the Committee that the CCG are now attending 2g’s internal quality meeting. He asked the Committee for the views on the frequency of CQRF meetings considering monthly quality meetings are attended. It was agreed that bi monthly meetings are still required. 7. Other commissioned services
7.1 NHS111
DF advised that NHS111 is performing well at the moment and the step in from WMAS continues. Staff are reporting hugely increased satisfaction rates. There is increased clinical support in pathway. Clear from WMAS performance that frontline ambulance activity is increased in Herefordshire. Call reviews are very good. WMAS have invested in some clinical training in non-clinical staff to increase their understanding of why they are asking certain questions. This appears to have had a positive effect.
7.2 Nuffield
The regional meeting was held in January so the CCG and Nuffield contract meeting has been arranged for the end of January.
7.3 WMAS
There have been a couple of contracting issues regarding WMAS one of which is over performance. There is an additional 11% 999 activation across the county. The ambulance service has fed back that they feel their service was under contracted. WMAS have been asked how they can minimise response rates to include looking at community paramedics as an alternative to an ambulance and development of wider support to homes, nursing homes and challenging high callers.
7.4 Primecare
Primecare are looking at how they gain patient feedback as this is currently low and have asked HealthWatch how they could improve this. There are some challenges around the GP locum support they are providing to A&E. They are using their regular GP’s for this which means backfilling is needed. As this is on an adhoc basis, this is hard to plan for. RW asked if they are engaged in our work streams such as virtual wards. DF advised that Jon Allen has been involved in much of this work and that they are engaged in all work streams. IT stressed the importance that all services join up as information relating to care homes are faxed to Primecare but not NHS111 relating to special patient notes. DF advised that in NHS111 board it was asked that OOH’s can see same special notes as Primecare. This is being dealt with at NHS111 Board to resolve this process. DF said that bigger picture to tie this all together is dealt with by STIG and urgent care working group. QPS need to identify where these aren’t tied up and flag back to these two groups.
7.5 Shaw Health Care
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SL advised that a meeting with Shaw Health Care has been arranged as has 2 assurance visits for the end of February.
7.6 Primary Care quality
The Committee were advised that there is now a local primary care strategy. DF went to the Primary Care Steering Group and advised it had been agreed that they will become the forum locally that will receive the dashboards that are currently being designed by CF. These dashboards will come back to QPS once developed for signoff.
8. CCG Performance Framework MF took the Committee through the performance framework highlighting the following areas:
A&E 4hr wait: This has settled down but still struggling. Exception reports are being completed to the AT weekly. This won’t meet target by end of year. TDA recovery plans in place
62 day cancer waiting times: Action: DF to raise 62 day cancer waiting times at CQRF for assurance that they are sighted on this and for an overview report to come to QPS. CP asked whether the CCG had been made aware of ‘Cancer Buddies’ that had held their 2nd meeting in January. This is being run by Alison Stemp at the Macmillan Unit. Action: CP to send information regarding Cancer Buddies to IT for circulation to GP’s.
Friends & family: Remains below target but positive results in November data particularly in A&E which rose significantly.
RW queried the definitions around some of the figures. Action: MF to add definitions into the CCG Performance Framework.
IT informed the Committee that the Queen Elizabeth discharge letter is very clear as to what steps to take after discharge and whether WVT should be asked to look at this. CP advised the Committee that they have asked WVT if they provide a discharge letter. WVT are saying that they do, however the feedback from patients is that they don’t. Action – DF to suggest adding patient advice into the discharge letters 9. CQC Report The CQC carried out and inspection at WVT at the same time as the RRR. They were asked to look at pressure ulcers but got drawn in to looking at the day case unit. WVT have developed an action plan from the RRR and progress of this is being monitored. The CCG have challenged back that their completion of their actions aren’t detailed enough. All actions regarding mixed sex accommodation have been completed however there is still an issue as this is being used as an escalation area as well. There isn’t sufficient governance in place for this. WVT have been challenged regarding this so are currently developing SOPs. Action: DF to bring back formal iteration of CQC report and overview of action plan and exception report for where they are against the action plan.
DF advised in respect of pressure ulcers that these have reduced but it’s whether this is sustainable. WVT mark themselves against whether they can evidence that a pressure ulcer wasn’t avoidable so require the necessary documentation to prove this. DF asked if this is another issue that is flagged at Board to Board. Cat 4 have declined, cat 3 are declining, but cat 2 need to be looked at and sustainability of these reducing and processes need to be embedded. Action: DF to raise issues around pressure ulcers at Board to Board. 10. Patient Experience 10.1 Patient Experience Report (to include CCG feedback - Datix) SL took the committee through the CSU report on patient experience. SL asked AR if COST team have completed the training on Datix. AR confirmed that this had been completed and
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queried whether events by theme, can be tracked back as admission? SL advised that this report is developing all the time and a request for additional data has been made to the author of the report in the CSU for quarter 4. . 11. Infection Control Update ES took the Committee through the Infection Control report. A discussion was held around c-diff. Antibiotic prescribing will be picked up at the next HCAI Forum and will also be picked up as part of CF’s primary care strategy work.
IT asked whether A&E are monitored when they prescribe antibiotics. AR advised the Primecare and OOH’s are monitored. Sue Vaughn is the contact at WVT to discuss their own assurance. Action: ES to speak to Sue Vaughn around WVT assurance for antibiotic prescribing. 12. Medicines Optimisation Update Report AR advised that IG guidance has been finalised now and an understanding has now been gained. This will go to MOG next week then circulated to pharmacists.
Falcons rest and poachers cottage had a poor visit a year ago and have undertaken de- registration as a Nursing provider. This has been re-visited and is much improved now operating as a residential provider.
Sophie house was visited last week. They are addressing their action plan and WVT have been asked to provide extra support to assist. Another visit is planned for March. LR asked if we also need to look at Martha House as they are linked. AR to look this at but thinks they are working together. Action – AR to review assurance with Martha House 13. Risk Register (December) DF asked for comments on this. It was agreed that the following comments are to be added: Safeguarding has been updating but needs updating again in light of this week’s report. Risk of not implementing the RRR & CQC report for WVT to be added. Action: DF to update the risk register.
14. Community Hospitals IT declared an interest in this item. A discussion was held around issues that GP’s are flagging around transfers from WVT to Community Hospitals. The Committee were informed that the CCG have asked for quality impact assessments and overview of how WVT are managing escalation areas. There is lack of governance around the management of community beds. IT informed the Committee that patients are sometimes moved without discharge summaries, appropriate meds and are sometimes arriving with no notes. GP’s are engaged with the process. RW suggested that these are logged as a critical incident each time. GP’s and Community Hospitals should be asked to flag these all as incidents. In the meantime this is all to be feedback at Board to Board and Quality meeting to ask for assurance around escalation process and quality impact assessment. Action: DF to reply to Paul Downey and ask to complete SI’s for each incident regarding transfers from WVT to Community Hospitals and to copy in clinicians. Look to include this as KPI and raise at Board to Board. 15. KPMG Quality Review DF advised that the KPMG Quality Review is the internal audit report that is going to Audit Committee today. This is a positive report that highlights significant assurance. Issues are around how we interact and use the CSU. There are some actions out of this which are being tracked to go back to audit committee. This will be brought back to QPS next month. DF to ask to include CH’s in discharge part of action. Action: Actions from KPMG Quality Review to be brought back to February QPS. Community Hospitals to be included in ‘discharge’ section of this action plan. SL to bring back action plan.
DF asked his thanks was noted to the Quality team for all their hard work.
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16. Infection Prevention Policies for approval ES gave an overview of these policies as included within the agenda. AR raised an issue with prescribing guidance with catheters – remove work formulary and change to prescribing guidance.
Subject to this one amendment the Committee approved these policies. 17. RCA 12 Hour Breach DF advised that this report has been brought here as during a period of acute pressure, there have been three 12 hour breaches. DF took the Committee through each of these. The observation from these is that currently there is no escalation process that should trigger escalations processes that could have avoided some of these. DF asked that the Committee look over these and feed any comments back to him so that these can be feedback to WVT. Action: Committee members to provide any comments from the RCA 12 hour breach report to DF so that these can be collated and feedback to WVT. 18. Serious Incident Update SL took the committee through the serious incident update advising that WVT are the main reporter which is to be expected. Main reported category is pressure ulcers followed by slips trips and falls. Initial analysis is that these have a range of themes. Multiple ward moves which MC is looking at and will be feedback to CQRF in February. 19. Confidential Section
Safeguarding Update
See separate confidential agenda
20. Any Other Business
18.1 WHO checklist frequency of reporting DF advised that currently we receive these on a weekly basis for WVT and that the CCG have been asked whether these can now be received monthly. Performance has improved and is now in the high 90%.
RW gave apologies for next meeting 21. Key Meeting Messages for Board
Board to board meeting relating to quality
Highlighting the outcome of the Serious case review
Community Hospitals and Other interface issues
Dates of next meeting:
18th February 2014 10:30 – 13:00 22a Brockington 18th March 2014 10:30 – 13:00 18a Brockington 15th April 2014 10:30 – 13:00 18a Brockington
Distribution list: Dr Ian Tait GP Lead for Quality of Patient Services - HCCG John Wicks Interim Chief Officer designate – HCCG Diane Jones Lay Member – Independence Chair - HCCG Dr Andy Watts GP, Clinical Leader - HCCG
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David Farnsworth Executive Lead Nurse - HCCG Jill Sinclair Chief Financial Officer - HCCG Dr Richard Williams Specialist in Secondary Care – HCCG Stuart Hydon Contract Lead - CSU Lynne Renton Head of Safeguarding - HCCG Dr Alison Talbot-Smith Head of Clinical Outcomes and Service Transformation - HCCG Mike Emery Head of Business Delivery – HCCG Graham Taylor Lay member – Patient and Public Experience Susan Little Quality Assurance Lead - HCCG Emma Sneed Lead Infection Prevention and Control Specialist Nurse – HCCG Dr Saran Braybrook Pharmaceutical Advisor – HCCG Yvonne Coates Clinical Pharmacist – HCCG Alison Rogers Governance Pharmacist – HCCG Suzanne Penny Independent Chair – R&A – HCCG Greg Barriscale Performance & Information – CSU Marcus Farr Performance & Information Officer - CSU
Herefordshire CCG – Quality & Patient Safety Committee Page 7 of 7 Governing body – Item 14b
Governing Body
4 March 2014
SUBJECT Finance and Performance Committee
PRESENTED BY Jill Sinclair, Chief Finance Officer
PURPOSE OF THE REPORT
To update the Governing Body on the main issues discussed at the Finance and Performance Committee
KEY POINTS
The key areas and issues covered by the FPR committee:
The Committee were updated on the NHS Planning Process, and the main issues being raised within the proposed template submissions. A full update to the Governing Body is provided as part of 4 March 2014 agenda. It was highlighted that all staff had now completed mandatory training modules and IG training is completed and new employees have 3 months to undertake training, but further work was required to ensure all staff had personal development plans and clear work plans in place, though the majority of staff have these now in place. Sickness rates remain consistently low in January 2014. IG toolkit. IG toolkit is currently being prepared ready for submission by end of March 2014. IG Staff Handbook - Hereford CCG have taken the decision to implement a staff handbook from 2014/15 which will condense ALL previous IG procedures/policies into a single document and also address a number of issues that have been brought to our attention in relation to some of the technical solutions detailed within the procedures. The IG handbook will be developed by the Information Governance Support Officer with the Governance Manager ensuring that the document is personalised and reflects the working practices of the organisation. To enable this work to be done we ask that the current Information Governance Procedures are extended until August 2014 to allow appropriate amendments to be made and any changes in the next version of the toolkit (due out in June 2014) to be reflected. Membership of FPR – Confirmed membership of Committee to update the Terms of Reference (TOR). The Finance report for Month 10 was presented. A full update to the Governing Body will be provided as part of the Month 10 finance report.
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Governing body – Item 14b
Update on Accommodation. Options have been narrowed to 3 potential properties in Hereford. PropCo are supporting our work and will ensure a business case and project plan for the move are put in place. Area Team will sign off the business case. Decision has to be made by end of March. Chief Officer has been delegated responsibility. Contract Update – We intend to finalise contacts with WVT and 2gether by 28th February 2014 but due diligence and further conversations are to be undertaken. Integrated Equipment Store (ICES) is jointly commissioned with Herefordshire Council through a section 75 agreement. - ICES is currently provided by Herefordshire Council as an interim measure since the dissolution of their section 75 agreement with Wye Valley NHS Trust (WVT). Herefordshire Council is the lead commissioner under the s75 agreement and has led work to identify a new provider for the equipment store through a competitive tender- that provider is NRS Ltd and will be the provider of ICES from 1st April 2014; - Herefordshire Council have given notice to the CCG that they no longer wish the budget for ICES to be pooled instead moving to separate but aligned budgets; - ICES will continue to be joint commissioned under the s75 agreement; - Under the pooled budget the costs of the equipment store were split 50:50 between health and local authority funds. From 1st April there will be work to identify an accurate funding responsibility for equipment issued; - The work leads to a financial risk for HCCG as other regions with integrated equipment stores see health picking up a greater share of the total costs - WVT has an anomalous role as a provider, funding 20% of ICES costs.
RECOMMENDATION TO THE COMMITTEE
The Governing Body is asked to note the following:
ICES new funding arrangements Accommodation decision to be approved by Chief Officer by end of March 2014 Finance Risk Register to be reviewed Contracts to be completed 28th February – on track
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Governing body – Item 14b
POLICIES AGREED
IG Handbook programme of work and integration to ‘one staff handbook’
ATTACHMENTS (if appropriate)
Finance and Performance minutes dated January 2014
CONTEXT & IMPLICATIONS
Financial Statutory Financial Duties
Department of Health Guidance
Legal Health and Social Care Act 2012
Risk and Assurance All key risks are identified and mitigating actions (Risk Register/BAF) are recorded and managed in line with the organisations risk management policy
HR/Personnel As above
Equality & Diversity Equality Impact Assessments are undertaken on all projects and programmes, and ensuring the involvement of vulnerable groups in the CCG work will be part of the groups work
Strategic Objectives Supports delivery of all strategic objectives
Healthcare/National Policy Health and Social Care Act 2012
(e.g. CQC/Annual Health Check)
Partners/Other Directorates Herefordshire Council
NHS England
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Governing body – Item 14b
Health and Wellbeing Board
Carbon Impact/Sustainability n/a
Other Significant Issues n/a
GOVERNANCE
Process/Committee approval n/a with date(s) (as appropriate)
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FINANCE AND PERFORMANCE COMMITTEE
Tuesday 28 January 2014 – 9.30 – 11.00am Room 14a Brockington, Hafod Road, Hereford, HR1 1SH
MINUTES
Agenda Item
1. Welcome and Introductions
Present: JS – Jill Sinclair, Chief Finance Officer ME -Mike Emery, Head of Business Delivery DF – David Farnsworth, Executive Lead SH – Stuart Hydon, CSU Contracts Lead MF – Marcus Farr, Performance and Information Officer
2. Apologies for absence
Apologies were received from Adrian Griffiths and Fiona Nikitik.
JS advised that she will be meeting with Richard Kippax who has shown an interest in taking over the chair from Dr Andy Black. There is also a requirement for a Lay Member and an external Lay Member for the Committee.
ACTION ME to take forward
3. Minutes of the last meeting
Minutes of the last meeting dated 17 December 2014 were considered for accuracy and agreed.
4. Declaration of Interest
There were no declarations of interest.
5. Actions from last meeting
Updated Action Log attached.
Item 5 Action Log 26 November 2013.doc
6. Performance Reporting
Performance and Assurance Report
1
Contract and Activity Update
MF gave an update on the current position; the individual domain ratings are largely unchanged since last month with performance against the NHS Constitution being red rated. The last domain assessing organisation. There are key areas where current performance is off track. Development will remain amber green until all the authorisation conditions are lifted. Summary of current
The MRU is opening on 30 January. A Press Release will be sent out and sent to WVT.
ACTION ME to check
The following was also highlighted:
62 day cancer – there are pressures on waiting times. The Governing Body have raised issues and need clarity on what plans are in place.
ACTION SH to speak to WVT
A decision on quality issues need to be raised a needs to be sent to DF and ME to give assurance.
ACTION MF to do a summary for SH
ACTION Fines - SH to follow up – MF to ask Greg Barriscale for details on the Gloucester fines and give to SH
7. CSU Performance Update
SH gave an update on the provider KPI performance and provide contractual performance, providing highlights for further action on the Performance Report and the following was noted:
The Performance Report gives monthly updates
KPIs are performing, however there were concerns around communications and bi functions but are now back to satisfactory. ME received a call on Friday to advise that KPI was rated 7. The CSU here are moving to work the Hereford way.
A development session has been set up in March 2014, the CSU will be invited to discuss and update the team.
8. NHS Planning Update (review of plan on page, quality premium and key targets)
ME gave an update on the report which provides details of the CCGs Corporate and functional Risk Register and the following was also noted:
There are 4 or 5 issues still not agreed.
CCGs have now been provided with initial guidance on the expectations for the planning around 13/14 and beyond.
Completion of a two year operational plan template including finance templates to be submitted to the NHS Area Team by the 31 January 2014.
2
ACTION ME ring Steve Jarmin Davies
ACTION JS to ring David Williams
Push better care fund.
Investment in paramedics.
CDIF – waiting to be published nationally.
Work with WVT on their processes.
If GP surgeries open 7 days what impact would it have on the A&E department.
9. Finance Monthly Update and Report Month 9
Update on WVT Cash PBR Road Testing Year End Planning Budget Setting
JS gave an update on the Month 9 Finance Report and the following was noted:
We are on track to deliver year end.
WVT trust cash £3m.
PBR Road Testing this is linked to planning.
Year End Planning – The Financial Plan Year End Timetable to Audit Committee which was discussed with External Audit. JS advised that they need Rob Pinches to be available for year end, as part of the team as Louise Nunn will be leaving at the end of February 2014.
Budget Setting - the draft budgets will be out mid-February.
Area team template update on contracts, Marcia Pert has sent this to JS who will forward on.
10. Risk Registers Corporate Finance OD & Governance
To ensure that the two registers are reviewed at this Committee. JS will update the Finance Risk Register as the Auditors have asked us to do this.
Deep Dive for audit. Any comments back to ME please.
ACTION ME to bring updated Risk Registers back to the next meeting
3
11. Workforce and HR Report
The spread sheet provides us where we are with staff in post. The sickness recorded is up to the end of December 2013. It shows a positive1%, but some sickness in December has not been recorded, once updated it should stay under 2%.
The Staff Survey shows that staff are feeling under pressure. The staff structure will be reviewed when the new CO is in post.
ACTION: ME to look into appointing an Urgent Care Post
ACTION: ME to take to SMT updated record of all staff sickness and annual leave
12. Policy Update Conflicts of Interest
The Conflict of Interest was approved at the meeting.
13. Accommodation – options appraisal
ME gave a verbal update and advised that we have not received the report from DTZ and Propco. It was suggested that when we receive the report that it is sent to members for review and to bring a verbal update to the next Governing Body. A decision on the property needs to be made by the end of February 2014. Jo Whitehead will view the two properties that we are interested in.
14. Forward Planning
To send out key dates to the Chair of Committees and to arrange for meetings to fall on Tuesdays or Thursdays. This meeting will be moved to afternoons in the future. Working through March proposed plan.
15. Any Other Business
Munish Bhalla is joining the CSU tomorrow for a week he has been brought in to cover planning.
Neil Hamer has been appointed for a joint post around planning. The monies have been allocated from Area Team
Appointing Contractors needs to be more structured around process especially for GPs.
ACTION: ME to clarify processes around the policy for contractors
16. Key Meeting Messages for Governing Body
Dates of next meetings:
Date Time Room Tuesday 25th February 2014 09:30 – 11:340 14a Brockington th Tuesday 25 March 2014 09:30 – 11:30 14a Brockington
Distribution list:
Membership:
GP Lead for Finance and Performance Vacant
Chief Officer Vacant
Chief Finance Officer Jill Sinclair
Deputy Chief Finance Officer Louise Nunn
CSU Contracts Lead Stuart Hydon
Head of Commercial Development Adrian Griffiths
Head of Business Delivery Mike Emery
Board Nurse (or nominated Deputy) David Farnsworth
Practice Manager Lead Fiona Nikitik
5
Governing Body – Item14c
Communications & Involvement Working Group th Thursday 30 January 2014 1300 – 1500 22a Brockington, 35 Hafod Road, Hereford, HR1 1SH
Minutes
Agenda Item
1. Welcome and Introductions Euan McPherson David Farnsworth Mike Emery Diane Jones Lynne Renton Fiona Nikitik Paul Honeghan Jacinta Meighan-Davies Maria Hardy Helen Hancock 2. Apologies Susan Little, Alex Fitzpatrick, Rebecca Haywood-Tibbetts 3. Minutes of the last meeting The minutes of the last meeting were approved 4. Actions To review the on-going actions from previous meetings
C&I Action Log November 2013.doc
Action: PH to include action plan with RAG ratings in future meetings.
5. Urgent Care Consultation Feedback MH took the Committee through the reports as included within the agenda advising the Committee that they are now working towards re-contracting for urgent care focussing on outcomes and not activity. The communications team have proposed three questions which MH will circulate for comments. Action: MH to circulate three proposed questions from communications team for comment. Three workshops have been set up to support dialogue and discussion. MH explained that she has been discussing with EM work that is being done to ensure that work is not duplicated. It was agreed that there was a need for a central repository. 6. Patient Engagement Policy The group reviewed this policy. DF advised that ‘Board’ should be amended to ‘Governing Body’. Subject to this change, this policy was agreed. Action: Patient Engagement Policy to go to QPS for sign off. 7. Patient Domains DF said that this document needs more analysis. MH advised that there is a quality assurance
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issue of data that has been entered into datix. Recently there was training on the system where they look at complaints. When they drilled down further they realised that these were actually compliments. SL has been informed of the issues and is looking at this further. The patient domains report needs refining with a revised version to come back to the next meeting. Action: Revised patient domains report to come to March Communications & Involvement meeting. 8. Voice of the Child LR advised that the voice of the child is an HSCB priority for the next year. WVT have an action plan looking at how they will develop this and CCG will have a CQUIN with WVT and 2G for this. BHT has met with HVOSS who have a youth group who are willing to meet with us to say how the voice of the child can be captured. An action plan will be developed from the first meeting of the Task and Finish Group chaired by DJ, and this can then be shared back at next Communications & Involvement meeting. The CCG need to report quarterly to HSCB. For the 1st quarter, HSCB have asked WVT to provide focus groups to look across acute and community to feedback the child’s view of the services that they have received. RHT is meeting with JB to see how we capture the voice of the child with disabilities. Other children that need to be included are SEN children and pupil premium children. 9. Diabetes Patient Held Record JMD advised the Committee that the diabetes patient held record had been launched and continues to be rolled out across primary care. The report brought to this meeting is the 6 month review. The survey was sent to all practices to practice nurse leads who support diabetes clinics. There was feedback from 8 nurses due to high workloads. Of these, the booklet is being disseminated to about 50% of patients and their registers and patients feel that it’s useful. Feedback is particularly positive regarding the ‘How is my body doing’ section. Practice nurses also like this section and feel it fits in well with clinical processes. Every nurse said that they would like to have more time to spend on personalised care planning. Promotion and education events continue. A discussion was held around where this can be promoted further. Action: PH to promote diabetes patient held record on the members newsletter, GP newsletter, internal newsletter and the CCG website as a good news story. The Group were advised that KB is leading on personalised care planning across all conditions so this work has linked in with that. Action: Report to come to Communications & Involvement regarding the process the work on diabetes patient held record followed and learning that can be taken from this. 10. Template Approval PH showed the Group the templates and advised that he would circulate these to the Group for comments. The Group agreed that all photos need to be local Hereford scenes and people. A guideline booklet is to be produced outlining what can and can’t be used within these templates. Action: PH to circulate templates for feedback. 11. Staff Survey HH advised the Group that there was a good response of 27 people (78% response rate) to the staff survey. Feedback on training is good, bullying and harassment in nil. 33% report to be ‘very stressed’ and people are saying that they aren’t being asked to use their skills. PDP’s are low so this needs to be improved. Recognition needs to be looked at so PH has been tasked to look at this. 44% do 5+ hours a week extra and 22% do 11+ hours extra work a week. HH advised that a full report will come back to Communications & Involvement with an action plan in February. Action: HH to bring full report and action plan for staff survey to February meeting. DJ asked for assurance that key issues that are concerning will be tacked. JW and SMT to be informed of staff survey results to inform the action plan. Action: Update from staff survey results to be given to SMT and JW to develop action plan to tackle key issues. 12. Update of Protocols (HealthWatch & Compact) ME gave an overview of Compact that has been developed within Herefordshire advising that there is nothing controversial within the document. The Group agreed to support Compact. This is to go to Governing Body in March for ratification. It was agreed it’s important that when this
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goes to Governing Body, agreement also needs to be made to resource the commitment to a way of working with the 3rd sector and to attending meetings. Action: Compact to go to Governing Body in March for ratification. Ensure understanding at Governing Body of resource needed and commitment to attend meetings for this. 13. North Staffordshire Feedback DJ gave an overview of the North Staffordshire Patient Congress Feedback. The evening was costly in time taken to feed this structure and wasn’t truly representative. There is a need to look at better ways of bringing groups together by using patient groups and third sector more creatively. A listening hub was suggested so that people can come in and put in their ideas. Also the opportunity for CCG Governing Body members to meet people such as a listening and sharing event. Could this be something that is twice a year or before the AGM. DJ advised that first a conversation needs to take place at SMT to decide what resource and commitment there is to set this up before we decide how we deal with this. Action: Discussion with JW and SMT to decide resource and commitment that can be made to set up a patient congress. LR suggested writing to Helen Coombes to ask if we can link into the Learning Disability Champion Board. Cllr Chappell is the lead on this so he could also be written to. Action: ME to map stakeholders that need to be written to regarding a Patient Congress. 14. Patient Leader Programme DJ gave the Group an overview of the Patient Leader Programme highlighting the need to develop potential patient leaders. There was a wide discussion about all the key work streams and activity that is currently being undertaken. The need for clarity around all these areas was identified to ensure that there was no duplication and that all activity was being captured and logged. Action: ME, PH, DF and EM to work on the wider engagement strategy and this will be an element of the task and finish group looking at the various strands of engagement work being undertaken at the moment. Action: Virtual Feedback on the Task and Finish group work to be given to members of the Communications Group in 6 weeks with a full report to come back to the March meeting. LR suggested that a piece of work is needed around engaging residential care and nursing homes. DF asked how we use existing patient networks and groups engaged with this. Action: ME to update communications plan and highlight what needs to be done next to move this forward to include engaging different groups such as residential care and nursing homes and existing patient networks. FN highlighted that there is a nursing home project for GP’s and this may be an opportunity to seek ideas and views. DJ advised that at a recent LAT event patient leaders even though trained, felt very intimidated. EM advised that a cultural shift is required and that joint training is required. 15. Equality & Diversity Update HH advised that an Equality and Diversity annual report has been drafted and is to be circulated to the Group for comment. There is a review scheduled for September. ME advised that the Governing Body needs to be sighted on this so will put together a report for the next Communications & Involvement meeting. Action: ME to produce Equality & Diversity update report for February Communications & Involvement meeting. HH advised that in future before any new work is started, an EIA needs to be completed. There will be training in March for this. 16. Primary Care Strategy FN advised the Group that the AT have a primary care strategy but we also have our own localised strategy. There is currently an action plan being produced from this that will go to STIG. ME advised that there needs to be a conversation regarding this with AW about a formal discussion at Governing Body. Action: FN to raise Primary Care Strategy with AW so that a formal discussion can go to Governing Body. It was suggested that as part of the development of the patient groups, every practice is encouraged to have a patient group explaining that when they have their annual visit, demonstration of this group may prove valuable.
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17. E-consultation Report JMD took the Group through the E-consultation report. There was a discussion regarding the address used on patient surveys as often, when they see the Staffordshire address, this puts patients off completing this. It was agreed that a local address does encourage people to complete surveys as they can identify with this as a local issue. People also still don’t recognise what the CCG is so needs to be localised as much as possible to encourage responses. The pilot finished in November. The concept is sound with positive clinician and patient feedback. The pilot has been undertaken at a pivotal time as NHSE sets out plans for revision of Choose and Book to support a single NHS electronic referral service (e-RS) which means possibly move the concept of e-consultation into the choose and book system. This would start by building on the pilot specialities first. Looking at a CQUIN for WVT and LIS for practices for this. DF informed the Group that the quality of patient feedback is good and asked where this sits to ensure we don’t lose sight of this feedback. DF advised that this goes into the patient experience reporting but the challenge is resource to help collate this. It was agreed that the GP newsletter needs to thank those practices that took part in the pilot and how much value their input has been. Action: PH to include a section in the next GP newsletter thanking those practices that took part in the e-consultation pilot. DJ confirmed that the Group endorsed the e- consultation pilot patient engagement activity and findings. 18. Communication & Engagement Update PH advised that he had updated the tactics and action update highlighting the following key areas: Membership Scheme – there are currently 205 members. Action: PH to look at membership per head of population for other areas to take an average of what good uptake of membership schemes is. FN advised that PPG’s are not being used enough. It was agreed that the newsletter needs to go to PPG’s, councillors and parishes. Action: PH to provide a virtual update to ME in 4 weeks regarding membership figures and newsletter to PPG’s, councillors and parishes. Patient Congress is on red. Action: LR to look into ways the voice of the child can be captured for patient congress. Datix – move to amber. Winter pressures – press release regarding this has gone out. DF flagged that urgent care working group earlier this week there was a discussion about public/media publicity bringing all discussions together between all sectors. Richard Caddy is looking at this. This can move to amber. Emergency Planning – Action: ME to discuss emergency planning with PH to strengthen and test strategies. A discussion was held around the need for child friendly PALS and complaints leaflets. Action: LR to ask Andy Churcher for the set of agreed symbols and diagrams that have been agreed for use in Herefordshire. LR to email these to PH to use to develop child and LD friendly patient leaflets. Action: PH to update Communications & Engagement template. 19. Any Other Business DJ advised the Group on the meeting with patient from St.Katherines Surgery who attended Governing Body. DJ suggested that all practices are emailed Governing Body meeting dates so that they can be displayed.
LR provided the Group an update on the serious case review that was published last week. HSCB led on any press interest on this.
LR advised that there was national press interest regarding a woman in the criminal justice system for poisoning her child. There may be some press interest around this. This is to be directed back to the police.
MH queried how we communicate to members of the public. Would it be helpful if we had a
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pictorial representation of what we do as a CCG that includes virtual wards etc. This can then be a tool to prompt dialogue with people. ME suggested we build on what was prepared for Sir David Nicholson’s visit. HH, ME and PH to look into this. Action: HH, ME and PH to develop a pictorial representation for the CCG possibly building on work that was prepared for Sir David Nicholson’s visit. 20. Key Meeting Messages for Board
Dates of next meetings:
Date Time Room
27th February 2014 13:00 – 15:00 14a Brockington 27TH March 2014 13:00 – 15:00 14a Brockington 24th April 2014 13:00 – 15:00 14a Brockington
Distribution list:
Diane Jones Mike Emery David Farnsworth Fiona Nikitik Helen Hancock Paul Honehgan Susan Little Jacinta Meighan-Davies Lynne Renton Paul Ryan
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CCG Governing body
Tuesday 4th March
SUBJECT Communications & Involvement
PRESENTED BY Di Jones, PPI Deputy Lay Member
PURPOSE OF THE REPORT
To provide the governing body with an overview of the various Communication & Involvement activities.
KEY POINTS
Background Identified that there is a considerable amount of work being undertaken on communication and engagement across several areas. E.g. Urgent Care, Diabetes, CAMHS, visits to PPGs. etc. Concern raised that there is no overarching database/repository for all this work and that it is likely that work could be replicated and other gaps not filled. It was decided that a Task and Fish Group be set up to look at how all this work is integrated. Feedback to Communications & Involvement working group in March. Work being undertaken to look at child friendly leaflets also ensuring that across partners we are all using the same symbols for other groups of patients. Identified that still no PH engagement in this group. Highlights of staff survey shared with Communications & Involvement Group, verbal feedback given, full report to next meeting with action plan.
Actions since last Communications and Engagement Working Group:
Discussions undertaken to look at the future model of support for Communications & Engagement and wider work on Patient Experience to ensure that the Communications and Engagement Working Groups focuses is on the strategic /partnership relationships. A model suggested involves our key partners and has been discussed by DJ
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Governing body – Item 14c
with Healthwatch, Local Authority and HVOSS informally. The proposal is that there is a separate CCG officer led working group which meets regularly to ensure that the key tasks ensuring the outcomes identified by the CCG strategy are met.
The CCG lead on the setting up of a Community Voice Forum chaired by the CCG Lay member, it would meet regularly This group would include HW, Local Authority – particularly Public Health, HVOSS, lead for Voice of the Child, representatives from PPGs and any other identified stakeholders for specific pieces of work. This would also mitigate the lack of PH attendance at current Communications Working Group. Initial scoping meeting scheduled for 19th March 2014.
Using the principles of the Compact we would work together to ensure that when key strands of work are identified we will as partners look at where it would be beneficial to work together
Work on the Voice of the Child is progressing and using the principles outlined above a key meeting has just been undertaken looking at developing the role of Youth Health Champions. We hope that working with LA, HW and HVOSS that it is possible to develop a proposal for perhaps a Lottery bid.
RECOMMENDATION TO THE Governing Body
To agree with the Community Voice Forum led by CCG
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Governing body – Item 14c
CONTEXT & IMPLICATIONS
Financial Extent of communications and Involvement work limited by no dedicated budget to support activities.
Legal Health and Social Care Act 2008
Health and Social Care 2012
Children Act 1989, 2004
Mental Capacity Act 2005
Mental Health Act 1983, 2007
Risk and Assurance All key risks are identified and mitigating actions are (Risk Register/BAF) recorded and managed in line with the organisations risk management policy.
HR/Personnel
Equality & Diversity Equality Impact Assessments are undertaken on all key projects and programmes, ensuring the involvement of all hard to reach and vulnerable groups.
Strategic Objectives Underpins delivery of all strategic objectives
Healthcare/National Policy Everyone Counts and NHS Planning guidance and associated documents - Health and Social Care (e.g. CQC/Annual Health Act 2012. Check)
Partners/Other Directorates Herefordshire Council, Public Health, NHS England
Health and Wellbeing Board, Providers, voluntary organisations, Healthwatch, Stakeholders and patients
Carbon N/A Impact/Sustainability
Other Significant Issues N/A
GOVERNANCE
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Governing body – Item 14c
Process/Committee approval with date(s) (as Approved by Communications & Involvement Group appropriate) members by email - July 2013.
KEY ATTACHMENTS
Attachments Minutes from January 2014 Communications & Working Group attached.
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Governing body – Item 14e
Governing Body
th 4 March 2014
SUBJECT Bed Census
PRESENTED BY David Farnsworth, Executive Lead Nurse
PURPOSE OF THE REPORT
To provide the Governing Body with an overview of the Bed Census undertaken at WVT during December 2013.
KEY POINTS
This report highlights
1. A snap shot of bed usage across adult WVT inpatient settings on a single day; 2. An insight into the demographic profile of patients across all adult hospital inpatient beds; 3. An understanding of the numbers of inpatients that are still in hospital but could be discharged to alternative locations; 4. An understanding of the reasons why patients are not being treated in, or discharged to, alternative locations; 5. Work underway to inform improvement strategies and prioritise development/innovation opportunities that support patient flow
RECOMMENDATION TO THE COMMITTEE
The Governing Body is asked to:
Note and discuss the bed census, and identify key priorities to inform the work of the Urgent Care Working Group
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Governing body – Item 14e
CONTEXT & IMPLICATIONS
Financial
Legal Health & Social Care act 2008
Risk and Assurance Includes updates on actions to mitigate risk (Risk Register/BAF)
HR/Personnel Limited resources to support urgent care operational programme
Equality & Diversity None identified
Strategic Objectives Meets the strategic objectives in relation to Governance and Quality
Healthcare/National Policy Reflects NHSE guidance
(e.g. CQC/Annual Health Check)
Partners/Other Directorates Across Health & Social Care programme
Carbon Impact/Sustainability N/A
Other Significant Issues None identified
GOVERNANCE
Process/Committee approval with date(s) (as appropriate)
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“If something else was available (what) , would this patient be in hospital today?”
Wye Valley Trust Inpatient Bed Census Tuesday December 3rd 2013 Introduction Purpose 1. To provide a snap shot of bed usage across adult WVT inpatient settings on a single day;
2. To provide an insight into the demographic profile of patients across all adult hospital inpatient beds;
3. To gain an understanding of the numbers of inpatients that are still in hospital but could be discharged to alternative locations;
4. To gain an understanding of the reasons why patients are not being treated in, or discharged to, alternative locations;
5. Review census data to understand impact of service developments since the last bed census;
6. To inform improvement strategies and prioritise development/innovation opportunities that support patient flow.
Scope – WVT adult inpatient wards
County Hospital Community Sites Frome (35) - AAU Bromyard (18) Arrow (25) - medical Leominster (26) Leadon (20) - surgical Hillside (22) Lugg (30) - medical Ross (32) Monnow (18) - surgical Redbrook (24) - surgical orthopaedic Teme (20) – surgical orthopaedic Wye (26) - medical/stroke County Hospital Beds: 198 Community Hospital Beds: 98 TOTAL: 296
Methodology
• Single day data capture (Tuesday 03/12/13); • 4 x MDT teams visiting wards between 09:00 and 20:00hrs; • Census completed through review of clinical notes and discussion with inpatient care teams; • Patient level information gathered on: oDemographics oPre-admission oInpatient Care oDiagnostics oAftercare oDischarge oOpportunities MDT Census Teams
TEAM A TEAM B TEAM C TEAM D Bromyard Hillside Frome Teme Leominster Ross Leadon Wye Monnow Redbrook Lugg Arrow
Jane Ansell Jan Reynolds Liz Towel Claire Old Liz O’Hara Alison Talbot Smith Tracy Hill Verena Flatt Linda Howells Jess Lambert Catherine Rosie Dianne Kent Jan Lawton Claire Carlsen Fiona Blackwell Sue Vaughan Tracy Scott Sandra Mahner Kathryn Pell Lynsey Innes
MDT Representation from: Nursing, Medical, Occupational Therapy, Physiotherapy, Administration, Pharmacy, Management, Adult Social Care, and CCG. Information and census development supported by: Nick Exon and Ben Knight Data Capture
Location Bed Capacity No of Patients Reviewed Bromyard 18 18 100% Leominster 26 24 92% Hillside 22 19 86% Ross 32 28 87% Frome 35 31 88% Leadon 20 20 100% Monnow 18 18 100% Lugg 30 22 73% Teme 20 17 85% Wye 26 25 96% Redbrook 24 22 91% Arrow 25 25 100% Total 296 269 90%
• Due to time availability not all patients were reviewed • Medical overspill patients (e.g. in day case) and women's health were not reviewed Analysis Demographics – Gender by ward
25 269 patients: 150- Female (55%) 107 - Male (40%) 12 - Not recorded (5%) 20
15
F M 10 Not recorded
5
0 Demographics – Age Profile by Gender
• 269 patients were reviewed • 78% (211 patients) are 65yrs + • Of those patients who are 65yrs +, 65% (127 patients) are female
10
9
8 F M
7
6
5
4
3
2
1
0
81 89 97 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 83 85 87 91 93 95 99
101 103 Pre-admission
Does the patient live alone (Y/N) GENDER Not Grand Total F M recorded N 142 73 65 4 Y 111 70 35 6 UNKNOWN/NOT RECORDED 16 7 7 2 Grand Total 269 150 107 12
• 41% of the inpatient population are recorded as living alone. • Of the 111 patients living alone, 87% are over the age of 65 • Twice as many females than males are recorded as living on their own • 71% over the age of 65, living alone are female
(National Census (2011) reports number of 1 persons households in Herefordshire as 12.4% One person households for people over 65 = 6.2%)
Admission route
Transfer from other Total hosp (not A&E) UNKNOWN 3% 7% emergency A&E 0% Emergency - Clinic Elective - Waiting 2% List 13% Emergency - GP 9%
Emergency - Local A&E 66%
Over two thirds of adults are entering WVT inpatient wards via emergency flows May require further GP Surgery Bed Usage exploration
Registered Patients % Herefordshire Herefordshire Practice Name (July 2012) population Beds used % beds used Moorfield House Surgery 14628 8.2% 19 9.0% Cantilupe Surgery 11861 6.6% 11 5.2% Sarum House Surgery 11043 6.2% 13 6.2% Alton Street Surgery 10611 5.9% 7 3.3% Wargrave House 9555 5.4% 16 7.6% Nunwell Surgery 9360 5.2% 13 6.2% Westfield Walk Surgery 9261 5.2% 11 5.2% King Street Surgery 8901 5.0% 13 6.2% The Marches Surgery 8734 4.9% 12 5.7% St. Katherine's Surgery 8726 4.9% 8 3.8% The Meads 8337 4.7% 13 6.2% Pendeen Surgery 7929 4.4% 12 5.7% Belmont Medical Centre 7908 4.4% 5 2.4% The Mortimer Medical Practice 7696 4.3% 10 4.8% Greyfriars Surgery 6024 3.4% 9 4.3% Golden Valley Practice 5880 3.3% 4 1.9% Quay House Medical Centre 5591 3.1% 6 2.9% Weobley Surgery 5353 3.0% 8 3.8% Fownhope Medical Centre 4796 2.7% 1 0.5% Much Birch Surgery 4696 2.6% 5 2.4% Ledbury Market Surgery 4494 2.5% 5 2.4% Kingstone Surgery 4253 2.4% 7 3.3% Colwall Surgery 2934 1.6% 2 1.0% 178571 210 (59 patients were registered with OOC GPs or practice not recorded) Community Inpatients & GP Surgery
Community Site GP Practice Bromyard Hillside Leominster Ross Grand Total MOORFIELD HOUSE SURGERY, HEREFORD 3 3 1 5 12 WARGRAVE HOUSE SURGERY, HEREFORD 4 1 3 8 NUNWELL SURGERY, BROMYARD 5 1 1 7 THE MARCHES SURGERY, LEOMINSTER 1 5 6 THE HEALTH CENTRE, LEOMINSTER 2 3 1 6 THE MORTIMER MEDICAL PRAC, KINGSLAND, LEOMINSTER 3 2 5 CANTILUPE SURGERY, HEREFORD 2 1 2 5 THE SURGERY, KINGTON 1 1 2 4 THE SURGERY, WEOBLEY 1 2 1 4 PENDEEN SURGERY, ROSS-ON-WYE 4 4 22A KING STREET, HEREFORD 2 2 4 SARUM HOUSE SURGERY, HEREFORD 2 1 1 4 ST.KATHERINES SURGERY, LEDBURY 1 2 3 GREYFRIARS SURGERY, HEREFORD 2 1 3 ALTON STREET SURGERY, ROSS-ON-WYE 3 3 THE SURGERY, HEREFORD 2 1 3 BELMONT MEDICAL CENTRE, BELMONT, HEREFORD 1 1 1 3 THE SURGERY, HEREFORDSHIRE 1 1 2 Grand Total 18 18 24 26 86 Inpatient care
Does the patient require clinical input Acute Community Grand Total N 7 18 25 Y 144 70 214 UNKNOWN/NOT RECORDED 29 1 30 Grand Total 180 89 269
• Nearly 10% of patients were recorded as not requiring clinical input • 5 of these 25 patients were recorded as a delayed discharge • Due to the free text nature of this part of the census, it is difficult to carry out further analysis
Expected date of discharge
Is there an EDD in place Acute Community Grand Total N 49 7 56 Y 129 81 210 UNKNOWN/NOT RECORDED 2 1 3 Grand Total 180 89 269 • 78% had a recorded EDD, but……..
Setting No. of Pts. with No. of Pts. % of Pts. EDD unaware of their unaware of their EDD EDD
Community 81 14 17%
Acute 129 31 24%
• Nearly a quarter of patients who had an EDD in the County Hospital were unaware of this date. • EDDs were typically displayed on the ward boards, but not in notes or at patients bedside Delayed Discharge
Is this person a delayed discharge? (Y/N) Grand Acute Community Total N 110 44 154 Y 18 12 30 UNKNOWN/NOT RECORDED 52 33 85 Grand Total 180 89 269
• 11% of inpatients were recorded as a delayed discharge • Combination of health and social care reasons including • Patient/family choice • Care home/nursing home placement • Care package in own home • Community adaptations • Community hospital bed
Aftercare
Does this patient require additional Social Care intervention (Y or N)
N 112 Y 108 UNKNOWN/NOT RECORDED 49 Grand Total 269
• 40% of the 269 inpatients were identified as needing additional Social Care Intervention after discharge. Of those 108 patients: • 87% are 65yrs + • 65% live alone • 50% were not receiving any formal support prior to admission
• Further analysis identified that 70% of the community hospital inpatients were recorded as needing additional Social Care Intervention after discharge.
Opportunities
Common themes identified as barriers to enabling people to go home sooner included:
SYSTEM CAPACITY OTHER • Awaiting specialty • Awaiting alternative • Transfer to independent review/assessment bed e.g. community provider e.g. nursing • Awaiting diagnostic hospital home tests or review of • Home treatment e.g. • Family Choice results virtual wards • Allowing “housebound • Onerous referral • Interim care package at home” processes & setting up • Diagnostics at home packages of care • Alternative care pathways e.g. CAU, VW, rapid access to OPC
Additional observations
Excellent standards of care and high levels of clinical commitment were seen across all ward settings
• Too much documentation - onerous and complex, often left to nursing staff to complete • Lots of admission information - not much on discharge • Information in different formats and locations – like putting together pieces of a jigsaw • Variation in processes between wards • Excessive paperwork to refer to other services • Ownership and understanding of EDD • Custom and practice of admitting patients to CHs rather than straight home • Lack of communication with GPs & pre-admission care team • Risk averse – “Housebound in Hospital vs. Housebound at Home ”
Summary Prior to admission
Female
Over the Emergencies age of 65
Not being Living alone supported Inpatient care
High Quality Care
Communication Traditional Use with Community of Beds Providers
Variation in Copious Processes Documentation Coming out of hospital
Discharge Planning
Awaiting Needing impact of new additional developments support
Capacity of Services Wye Valley Trust Urgent Care Programme Overview
• System wide review of non elective patient flow • Multi stakeholder Urgent Care Summit held to develop programme • Programme approved by Trust Executive Group • 6 work streams identified • Projects owned by senior clinical leaders & managers
Urgent Care Programme
Acute Assessment & Ambulatory Care
Emergency Sick Speciality Department Stream Redesign
Improving Flow and Discharge
Bed Short Stay Considerations Stream
Improving Discharge Governing body – Item 14g
CCG Governing Body
4th March 2014
SUBJECT Audit and Assurance Committee Update
PRESENTED BY Christine Daws, Lay Member Audit and Assurance
PURPOSE OF THE REPORT
To update the Governing Body on the Audit and Assurance meeting that took place on 21st January 2014
KEY POINTS
The key areas and issues covered by the Audit Committee at its meeting on 21st January 2014:
An update on the latest guidance around PCT legacy issues was given by the CFO It was noted that the DOH had currently concluded that accounting balances would not transfer to CCGs and would be held by NHS England . Any payments made in 2013/14 that related to 2012/13 would be charged to NHS England.
The Internal Audit Progress Report and associated papers were presented. Financial Reporting, Health Care Contracting, and Quality Review Internal Audit Reports were presented with significant assurance. The Financial Systems Audit was concluded as full assurance.
The Chair raised her concerns that the Audit Committee had not been informed of the new provider of Counter Fraud services. The CSU provided the Counter Fraud service for the CCG and had gone out to tender as a result of the previous post holder leaving. CW Audit Services had been awarded the work and presented the close down report and the Progress Report to date.
The External Audit Progress Report was presented which included an update on national audit issues. The Audit Plan for 2013/14 was presented, key financial in year risks were discussed and it was noted that the CCG were close to agreeing a year end settlement with Wye Valley Trust. The VFM approach for the first year of the CCG was discussed.
The Corporate Risk Register was presented and discussed. It was noted that the Audit Committee would undertake a deep dive on Business Delivery risks at its next meeting.
The proposed Board Assurance Framework (BAF) was presented. The Committee made a number of comments for inclusion for future versions of the BAF. It was agreed that Internal Audit’s review of governance would include a review of the BAF and reporting mechanisms
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Governing body – Item 14g
The Gifts and Hospitality Register was presented. The Committee asked about the propriety of a drugs company sponsoring GP Parliament meetings. It was agreed that this would be reviewed and reported back at the next audit meeting.
The updated Whistleblowing policy was presented. It was requested that this policy be reviewed to ensure that telephone numbers were accurately reflected.
The Information Governance update was presented and an update on a current legal issue was discussed.
The updated Conflicts of Interest Policy was presented and approved by the Committee.
A verbal update on the Authorisation Risks was presented by the Interim Chief Operating Officer. Progress made was noted by the Committee.
The requested amendments to the Scheme of Reservation and Delegation was presented by the Deputy Chief Finance Officer and agreed by the Committee.
The Annual Accounts timetable for 2013/14 was presented with key dates highlighted. It was noted that there was a delay in receiving the NHS England ‘Annual Reporting Manual’. It was noted that the Annual Accounts briefing together with the draft Annual report would be presented to a special briefing meeting on 17th April.
The Committee received an update on the evaluation of the MSK project, which had been discussed at Governing Body and who had decided to bring the pilot to a close.
The Committee, in its confidential session, agreed to the recommendation from its subcommittee to appoint Baker Tilley as the new Internal Auditors to the CCG from April 1 2014.
POLICIES AGREED
The ratified policies for conflict of Interest and Whistleblowing were approved by the Audit and Assurance Committee.
RECOMMENDATION TO THE COMMITTEE
The Committee is asked to note the report and the decision to appoint Baker Tilley as Internal Auditors to the CCG from April 1 2014.
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Governing body – Item 14g
CONTEXT & IMPLICATIONS
Financial Statutory Financial Duties
Department of Health Guidance
Legal Health and Social Care Act 2012
Risk and Assurance All key risks are identified and mitigating actions are (Risk Register/BAF) recorded and managed in line with the organisations Risk Management Policy
HR/Personnel As above
Equality & Diversity Equality Impact Assessments are undertaken on all projects and programmes, and ensuring the involvement of vulnerable groups in the CCG work will be part of the groups work
Strategic Objectives Supports delivery of all strategic objectives
Healthcare/National Policy Health and Social Care Act 2012
(e.g. CQC/Annual Health Check)
Partners/Other Directorates Herefordshire Council
NHS England
Health and Wellbeing Board
Carbon Impact/Sustainability n/a
Other Significant Issues n/a
GOVERNANCE
Process/Committee approval Appointment of Internal Auditors from April 1 2014 with date(s) (as appropriate)
Herefordshire CCG – AUDIT & ASSURANCE UPDATE Page 3 of 3