NHS Redbridge Clinical Commissioning Group Governing Body Meeting

NHS Redbridge Clinical Commissioning Group Governing Body meeting

20 July 2017 1.30pm Boardrooms, Becketts House, Ilford, IG1 2QX

Item Time Lead director Attached, verbal or to follow 1.0 Welcome, introductions and apologies 1.30 Chair 1.1 Declaration of conflicts of interest Attached 1.2 Minutes of the meeting held on 26 May & 29 June Attached 2017 Attached 1.3 Matters/actions arising

2.0 Chair and chief officer reports 2.1 Chair’s report 1.40 Chair Attached 2.2 Chief officer’s report 1.45 CB Attached 2.3 Patient engagement report 1.50 KA Attached

3.0 Governing body assurance 3.1 Governing body risk assurance framework report 1.55 LM Attached 4.0 Corporate strategy and planning 4.1 Corporate objectives 2.05 CB Attached

5.0 Service transformation and development 5.1 Urgent care case for change 2.15 LM Attached

6.0 Quality and performance 6.1 Integrated contract management report 2.25 TT Attached 6.2 Finance report 2.35 TT Attached 6.3 Quality report 2.45 JH Attached 7.0 Development/governance 7.1 Finance and Delivery committee – revised terms of 2.55 MP Attached reference 7.2 Finance & delivery committee chair’s report 3.00 KP Attached 7.3 Audit & governance committee chair’s report 3.05 KP Attached 7.4 Work of the FRPB and Financial Recovery 3.10 TT Attached Programme Progress Summary 7.5 Minutes of sub – committees and relevant fora: 3.15 Attached • Primary care transformation programme board • Joint executive committee • Patient engagement forum

8.0 AOB 3.20

9.0 Questions from the public 3.25

10.0 Date of next meeting – 28 September 2017 3.30

Glossary of terms and abbreviations

Term Explanation

AO Accountable Officer

ACS Accountable Care System

ADL Activities of Daily Living

APC Area Prescribing Committee

ASH Accredited Safe Haven

BCF Better Care Fund

BHR Barking and Dagenham, Havering and Redbridge

BHRUT Barking, Havering and Redbridge University Trust

BPPC Better Payment Practice Code

CAPS Clinical Application Services

CCG Clinical Commissioning Group

CCS Complex Care Service

CDOP Child Death Overview Panel

CEO Chief Executive Officer

CFO Chief Finance Officer

CHC Continuing Healthcare

CHS Community Health Services

CHSCS Community Health and Social Care Services

CIL Community Infrastructure Levies

CO Chief Officer

COO Chief Operating Officer

CQC Care Quality Commission

CQRM Clinical Quality Review Meeting

CQUIN Commissioning for Quality and Innovation

CSU Commissioning Support Unit

CTT Community Treatment Team

CVS Council of Voluntary Services

CYPP Children and Young Person Plan

DI Discovery Interview

DOH Department of Health

DTOC Delayed Transfer of Care

ECG Electrocardiogram

EHC Education, Health and Care

ELHCPB East London Health and Care Partnership Board

EMT Executive Management Team

EoI Expression of Interest

EOL End of Life Care

FNP Family Nurse Partnership

FRPB Financial Recovery Programme Board

FRPDM Financial Recovery, Planning, Delivery and Monitoring

FT Foundation Trust

FYE Full Year Effect

GBAF Governance Board Assurance Framework

GP General Practitioner

H4NEL Health for North East London

HCAIs Healthcare Associated Infections

HE NCEL Health Education North Central and East London

HSC Health Scrutiny Committee

HWBB Health & Wellbeing Board

IAPT Improving Access to Psychological Therapies

ICPB Integrated Care Partnership Board

ICM Integrated Case Management

ICSG Integrated Care Joint Health and Social Care Steering Group

IFR Individual Funding Request

IRS Intensive Rehabilitation Service

IST Intensive Support Team

JAD Joint Assessment and Discharge Service

JCB Joint Commissioning Board

JEC Joint Executive Committee

JHWS Joint Health & Wellbeing Strategy

JSNA Joint Strategic Needs Assessment

KGH King George Hospital

KPIs Key Performance Indicators

LAC Looked After Children

LAS London Ambulance Service

LETB Local Education and Training Boards

LMCs Local Medical Committees

LPC Local Pharmaceutical Committee

LSCB Local Safeguarding Children’s Board

LTC Long Term Conditions

MASH Multiagency Safeguarding Assessment Hub

MLU Mid-wife Led Unit

MSRB Maternity Systems Readiness Board

NEL North East London

NELCSU North East London Commissioning Support Unit

NELFT North East London Foundation Trust

NHS National Health Service

NHSE NHS England

NICE National Institute for Health and Care Excellence

OFSTED Office for Standards in Education, Children’s Services and Skills

OD Organisation Development

ONEL Outer North East London

PALS Patient Advice and Liaison Service

PEFs Patient Engagement Forums

PELC Partnership of East London Cooperatives

PMCF Prime Minister’s Challenge Fund

PMO Project Management Office

POD Point of Delivery

POLCV Procedures of Limited Clinical Value

PPGs Patient Participation Groups

PSED Public Sector Equality Duty

PTL Patient Tracking List

QIPP Quality, Innovation, Productivity and Prevention

RAG Red. Amber, Green

RTT Referral To Treatment

SAB Safeguarding Adults Board

SCB Safeguarding Children’s Board

SCN Strategic Clinical Network

SDPB System Delivery Programme Board

STP Sustainability and Transformation Plan

TDA Trust Development Agency

TSCL The Transforming Services – Changing Lives

UCC Urgent Care Centre

UCL University College London

UCLP University College London Partners

UEC Urgent and Emergency Care

UTI Urinary Tract Infection

VFM Value for Money

WELC Waltham Forest, East London and City

WICs Walk in Centres

YTD Year to Date

Declaration of governing body members

Last updated: May 2017

Name Role Organisation Nature of interest Amendment and date

Dr Anil Mehta Chair Fullwell Cross Medical GP Partner Centre

Metropolitan Police Forensic Medical Examiner

The cleaning company Owner - Sister in law

NHS England (Feb 2015) GP Appraiser

Healthbridge Direct (from Shareholder September 2014)

Fouress Enterprises Ltd Director

Dr Sarah Heyes Clinical director The Shrubberies Medical GP Partner/Principal Centre

Healthbridge Direct Shareholder (from September 2014)

Dr Muhammad Clinical director Forest Edge practice, GP Partner Tahir Hainault Health Centre

7 Name Role Organisation Nature of interest Amendment and date

Dagenham & Redbridge Medical adviser & club Football Club doctor

Redbridge local medical Member committee

Healthbridge Direct Shareholder (from September 2014)

Dr Mehul Clinical director Mathukia surgery GP Principal Mathukia Dr Chawla & Partners GP Partner from 1/5/16. Brother is a GP Principal

Valia Consultancy – Director/Owner/Shareholder Healthcare & research consultancy

PELC GP Locum

NOCLOR and NIHR GP research champion

Healthbridge Direct Share Holder (from September 2014)

Dr Shabana Ali Clinical director Southdene Surgery GP Partner/Principal. Daughter is receptionist/admin

Healthbridge Direct Shareholder. Daughter

8 Name Role Organisation Nature of interest Amendment and date

(from September 2014) works is receptionist/admin.

North East London GP with special interest in Foundation Trust cardiology

Avicenna Ltd Director. Husband is also a director

BMA Member

RCGP Member

NHSE GP appraiser (B&D CCG, Havering CCG)

Dr Syed Raza Clinical director Chadwell Heath surgery Salaried GP Redbridge Fairness Commission – removed Raza Syed Medical Ltd Director (June 2014) Jan 2017

Healthbridge Direct Employed at surgery that is (from September 2014) a shareholder. Employed as locum in the Hub.

Dr Jyoti Sood Clinical director Newbury Group Practice GP Partner (2003) Redbridge GP Alliance Federation – removed ESS Wanstead GPwSI – Diabetes & April 2017 Dermatology (2011)

Ealing Hospital NHS GPwSI – Diabetes & Trust Dermatology (2010)

9 Name Role Organisation Nature of interest Amendment and date

Soods Limited – Locum Director. Husband is a agency partner (2005)

NHS England GP appraiser (2003)

London Deanery GP trainer (2004)

Imperial College Undergraduate GP trainer (2011)

Communitas Clinics Provide minor surgery (Havering) (2013)

Redbridge LMC Member (Sept 2016)

Care Quality Special Advisor (Sept 2016) Commission (CQC)

Healthbridge Direct Shareholder (April 2017) Added April 2017

Dr Anita Bhatia Clinical director Southdene surgery GP partner

Healthbridge Direct Shareholder (Sept 2014)

Mychem Ltd Husband is owner/director of pharmacy – Mid Essex CCG

Phoenix Medics Ltd Brother is a director – freelance GP-services to

10 Name Role Organisation Nature of interest Amendment and date

NHS/private sector

Essex Local Prescribing Husband does remunerated Committee ad-hoc work

Dr Shujah Clinical director Castleton Road surgery GP Partner Added May 2017. Hameed Partners in Healthcare Director (1/2015) Locum GP at Castleton Rd – removed 24/5/17 Healthbridge Direct Locum GP (1/2015)

PELC Locum GP (1/2015)

BHR GP Solutions Locum GP (1/2016)

Ah-Fee Chan Secondary care North Middlesex Consultant in Anaesthetics consultant University Hospital NHS and Intensive Care Trust Medicine

Nadia Medical Services Director of the company Ltd (March 2015) providing consultant services at a range of private facilities in London where practice privileges are given

Charles Associate None None North Essex Partnership Beaumont Independent Lay Foundation Trust – Voting Member for removed 25/4/17 Audit Committee and 5

11 Name Role Organisation Nature of interest Amendment and date

Individual Funding Request Panel

Conor Burke Accountable officer None Your business works (not trading) - removed Jan 2017

Redbridge college – removed Jan 2017

Louise Mitchell Chief operating officer None None

Tom Travers Chief financial officer Royal Free Foundation Wife works in finance Trust department

Jacqui Himbury Nurse director None

Khalil Ali Lay member Dr Joseph’s GP practice, Family GP Collier Row, Romford

St Francis Hospice, Spouse is donor Havering

Cancer Research Spouse is a donor

Kash Pandya Lay member - Essex Ministry of Justice Lay Member (2010-18) Hillcroft College for Governance Advisory Committee women, Surbiton – removed May 2017. Her Majesty’s Inspector Associate Inspector (2011) 6

12 Name Role Organisation Nature of interest Amendment and date

of Constabulary Health & Safety Executive – removed Brentwood Citizen’s General advisor (2009) May 2017. Advice Bureau Berwin Leighton Paisner Barking and Dagenham Lay Member (BLP) removed May CCG 2017.

Havering CCG Lay Member

PricewaterhouseCoopers Kiren Pandya (son) Management consultant (2013)

Accenture Anand Pandya (son) Added May 2017 Solicitor

University of Essex Independent Audit Committee member (2013- 19) Southend on Sea Borough Council Independent Audit Committee Member (2016- 18)

Draft - Part 1 Redbridge Clinical Commissioning Group Governing Body Meeting – 26 May 2017 2.20pm.at Becketts House

Present: Dr Anil Mehta (AM) Clinical Director and Chair Dr Shabana Ali (SA) Clinical Director Dr Syed Raza (SR) Clinical Director Dr Sarah Heyes (SH) Clinical Director Dr Mehul Mathukia (MM) Clinical Director Dr Muhammad Tahir (MT) Clinical Director Dr Shujah Hameed (SHa) Clinical Director Dr Ah Fee Chan (AFC) Secondary Care Consultant Kash Pandya (KP) Lay member - governance Khalil Ali (KA) Lay Member-PPI Tom Travers (TT) Chief Finance officer Jacqui Himbury (JH) Nurse Director Louise Mitchell (LM) Transformation Director

In Attendance: Marie Price (MP) Director of Corporate Services Angela Ward (AW) Company Secretary Lee Eborall (LE) NEL CSU Pod Director Vicky Hobart (VH) LBR Director of Public Health

Apologies: Conor Burke Chief Officer Dr Joyoti Sood Clinical Director Dr Anita Bhatia Clinical Director

Item Action 1.0 Welcome and apologies The Chair welcomed members to the meeting and apologies for absence were noted.

1.1 Declarations of conflicts of interest The Chair reminded governing body members of their obligation to declare any interest they may have on any issues arising at the meeting which might conflict with the business of Redbridge clinical commissioning group.

Declarations declared by members of the governing body are listed in the CCG’s Register of Interests. The Register is available either via the secretary to the governing body or the CCG website at the following link:

http://www.redbridgeccg.nhs.uk/About-us/Our-governing-body/register-of- interests.htm

Dr Hameed had recently advised the governance team that he was a GP partner at the Castleton Road practice and the register had been updated.

1.2 Minutes of the last meeting The minutes of the meeting held on 30 March were agreed as a correct record.

1.3 Matters Arising 6.4 Quality Report- the update requested at the last meeting was included on the agenda. Closed.

7.0 AOB-The draft Health and Wellbeing Strategy was on the agenda as planned. Closed.

Locality Arrangements-As requested the primary care team was now in dialogue with the practice concerned. Closed.

2.0 Chair and Chief Officer’s reports 2.1 Chair’s report The Chairman reported on a number of activities since the last meeting:  The lifting of the Directions on Havering relating to RTT

 New Directions received by BHR in respect of the financial situation  Strategic work at both BHR and NEL responding to challenges faced and developing networks and localities  A meeting with Anne Rainsbury to discuss primary care as part of STP, where there was a clear understanding of the challenges faced locally and a recognition of good clinical engagement as we move towards an Accountable Care System.  A positive meeting with the London Mayor discussing the problems of general practice and again with a good understanding of primary care issues and welcoming of further dialogue  Regular IJEC and Informal CDs meetings and attendance at the Health & Wellbeing Board

The briefing was noted. 2.2 Chief Officer’s report MP covered the report from the Chief Officer on key issues and meetings :  There was critical focus around the SDP and achieving the planned cost reduction with £31.5m assured to date.  The CCGs had identified £44m of opportunities to date against the £55m cost reduction and work continued to close the gap  The positive position of the Directions around RTT being lifted that reflected the huge amount of work done to achieve this  Directions on the CCG had since been imposed around the financial position, which led to critical work with partners to deliver a sustainable financial position  Discussions at the Health and Wellbeing Board on Care City innovation and Social Prescribing programme.  The report identified a number of key meetings attended

The progress report was noted.

3.0 Governing Body Assurance 3.1 Governing Body risk assurance framework report The report referred to two risks being de-escalated from red to amber. The BH 62 day cancer target had been met since September 2016 (typo changed) and the BHRUT 18 week RTT standard was meting the trajectory

and on target to meet the September 2017 target.

The five risks on the GBAF were  BHRUT emergency care performance  BHRUT 62 day cancer target

 BH performance against key targets , A& E and RTT

 BH quality concerns  Risk to delivery of the CCG’s budget

KA commended LM’s good additional work in supporting BHRUT in the retrieval of the RTT position and this was seconded by the Chair on behalf of

the CCG. KA questioned whether STPs should be considered as a risk as it

was important that funds were well distributed and currently they had no statutory powers. MP added that STP also helped mitigate risk and consideration would be given how to reflect that. The Chair questioned whether a sixth risk was whether the WEL proposals for multiple ACS posed any risk and a seventh was primary care risk due to lack of GPs and district nurses and the ageing current professionals. MP advised it was a technical MP

issue registering risk but she would discuss these proposals with the relevant

directors and report back.

The governing body noted the current risks escalated to the GBAF and had raised some potential risks for further consideration.

3.2 BHRUT performance TT presented the usual analysis of performance at BHRUT and updated on key actions taken by the CCG to seek improvements. As the Trust had demonstrated considerable improvements it was proposed that this should be the last exception report provided and performance would now be seen in the regular quality and contract reports.

Updates were provided on A& E, RTT and Cancer Waits where for A & E the Trust did not meet the STF trajectory in QTR3 and the CCG had supported their appeal for STF funding, which was upheld. MM added that the position had been challenging for the Trust and the CCG needed to be assured of continuity of performance achieved. KA requested attention be focussed on BH as the risk rating was high.

TT added that the agenda was driven by the risk profile, the risk to the CCG corporate objective had diminished and focus would now be within the contract and quality reports.

The governing body noted the significant delivery of the RTT recovery trajectory, the action being taken to mitigate risks and agreed that future reporting forms part of quality and contract reports.

4.0 Service transformation and development 4.1 System delivery framework (SDF) TT reiterated the BHR CCGs were required to deliver £55m savings in year with £35m against the BHRUT contract. The SDF had been established to drive recovery. BHRUT had provided assurance of a value of £18m against the £35m. The BHR CCGs had identified a total opportunity of £44m and assured a value of £31.5. TT added that the close partnership system work with the Trust had put the CCGs in a strong advanced position for the STP.

The Chair questioned reducing reliance on the risk pool and TT advised that Board to Board meetings were planned and a forensic review, which would expand into NELFT eventually. The System Delivery Board was looking at both QIPP and Provider SIPs. Members questioned what transaction was planned to replace Payment by Results and TT advised it would be designed and gave an example of the Bolton model using a capitated budget system, a risk share with a capitated budget.

KP noted the immense change affecting the health economy and there were various models emanating between block contracts and capitation arrangements. He gave credit to all staff for finding opportunities of £44m savings and flagged that the Trust cost improvement programmes added to this with the Health Economy seeking around £100m. The Chair emphasised the importance of hospital referral management.

The governing body noted the current delivery against the SDF.

4.2 Consultation on the draft Health & Wellbeing Strategy for Redbridge 2017-2021 This was the second Health and Wellbeing strategy and now covered the period 2017-2021. The draft had been out to consultation for 12 weeks until 12 June when all feedback would be captured and considered. It was noted

the strategy was drafted before local financial positions were cleared.

Engagement to date had viewed priorities and AC models and the report outlined the thrust of the strategy in the way of vision and ambition. These were reflected in 10 directional statements and six ambitions/broad outcomes to be achieved covering child health, diabetes, cancer, mental health, end of life care and housing.

KA reported on feedback from patient engagement fora, which requested

simplified statements and a descriptor for inequality. They had welcomed focus on diabetes, cancer, mental health, children with complex needs and were concerned about the needs of young people and the number of rough sleepers in the borough. He requested that locality engagement be included

to ensure the strategy was developed upwards rather than a top down approach.

VH was pleased to note 120 responses received to date, the comments

today would be included and current finances would need to be considered when priorities were finalised in the strategy. Further feedback would follow after the consultation period ended.

The governing body noted the draft and consultation period and required CCG input and responsibilities and would receive the agreed strategy VH following consultation in July.

5.0 Quality and Performance 5.1 Patient experience report KA firstly wished to record on behalf of the CCG and the Patient Engagement Forum (PEF) his appreciation of Boba Rangelov’s good work on PPI and wished her well in her new job. He thanked LM for attending the Forum to outline issues arising from the ‘Spending Money Wisely’ consultation and noted the PPGs had also been encouraged to respond. LM welcomed a good response to the public consultation, with over 600 responses. The PEF had also benefitted from a visit by Natalie Keefe from the primary care team to explain the locality model further.

The report outlined KA’s regular update on on-going engagement activities such as the activities of the PEF, strengthening relationships with the voluntary and community sector, a wheelchair and equipment service review, PPG development and a questionnaire and engagement on CCG proposals to address the financial challenge.

The governing body noted the contents of the patient experience report and that responses from the CCG were fed back to the PEF and other stakeholders.

5.2 Finance and activity report TT confirmed that the final accounts for 2016/17 had reported a break-even position on the CCG resource limit of £386m but had not achieved its £370k planned surplus. There were M12 adjustments including use of 1% non- recurrent reserve. This new year began with an opening underlying deficit as £0.75m was being carried forward. Achieving break-even at the next year end would be extremely challenging and it was important for all NEL CCGs and Providers to manage the problem down. TT advised that the risk pool money was not a loan but future risk pool arrangements were yet to be determined.

KP added that he was concerned that the support would not be ongoing and it was vital to resolve locally. TT added that the internal BHR risk share continued, PMS created particular issues for primary care growth and there

was an overall BHR deficit. Primary care prescribing budgets were helpfully underspent but this was offset by CHC pressures. WF CCG had done some work on this and liaison with them would follow. A challenge for the CCG would be to retain focus on development and transformation.

The governing body had earlier agreed to adopt the end of year accounts and the finance team were thanked for their good work. The current financial position was noted.

5.3 Contract report TT presented the report on contracts with the CCG’s main providers BHRUT, BH, NELFT, PELC and the LAS.

AT BHRUT attention was drawn to a good position on infection control and

no breaches in the dignity standard. The Summary Level Hospital Mortality Indicator (SHMI) and Hospital Standardised Mortality Ratio (HSMR) were outside the expected range and warranted further review. This was covered in the next report on quality.

BH was not showing yet the level of improvement seen at BHRUT.

Under 83% had been achieved in A & E but the over 52 week waits were

showing a level of stability. However there was strong performance in achieving the cancer targets.

NELFT demonstrated no adverse performance on the community side and in mental health provision there was the continual challenge against the IAPT

target. Attention as drawn to below standard performance for CAMHS

referrals and a red rating recorded. SH criticised the unattainable target of referring 1 in 4 patients as this did not reflect the needs of the Wanstead/Woodford locality as many patients declined the offer of such therapies.

MT stressed the serious problem with the access criteria to CAMHS with

some children under the Court of Protection. There was much focus on the

high end of the autism spectrum. IAPT was for aged over 18 and extending the criteria to those over 15 would be beneficial and support target achievement. JH requested CDs provide any details of access issues to JH CAMHS as this linked to her responsibilities around Safeguarding Children and Sue Elliott would pick these up. SH had letters transferring care from CAMHS to NELFT that he could forward on. JH would bring a report to the JH next meeting on any issues and explore if LBR dis-investment had an impact on provision and consider the risks.

PELC had over-performed against 111 service activity and OOH activity was significantly down on the same period the previous year. There was a performance review in March and discussion on lower acuity patients for the same period.

The LAS had showed some improvement in February to 58% of Cat. A calls responded to in 8 minutes against the 75% target. The recovery trajectory was kept under regular review across London. The LAS were requesting additional funding to match an increase in demand but the CCG was currently challenging the additional activity. KA felt the underperformance was unacceptable over recent years, particularly in life threatening circumstances and also in the challenging times of spending money wisely. He called for recognition of the work being done on the 13 specialties by clinicians in the reporting.

The governing body agreed the M11 activity report for the four providers, reviewed the performance against standards and remedial actions in place and raised some areas that might be appropriate for the risk registers.

5.4 Quality report JH’s report was divided into two sections, firstly the system wide overview of quality indicators and secondly on operational issues and challenges the CCG manages with providers to ensure patient safety.

The NELFT CQC inspection had led to the development a Trust Strategic Quality Implementation Plan that addressed 137 ‘must’ and ‘should do’ actions by 31 March 2017. The Trust were currently behind and achieved 61% by that date and an extension to the end of July had now been agreed. The outstanding actions had been risk assessed. The Brookside unit had been revisited by the CQC and was no longer under the ‘requires

improvement rating’.

BHRUT was a CQC mortality outlier for UTI in May and fuller understanding was awaited of the cause. The CCG had been monitoring the upwards trend in SHMI data as this was the highest reported level in London. The Quality & JH/CK Safety Committee was setting up a clinician to clinician meeting to understand this further, whilst noting a serious robust approach to mortality at the Trust was evident.

GP Alert system has undergone a further recent review following concerns raised by CDs. A robust process was agreed by the Committee last year but this was found not to be working effectively. Reasons were several not least an IT link issue, capacity to communicate outcomes and an unhelpful parallel system. An improvement plan had been developed and immediate actions taken. The Audit Chair had requested an internal audit review and that would be reporting on its investigations shortly.

For Barts Health the Chair questioned the learning from complaints and JH referred to quality concerns being discussed with WF CCG, CSU and LM to look across WX finance, quality and performance and assess the risk and mitigation.

SH raised the serious impact that the cyber attack on WX had on local practices and patients, partly due to a paucity of information after the first day or two. This included the closure of phlebotomy without notification leading to spoilt tests and this was escalated to the medical forum. Normally SH would get around 170 path lab results on a Monday and there were none until they started trickling through on the Thursday after the attack, with messages that 80% were spoilt and had to be retaken.

SA added that radiology, ultrasound, x-ray was delayed and additional work was generated for GPs. The lead commissioner was requesting that the Trust identify potential clinical risk and mitigating action for the primary and community sector impacted by WX services. JH noted that the impact on primary care needed to be accounted for and much was about communication and a response was awaited but the CCG would be taking a firm approach. VH added that if there had been an impact on social care due to delayed discharge this needed to be factored in too, as good communications was vital to the Borough’s Resilience Plan and such lessons needed to be captured. LA added that the CSU would support with feedback on the communication issues.

The governing body reviewed and discussed the quality issues in the report and suggested some further actions for further improvements /assurance.

6.0 Development/Governance 6.1 Finance Committee Proposals MP presented a report setting out the basis for proposals to amalgamate the functions of the Investment Committee into the FRPB. The report proposed some enhancements to the FRPB membership to ensure quoracy. These proposals and the draft Terms of Reference had already been supported by the FRPB.

The governing body agreed to dis-establish the Investment Committee and to incorporate its functions into the FRPB and they agreed the consequent revised Terms of Reference of the FRPB.

6.2 East London Health & Care Partnership (ELHCP) MP reported that the Partnership Agreement (formerly known as the Memorandum of Understanding or MOU) had been approved by ELHCP and now required sign-up by CCGs. Although one representative for BHR was mooted, the CCGs had insisted on three seats which had been agreed. Governance arrangements would be developed over time and therefore a pragmatic approach was being taken. This was an arrangement to make decisions together, noting CCGs retained their separate statutory powers.

Issues were raised around the name of the partnership given we and other BHR CCGs are NE London rather than just east London. Feedback will be provided explaining that BHR wished the title to be changed to North East i.e. NELCHP. KA called for recognition of the role of the Lay Member, acting on behalf of patients and MP added that lay representation would happen via the Audit function (lay member for governance) and for PPI lay members through the ‘community group’ being established.. KP called for the effectiveness of

the partnership to be reviewed in 6 months.

The governing body agreed to sign up to the Partnership Agreement.

6.3 Finance & Delivery Committee Chair’s report The Chairs report and the minutes of the meeting held on 27 April 2017 were noted.

6.4 Audit & Governance Committee Chair’s report The Chairs report and the minutes of the meeting held on 24 April 2017 were noted.

6.5 Work of the Financial Recovery Programme Board (FRPB) and financial recovery programme progress summary The report was noted.

6.6 Minutes of sub-committee and relevant fora: Primary Care Committee-the minutes of the meeting held on 12 April 2017 were noted.

Quality & Safety Committee - the draft minutes of the meeting held on 25 April 2017 were noted.

Patient engagement forum- the minutes of the meeting held 14 March 2017were noted.

Joint executive committee- the minutes of the meeting held 9 February 2017 were noted.

7.0 AOB JH reported that a CCG quality assurance visit to BHRUT had taken place following the recent national cyber-attack and the Trust had impressively responded very quickly. There was a separate unrelated issue around the cyberlab.

8.0 Questions from the public. 8.1 Andy Walker raised two questions Q1. AW questioned why new GP surgeries were not being built. A1. MP responded that the CCGs were not funded to build practices and this was a function of NHSE and Property Services. The Chair added that it was more complex and related to a shortage of GPs.

Q2. AW noting recent cyber-attacks, would prefer the BHRUT board to meet monthly to gain fresh information, noting that they had moved to bi-monthly. A1. MP responded that it was not for the CCG to comment on BHRUT board arrangements but the CCG met bi-monthly also.

8.2 A local GP raised a question: Q1 Raised questions about how the size of locality populations differed and between hub costs per patient and GP surgery costs per patient. He felt GPs could provide 8-8 access if funds were available to practices.

The Chair responded it was not just numbers of appointments but quality was

important. It was accepted that hub care would be different to the GP surgery.

TT confirmed that each CCG had its own money and the tariff of the access hubs was equal across BHR.

9.0 Date of the next meeting The next scheduled meeting was 20 July 2017.

Draft Minutes of Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups Governing Body meeting held on 29 June 2.30 – 3.30pm. at Becketts House

B&D CCG Havering CGG Redbridge CCG

Kash Pandya Kash Pandya Kash Pandya Dr Gurkirit Kalkat Dr Ann Baldwin Dr Anil Mehta Dr Jagan John Dr Alex Tran Dr Syed Raza Dr Anju Gupta Dr Maurice Sanomi Dr Shabana Ali Dr Ravi Goriparthi Dr Gurdev Saini Dr Shujah Hameed Dr Kanika Rai Dr Ashok Deshpande Dr Sarah Heyes Conor Burke Conor Burke Dr Jyoti Sood Sharon Morrow Alan Steward Dr Anita Bhatia Tom Travers Tom Travers Dr Muhammad Tahir Jacqui Himbury Jacqui Himbury Dr Mehul Mathukia Sahdia Warraich Richard Coleman Conor Burke Louise Mitchell Tom Travers Jacqui Himbury Khalil Ali

8 required for quorum 8 required for quorum 9 required for quorum quorate quorate Quorate

In attendance: Marie Price Director of Corporate Services BHR CCGs Anne-Marie Keliris Company Secretary BHR CCGs Katy Scammell Public Health Consultant, London Borough of Redbridge Sue Lloyd Public Health Consultant, London Borough of Barking & Dagenham Cathy Turland CEO, Healthwatch, Redbridge Frances Carroll Chair, Healthwatch, Barking & Dagenham Lee Eborall Director, NELCSU

Apologies: Barking & Dagenham- Dr Waseem Mohi, Dr Ramneek Hara Havering- Dr Atul Aggarwal Redbridge- Ah-Fee Chan

Minute Action 1.0 Welcome, Introductions and Apologies Kash Pandya agreed to act as Chairman to this ‘Governing Body in Common’ of Barking & Dagenham, Havering and Redbridge CCGs. The governing body members were welcomed to the meeting.

Apologies for absence were noted as detailed above.

1.1 Declaration of Conflicts of Interest

The Chair reminded governing body members of their obligation to declare any interest they may have on any issues arising at the meeting which might conflict with the business of the three CCGs and the proposals before us.

No further conflicts of interest to those recorded in the registers, were raised by members that were present, other than Sahdia Warraich who reported on a change to her declaration which she would report to the governance team but did not directly relate to the item to be discussed at the meeting.

2.0 Spending NHS Money Wisely The Chair thanked members for attending the governing body meeting in common and reported that the governing bodies were meeting together because this was a joint consultation.

The Chair reported on the financially challenged situation of the BHR CCGs and the need to save £55m in 2017/18 and as responsible commissioners the CCGs must live within our means which means we would need to consider difficult decisions.

‘Spending NHS money wisely’ identified a potential £5.2m of savings through restricting or no longer funding a number of treatments and procedures under the following categories:

 IVF  Male and female sterilisation  NHS prescribing  Cosmetic procedures  Weight loss surgery

The Chair handed over to the six clinical directors who led the process.

Dr Anita Bhatia reported that the six clinical leads, all local GPs, were tasked with looking at a number of proposals, 33 in total, designed to help the local NHS meet what is a considerable financial challenge.

The papers for the meeting contained all the detail needed to review the proposals and consider the recommendations, along with the decision making business case, the consultation report, financial impact and the recommendations methodology.

The list of proposals in the eight-week public consultation – ‘Spending NHS money wisely’ - amounted to potential savings to the NHS in our area of around £5.2million. Dr Bhatia reassured the governing bodies of the rigour of the approach in the discussions the clinical leads had to make its recommendations and it was noted that these discussions were challenging, and an important piece of work that was taken very seriously.

Throughout the process, clinical directors approached decisions as clinicians and put patients first, but against that backdrop of financial challenge and a responsibility to protect the most essential services for local people. The clinical directors had valuable support from a small panel at its meetings, including public health expertise.

Dr Sarah Heyes thanked Dr Bhatia and echoed her comments on the rigour of the discussions and the challenging process.

Dr Heyes reported that from the 33 recommendations were grouped around five themes – IVF, Male and female sterilisation, NHS prescribing, cosmetic procedures and weight loss surgery.

IVF The consultation included proposals to stop funding IVF altogether, moving from three cycles to none but this was unanimously rejected and agreed a different position. It was recommended moving from three cycles to one. This will bring us into line with 125 other CCGs across the country with a saving of £1.07m.

Male and female sterilisation The consultation proposals around male and female sterilisation have been rejected by the clinical leads and the recommendation is not to implement. It was felt there was likely to be an impact on other services within the system such as unplanned pregnancies. Local authority colleagues had expressed the same concerns.

NHS Prescribing The proposals consulted on around NHS Prescribing involved a great deal of debate and were able to agree almost unanimously on all of these.

It was made very clear that any patients receiving treatment for cancer will continue to be prescribed the drugs they need and any patient with long-term chronic pain will also continue to receive prescribed medicines as they do now.

The recommendations on NHS prescribing will achieve a local saving of £1.01m. That figure includes £210,000 for stopping prescribing gluten-free products.

Cosmetic procedures The consultation included a wide range of cosmetic procedures and some of these were supported in our recommendations and others were not with the reasons set out in the report. The recommendations amount to a £710,000 saving to the NHS.

The proposals around the future funding of abdominoplasty, were not agreed and was deferred.

Bariatric, or weight loss, surgery The proposed changes to the criteria around bariatric, or weight loss, surgery were discussed at length and the group recommended tightening up those criteria, which will deliver a saving of £247,000.

In total, it was recommended to no longer fund 22 of the 33 proposals, which would see a saving of £3.03million, impacting on 8.87% of the population.

The report included the initial and the full Equalities Impact Assessments and it was noted that a patient experience expert was also able to help with any queries around taking full account of statutory protected characteristics.

Dr Maurice Sanomi reported on the deferred recommendation on the proposals on abdominoplasty or ‘tummy tucks’ and the significant debate of the practical implications of the proposals to stop funding. It was agreed that the current POLCE – procedures of limited clinical effectiveness – policy should be vigorously adhered to by GP colleagues because it already contains sound guidance on who should access this surgery or not. The CCGs will be highlighting the current guidelines to GP colleagues and will review this in six months’

Cathy Turland questioned whether the Department of Health’s consultation on the prescription of gluten free products will impact on the CCG’s consultation. Marie Price responded that the CCG were aware of this consultation but were unable to wait for the outcome of this consultation due to the financial challenges the CCG faces.

Cathy Turland questioned whether the equality impact assessment took into account disability, as disabled patients could struggle financially to pay for over the counter medication. Marie Price responded that equality impact assessments do not take into account deprivation or income as this is not one of the protected characteristics, she added that disability was considered.

Dr Goriparthi commented that there are many gluten free products available in supermarkets at reduced prices and GPs do not prescribe products for other intolerances i.e. dairy.

Dr Mathukia commented that practices will require adequate communications support. Dr Heyes reported that there will be a whole communications package available for GPs and practices. Dr Mathukia welcomed this, adding it was important for this to be extended system wide to include pharmacists and secondary care consultants. Dr Deshpande confirmed that colleagues across the wider system will receive communication on any decision made.

Dr Mathukia commented that it was important to be clear which travel vaccinations will no longer be available.

Dr Baldwin questioned whether there will be a point of contact for patients who have concerns or complaints. Dr Bhatia responded that the CCG are exploring options to support both patients and practices. CB agreed that clear signposting for patients and practices will be required.

CT questioned how local policy fits with Department of Health and whether the Secretary of State for Health decides what can be prescribed. CB responded that the CCGs decides on how its prescribing budget is utilised. CT agreed to write to the CCGs with further questions.

Dr John commented that BHR CCGs are not the first CCGs to take these difficult decisions and questioned whether there is any feedback from other CCGs. Dr Gupta responded that one CCG has stopped IVF completely and had received significant challenges which affected the recommendation the panel made. Dr Heyes commented that any significant changes will take time to embed and it was important to encourage patients to take care of their own health.

Katy Scammell asked whether there are any examples of negative impact on the restrictions of travel vaccinations. It was confirmed that Hepatitis A was still available and this was a concern that the panel had raised but no evidence of negative impact on the restrictions was noted. Katy Scammell questioned whether there is a reason for the low response rate from Redbridge residents. Louise Mitchell responded that the same approach was applied to all boroughs and the figure related to questionnaires returned, adding there were lots of public meetings where patients concerns were also answered.

Dr Tahir questioned what process should be followed if practices are challenged on the restrictions. CB responded that any challenge will follow the normal complaints procedure. Dr Heyes reported that the individual funding request process is also available.

Dr Tahir questioned if there will be indemnity of individual clinicians and how will they be supported. CB responded that this is not an individual issue for a GP but a commissioning decision by the CCG.

The Chair thanked the governing body members for the discussion and questions. He added that normal practice would allow the public to ask questions at the end of the meeting but in order to consider any comments in our decision making this would be brought forward.

Lorraine Silver, Chair of the Redbridge patient engagement forum raised the following concerns:  Wastage in many areas including medicines management  Patients who financially cannot afford to buy prescriptions over the counter  Restriction of gluten free prescriptions

Dr Bhatia acknowledged the concerns raised and reported that the medicines that are being restricted have limited evidence of clinical effectiveness. She also appreciated the concern raised with regard to gluten free products but the CCG needs to be consistent with its approach to prescribing for intolerances.

Marie Price referred to low income and reported that the NHS cannot means test. She also acknowledged that NHS wastage was a common theme in the consultation and will be discussing this further at the patient engagement forums. Conor Burke echoed this, adding there are still more savings that need to be achieved this year and welcome the input of all patents in this challenge.

Barking & Dagenham CCG governing body approved the recommendations detailed in the decision making business case.

Havering CCG governing body approved the recommendations detailed in the decision making business case.

Redbridge CCG governing body approved the recommendations detailed in the decision making business case.

The Chair thanked the clinical director leads for their hard work during and after the consultation.

3.0 Any Other Business There was no other business.

Matters arising/ action log from the Redbridge CCG Governing Body held on 26 May 2017

Action ref: Meeting Action required Lead Required by Status date

3.1 26 May The Chair questioned whether a sixth risk was whether the WEL proposals MP July 2017 Verbal update GBAF 2017 for multiple ACS posed any risk and a seventh was primary care risk due to lack of GPs and district nurses and the ageing current professionals. MP advised it was a technical issue registering risk but she would discuss these proposals with the relevant directors and report back to the risk lead.

4.2 26 May The governing body noted the draft and consultation period and required VH September Health & 2017 CCG input and responsibilities and would receive the agreed strategy 2017 Wellbeing following consultation in July. Strategy 5.3 26 May JH requested CDs provide any details of access issues to CAMHS as this SE/JH Verbal update Contract report 2017 linked to her responsibilities around Safeguarding Children and Sue Elliott would pick these up. SH had letters transferring care from CAMHS to NELFT that he could forward on. JH would bring a report to the next meeting on any issues and explore if LBR dis-investment had an impact on provision and consider the risks.

5.4 26 May BHRUT was a CQC mortality outlier for UTI in May and fuller understanding Verbal update Quality report 2017 was awaited of the cause. The CCG had been monitoring the upwards trend in SHMI data as this was the highest reported level in London. The Quality JH & Safety Committee was setting up a clinician to clinician meeting to understand this further, whilst noting a serious robust approach to mortality at the Trust was evident.

1 30

To: Meeting of the NHS Redbridge Clinical Commissioning Group Governing Body

From: Dr Anil Mehta, Chair

Date: 20 July 2017

Subject: Chair’s report

Executive summary The report provides an overview of key activities undertaken by myself and the CCG since the last governing body meeting.

Recommendations The governing body is asked to note the report.

1.0 Purpose of the report

1.1 To provide an update on my activities since the last meeting and on key CCG news.

2.0 Financial situation

2.1 We are making progress in addressing our financial challenges, but there is still work to do to ensure that we deliver against our plans and continue to identify opportunities to further close the remaining gap. My clinical and staff colleagues have worked hard under difficult circumstances to identify levels of savings opportunities on a scale not seen before in BHR – and not I believe in many other systems to date.

2.2 This scale of change requires us having to make changes locally that are not easy for any of us. We did not come into the world of commissioning to stop services for local people, but with a responsibility as a governing body to deliver within our allocated budget, we have had to make some difficult choices. We’ve done this in partnership with our system colleagues and by listening to the public through engagement and consultation. I want to thank everyone who contributed to our ‘Spending Money Wisely’ consultation. This won’t be the last set of difficult decisions that we need to take, but I do want to make sure that we take a balanced view by taking on board input from local people and professionals.

3.0 System developments

3.1 We had a positive board to board session between the BHR CCGs and BHRUT, and to which NELFT board members also attended. We have agreed on the key areas that we need to focus on over the next year and beyond to support development of a sustainable health system. I was heartened to hear the commitment to a focus on primary care provider bodies having a voice as a major player, given this is where most people experience NHS services.

www.southwark.gov.uk31

4.0 Networks and localities

4.1 We continue to make good progress, and are further exploring arrangements with regard to the role of GP federations and GPs as providers in the new landscape and ACS developments. On 6 July we held a BHR wide facilitated session of commissioning GPs and our Federation colleagues.

4.2 As commissioners and given the interests involved, we want to work through the governance arrangements to enable the system to have the requisite primary care leadership within the commissioner and provider functions. We will work closely with governance and legal colleagues to ensure that we develop sound arrangements.

5.0 Meetings

5.1 In addition to the many committee meetings I attend, below is a summary of other meetings I’ve been to since the last governing body meeting.

5.2 GB away day: we had a positive session with the three CCGs in May, exploring our strategic direction and considering the functions and leadership required at locality/network, BHR/ACS and at STP level. It was a lively and positive session with a great deal of consensus about our plans for the coming year, including our priorities and objectives ,the final versions of which are on this governing body agenda for agreement.

5.3 Weekly BHR CCG GB member meeting (IJEC): our meetings have focussed on progress with the system delivery and finance recovery plans and updates on key programmes.

5.4 Informal CDs’ meetings: I continue to have regular meetings with our clinical leadership team. Our focus has been on STP/ACS/locality/network developments, financial recovery and transformation programme performance.

5.5 Health and wellbeing board: the last meeting on 10 July focussed on the borough’s obesity strategy, consultation feedback on the health and wellbeing strategy, updates on the STP, integrated care partnership and the Better Care Fund.

6.0 Resources/investment 6.1 There are no additional resource implications/revenue or capital costs arising from this report.

7.0 Equalities 7.1 There are no direct equality implications arising from this report.

8.0 Risk 8.1 The CCG is managing a number of serious risks which are outlined in further detail in the assurance section of this agenda.

9.0 Managing conflicts of interest 9.1 There are no conflicts of interest arising from this report.

11 July 2017

To: Meeting of the NHS Redbridge Clinical Commissioning Group Governing Body

From: Conor Burke, Chief Officer

Date: 20 July 2017

Subject: Chief Officer’s Report

Executive summary This report provides an overview of key activities undertaken by the Chief Officer and the CCG since the last meeting.

Recommendations The governing body is asked to:  Note the progress report

1.0 BHR System Delivery Plan 1.1 We continue to make progress on our financial recovery plan, with £43.3m of the £55m target identified. Further information is provided in the paper later on the agenda.

2.0 BHR Accountable Care System and Sustainability and Transformation Plan (STP) 2.1 Following the refresh of Five Year Forward View STPs were identified as the transitional bodies to develop new Accountable Care Systems (ACS). Within the NEL STP footprint, a BHR ACS is assumed and supported and we will need to develop and define what exactly is meant by a BHR ACS with partners within BHR and STP colleagues over the next few months. The BHR Devolution Strategic Outline Case gives us a foundation to build on, and both the STP Team and the London Devolution Team are keen for the BHR system to lead and influence the ACS design.

2.2 Discussions are in train with our local authority colleagues through the newly established Joint Commissioning Board to explore the role of commissioners in the new system. In parallel, as part of the System Delivery Plan and with the support of PwC, our two local Trusts have begun discussions on how they respond and work together as providers within an ACS. This approach was endorsed at the Board to Board meeting of the BHR CCGs and BHRUT (also attended by NELFT) on 22 June. Both Trusts at the meeting highlighted the importance of primary care in the new model and gave a commitment to CCG Chairs to ensure primary care is invited to play a lead role.

2.3 The Integrated Care Partnership Boards in June and July will be used to bring together the STP, commissioner and provider discussions/workstreams to develop a system level set of recommendations for governing bodies/boards consideration.

2.4 On 3 July the East London Health and Care Partnership was officially launched. The Partnership will support effective collaboration and trust between commissioners and providers to work together to deliver improved health and care outcomes more effectively and reduce health inequalities across the local system.

www.southwark.gov.uk33

3.0 CCG Development 3.1 We held a three CCG governing body away day on 18 May where we discussed the strategic direction of the NHS and what this means for our ways of working and strategy going forward. We also discussed our corporate objectives for 2017/18 and these are on the agenda for approval.

4.0 CCG assurance 4.1 At the NHS England assurance meetings on 21 and 23 June discussions focused on the BHR CCGs’ performance on IAPT, dementia, and 2017/18 QIPP as well as the month 2 financial position and progress of the financial recovery plan

5.0 Operational Resilience 5.1 Further to the cyber-attack on some NHS organisations in May, neither the CCG nor any of our GP practices were not affected. The CCG manages the GP IT service for the borough’s GP practices and following a review of all systems, our IT department are confident all updates and patch requirements are in place. During the incident the CCGs worked in partnership with our providers to ensure patients continued to receive urgent care and treatment, and did all we could to help reduce delays for patients. Barts Health was the most affected trust locally and we worked closely with them to ensure messages and updates were shared as widely as possible.

5.2 Following the recent incidents in London and Manchester, and the heightened security level that was put in place, the CCG has reviewed and strengthened all incident plans to ensure that should a similar major incident occur in our area that we are able to support the response.

6.0 Health and Wellbeing Board update 6.1 At the meeting on 10 July discussions focused on health and wellbeing strategy, Better Care Fund, Redbridge obesity strategy and received the 2016/2017 annual report from Redbridge Healthwatch.

7.0 Meeting attendance 7.1 On 2 June I attended a meeting of London Trust Chief Executives and CCG Chief Officers, hosted by Anne Rainsberry from NHS England. Discussions focused on operational resilience, STP/ACS and the emerging integration workstream.

7.2 A forum on Accountable Care was held on 27 June, facilitated by Imperial College Health Partners and the Health Foundation. At the session they shared research findings and lessons from those implementing accountable care principles in new models of care across England.

8.0 Equalities 8.1 There are no equalities implications arising from this report.

9.0 Risk 9.1 There are no risks arising from this report.

10.0 Managing of conflicts of interest 10.1 There are no conflicts of interest issues relevant to this report.

11.0 Resources/investment 11.1 There are no additional resource implications/revenue or capitals costs arising from this report and no impact on sustainability.

To: Meeting of the NHS Redbridge Clinical Commissioning Group Governing Body

From: Khalil Ali, Lay Member (PPI)

Date: 20 July 2017

Subject: Patient Engagement report

Executive summary This report summarises patient and public engagement, feedback and insight gathered since the last meeting.

Areas covered:  The Patient Engagement Forum (PEF)  Joint PERF/PEF meetings  Spending Money Wisely consultation  NEL STP launch

Recommendations The governing body is asked to:  Note and comment on the contents of the report

1.0 Purpose of the report 1.1 To provide a summary of the CCG’s engagement with patients, the public and other stakeholders since the last meeting.

2.0 Patient Engagement Forum (PEF) Update 2.1 The PEF’s last meeting was 9 May. The Forum’s main topic was the role of localities in the Primary Care Transformation Programme (PCPT). Following a presentation by Natalie Keefe from the Primary Care Team, members raised questions about how the PCTP will engage with PPGs and the voluntary sector. Members also sought reassurances in the wake of trials of digital communications, with NK confirming GPs will not stop sending letters or calling patients who require this. They will also continue to reserve half of all appointments for those who contact the practice by phone or in person.

3.0 PEFs/PERF Chairs’, Vice-Chairs and Lay members’ meeting: 3.1 The group met on 20 June, with the main topic of discussion being the changing local NHS structures and their commissioning responsibilities. The group recognised individual CCG Patient Engagement Forums would lack the same degree of strategic influence in the wake of closer BHR collaboration and STP footprint level commissioning of some services. It was agreed that alternating between separate CCG meetings and a joint meeting could maximise the effectiveness of the forums, without losing a focus on different borough needs. A proposal to adopt this structure will be taken to the July

PEF/PERF meetings. Subject to agreement, the first joint meeting will take place in September.

4.0 Public consultation “Spending NHS money wisely”: 4.1 On 29 June the governing bodies of Barking and Dagenham, Havering and Redbridge clinical commissioning groups (CCGs) met in public and agreed to no longer fund certain treatments and procedures as we look to make savings for the local NHS.

4.2 Clinical leads described how during the consultation they had been heartened that local people largely agree with what we are doing – trying to save the local NHS money at a very difficult time. The clinical panel that made recommendations to the governing bodies carefully considered the outcome of the consultation in reaching their decisions. Not all the proposals consulted on were recommended or subsequently agreed – with some cosmetic procedure proposals not implemented and IVF going from three embryo transfers to one rather than none.

4.3 The full consultation report is on each CCG’s website and can be accessed here http://www.redbridgeccg.nhs.uk/Our-work/spending-nhs-money-wisely.htm

5.0 Sustainability and Transformation Plan 5.1 East London Health and Care Partnership, the new name for the NEL STP, launched on 3 July. The first meeting of its Community Group was held on 4 July. Lay members and members of Patient Engagement Forums were invited to attend. The launch was an initial stakeholder engagement event, with the ELHCP looking to increase patient and public engagement over the next few months as the STP starts to be implemented.

6.0 Community and Voluntary Sector 6.1 The Social Prescribing Project launched on July 5 at the Redbridge CVS, for members of the Community and Voluntary Sector organisations. A representative from the CCG was in attendance. We will report on the event at the next Governing Body meeting.

7.0 Resources 7.1 There are no resource issues relevant to this report.

8.0 Equalities 8.1 Engagement in the borough should contribute to reducing inequalities in access to healthcare and support the CCG in meeting its equality objectives. This work is progressed through the CCG’s patient engagement forum structure and in collaboration with patients, the voluntary sector and other key stakeholders.

8.2 The Pan London Equality and Diversity Leads met on 3 July. Feedback from this meeting will be provided to the next Governing Body.

9.0 Risks 9.1 There are no identified risks in relation to this report.

10.0 Managing conflicts of interest 10.1 There are no conflicts of interest relevant to this report.

Author: Tracey Bedford, Patient and Public Engagement Advisor, BHR CCGs Date: 28 June 2017

To: Meeting of the NHS Redbridge Clinical Commissioning Group Governing Body

From: Louise Mitchell, Transformation Director

Date: 20 July 2017

Subject: Governing body risk assurance framework report

Executive summary The governing body assurance framework (GBAF) has been reviewed to reflect the current significant risks to the organisation. There are five risks on the GBAF. Risk ratings are based on the June 2017 risk register.

The five risks on the GBAF are :- 1. Barking, Havering and Redbridge University Hospitals Trust (BHRUT) emergency care performance 2. BHRUT cancer 62 days 3. Barts Health (BH) performance against key targets, A&E and RTT 4. BH quality concerns 5. Risks to the delivery of the CCG’s budget

Recommendations The governing body (GB) is asked to:  Note and comment on the current risks escalated to the GBAF and that the levels of assurance in the controls and the mitigating actions being taken are appropriate  Raise and discuss other potential risks that may require escalation to the next GBAF or, where the risk has reduced, de-escalation.

1.0 Purpose of the Report 1.1 The purpose of the GBAF is to outline the key strategic risks to the Clinical Commissioning Group (CCG) in achieving its corporate objectives and the controls in place to provide assurance that the risks are being managed.

2.0 Background/Introduction 2.1 The CCG’s governing body has a responsibility to maintain sound risk management and ensure that internal control systems are appropriate and effective, and where necessary to take appropriate remedial action. The CCG’s risk register consists of risks that are local to the borough and risks that the CCG has in common with its collaborative partners, Barking and Dagenham and Havering CCGs.

3.0 Current risks on the GBAF 3.1 There are five risks on the GBAF. Please refer to appendix 1 for the full details. These fall under four of our six corporate objectives. (NB: there is a paper on the agenda with the organisation’s revised corporate objectives and will be aligned to the risk register and GBAF at the next meeting). The five risks are as follows:

Corporate objective 1 Ensuring that planned care is appropriate, timely and of high quality – with a particular focus on tackling the RTT delays.

Risk 1.3: BHRUT cancer performance standard: The Trust has an improvement trajectory in place to recover 62 Day Cancer Standard. This was achieved in March 2017 as per recovery plan (May 2017 at specialty level). However, the risk of continuity of delivery remains which poses a risk to patient experience and outcomes.

Mitigation:  Revised, robust and realistic trajectory (version four) from the Trust to resume delivery of the performance standard by year end and at specialty level (urology) by May 2017  Oversight and assurance of delivery will be monitored via the Planned Care Programme Board from June 2017  Fortnightly operational stock take meeting with the CCG, BHRUT and NEL Commissioning Support Unit  Collaborative capacity and demand plan agreed and completed  Daily monitoring of planned against actual activity. Formal letter issued to the Trust in regard to failure to sustain delivery of the 62 Day standard in April (issued in June) Response received on 12 June and further clarification sought from the Trust week of 19 June by Commissioners.

The Trust has achieved the agreed cancer trajectory at an aggregate level to resume delivery of the performance standard at the end of March 2017 and the specialty level target planned for May 2017. The data to confirm achievement of the May target will be available in July at which time this risk will be reviewed and may be de-escalated from the GBAF.

Collaborative objective 3: Implementation of the system wide urgent care strategy and redesign of the urgent care pathway

Risk 3.1: BHRUT's on-going failure to deliver A&E performance standards will impact, 1) quality improvement in emergency care, 2) put patients at risk, 3) cause reputational damage and 4) delay the implementation of acute reconfiguration programmes.

Trust performance has improved significantly over the past year, prior to the onset of winter pressures. In the context of the current nationally reported pressures the Trust is no longer identified as one of the very high risk Trusts in London. It should be noted however that performance is still fragile.

Mitigation:  The A&E Delivery Board is leading the work to support operational delivery. This is chaired by the BHRUT chief operating officer  BHR Urgent and Emergency Care (UEC) programme established with four delivery work streams to deliver improvement and mandatory requirements and address all risks. 17/18 trajectory agreed to meet national standard by March 2018. Plan for formal agreement at A&E Delivery Board 14 June.  BHRUT being held to account via contract meetings including SPR and CQRM  Internal CCG UEC Board monitors implementation (performance, plans risks)

Collaborative objective 5 High quality, compassionate and safe care for all commissioned services – delivering better outcomes. 2

Risk 5.4a and c. Barts Health (BH) performance – this risk groups together two performance areas that BH are failing to achieve, RTT and urgent and emergency care. There are also data quality concerns that present a further challenge for commissioners. The risks could threaten the long-term viability of the Trust and could put patients at risk and cause reputational damage.

All mitigations actions for assurance against risks 5.4a, 5.4c and 5.6 are via the lead commissioner, Newham CCG.

Risk 5.4a – 18 weeks RTT - significant issues exist affecting the delivery of this target - key issues with the number of patients on the incomplete waiting list and those waiting over 52 weeks.

Mitigation:  RTT recovery is reflected in the improvement plan work being undertaken by BH after being placed in special measures in March 2015 with oversight by our lead commissioners via the RTT and monthly performance meetings with the Trust.  Trust to produce an initial return to national reporting trajectory and roadmap for review at the RTT Recovery Programme Board on 9 June 2017 with agreement to return to reporting on RTT in October 2017  The Trust has undertaken a real time validation of the PTL and all pathways are on the PTL  A plan on the resumption of reporting will go to the Trust Board and the Contract Review Group (CRG) in September 2017  Lead commissioners will be commissioning an external review prior to resumption of reporting which will include a review of the PTL logic used by the Trust  Performance is reviewed at the CRG (lead commissioner)  Monthly BH (BHR CCGs) escalation and review meeting with updates on performance

Risk 5.4c: Urgent and emergency care - failure to deliver quality improvements at BH (specifically at Whipps Cross Hospital).

Mitigation:  UEC plan agreed in April 2017 but subject to ongoing assurance through NHSE.  Performance meetings including the Trust, commissioners and NHS Improvement (NHSI) with regular updates at the strategic performance review (SPR) meetings  Further update being sought from lead commissioner and will be re-escalated to GBAF  Trajectory to national standard by March 2018

Risk 5.6: If BH do not achieve their quality indicators, (Never Events, Serious Incidents - recurring themes and the 4 harms, 1) Healthcare acquired Infections (HCAI), 2) Venous Thrombus Embolisms (VTE), Pressure Ulcers and Falls, patients may receive poor quality of care and suffer harm. More recently further concerns have developed around the management of serious incidents and complaints as well as compliance with Regulation 20 – the Duty of Candour (specifically relating to Whipps Cross Hospital).

Mitigation:  Escalation and monitoring process, including risk mitigation, to be agreed with the lead CCG (WF)  All concerns have been formally escalated to the lead commissioner at the Quality Leads meeting  Waltham Forest CCG seeks further assurance on the progress of the quality improvement plans at contract review meetings.

Collaborative objective 6: Continued focus on our development as an organisation and health system so that we can meet the challenges ahead and deliver better outcomes, quality and financial efficiency.

Risk 6.1: Significant risks to the delivery of the CCG’s financial plan - legal directions on financial delivery of our QIPP requirements in year and management of any acute over activity relating to underlying performance: a) Legal Financial directions, b) If we do not deliver against the CCG’s QIPP plans the CCG will be in breach of its financial control total and c) risk of over performance in acute, continuing care or prescribing activity.

Mitigation:  Implementation of our action plan from the Well Led Review  BHR CCGs developed System Delivery Framework and Plan, as a mechanism to drive system recovery  Fortnightly Financial Recovery Programme Board (FRPB) chaired by the Chief Financial Officer  Financial Recovery Planning, Delivery and Monitoring group (FRPDM) established with the responsibility for oversight of the QIPP development process and monitoring delivery against plan, reporting to the Financial FRPB  Financial risk mitigation via our integrated financial strategy across north east London sustainable transformation plan (STP) with continued development through the STP process  Aim to overachieve the QIPP requirement to provide stretch generating schemes and therefore savings over and above the £55m target

3.0 Resources/investment 3.1 There are no additional resource implications/revenue or capital costs arising from this report. The cost of operating effective risk management arrangements is met from within existing resources.

4.0 Equalities 4.1 There are no equalities considerations arising from this report

5.0 Risk 5.1 This report also links to the following GB papers being presented at this meeting and provide greater detail on key risks mentioned above and the organisations mitigations.

 GBAF risks ref. 1.3 and 3.1 relates to the Integrated Contract Management report

 GBAF risk ref. 6.1 relates to the Integrated Contract Management report and the Work of the FRPB and Financial Recovery Programme progress report

 GBAF risk ref. 5.6 relates to the Quality report

6.0 Managing conflicts of interest 6.1 There are no conflicts of interest considerations arising from this report.

Attachments: Appendix 1 - Governing body assurance framework and summary

Author: Pam Dobson, deputy director, corporate services, BHR CCGs Date: 22 June 2017

40 Appendix 1 – NHS Redbridge CCG

Corporate objective 1: Ensuring that planned care is appropriate, timely and of high quality – with a particular focus on tracking the referral to treatment (RTT) delays.

Risk Description: Lead director: Louise Mitchell BHRUT cancer performance standard::The Trust has consistently not achieved the 62 day cancer waiting time target – with

potential clinical risk to the patient pathway impacting on early detection and survival rates. Risk ref: 1.3 Initial Assurances Current Gaps Target Risk Controls I = internal risk Evidence for Proposed actions Rating Rating E = external rating assurance Control Assurance 30/06/17 5/2015

The Integrated Additional remedial 1. Contractual meetings – SPR 1. Minutes of monthly Contract actions agreed for / CQRM. contractual meetings – Management urology specialty to SPR / CQRM and report provides return to the 62 day remedial action plans. (I) greater detail on standard by 31 May 2. Fortnightly cancer the 2017. The data to performance recovery board management of confirm achievement – BHRUT and CCG. 2. Minutes of the cancer this risk. of the May target will performance recovery be available in July. (4) x Impact (4) = Severe 16 = x (4) Impact (4) board. (I) 3. Fortnightly operational stocktake meeting between 3. Weekly cancer 8 (4)Likelihood Impact = x High (2) the CCG, BHRUT and NEL performance pack Likelihood Severe 12 = x Likelihood (4) Impact (3) CSU reviewed with weekly update to EMT regarding potential risks. (E)

Page 1 of 9 41 Collaborative objective 3: Implementation of the system wide urgent care strategy and redesign of the urgent care pathway

Risk Description: Lead director: Alan Steward BHRUT's on-going failure to deliver A/E performance standards will impact, 1) Quality improvement in emergency care, 2) Put patients at risk, 3) Cause reputational damage and 4) Delay the implementation of acute reconfiguration programmes. Risk ref: 3.1 Initial Assurances Current Gaps Target Risk Controls I = internal risk Evidence for Proposed actions Rating Rating E = external rating assurance Control Assurance 30/03/18 6/2013

There are no gaps and the commentary 1. Accident and Emergency 1. Minutes of the monthly The Integrated below provides update. Delivery Board (formerly Accident and Contract the SRG). Emergency Delivery Management A&E Delivery Board leading the Board. (E) report provides transformation programme to deliver greater detail Operating Plan commitments. BHRUT 2. Urgent and Emergency on the – with the support of partners – was Care (UEC) Programme 2. Minutes of the monthly management delivering the agreed STP trajectory but Steering group UEC Programme of this risk. winter surge has impacted on this.

Impact (4) = Severe 16 Steering Group. (E)

3. Contractual meetings – The A&E Delivery Board invited ECIP – SPR / CQRM – and 3. Minutes of monthly (4) x Impact (4) = Severe 16 the national UEC experts – to review contractual levers. contractual meetings – our plans and progress. Key feedback SPR / CQRM. (I) was the focus on the patient flow / 4. Winter only - daily surge discharge and this is now reflected in Likelihood (4) x Impact (3) = High 12

Likelihood (4) x calls with the Trust and 4. Notes of daily surge Likelihood our plans. call. (E) reassurance with NHSE Continued monitoring and management through local performance management framework

Continued liaison with NHSE and the NHSI to provide assurance on delivery, particularly through winter surge arrangements.

Now moving into assurance and support arrangements for 17/18.

Daily winter calls stepped down to bi- weekly.

Page 2 of 9 42

Collaborative objective 5: High quality and compassionate and safe care for all commissioned services – delivering better outcomes

Risk Description: (Two performance areas are grouped together here that BH are failing to achieve) Lead director: Louise Mitchell Barts Health (BH) performance. BH continues to fail operational standards, a) referral to treatment times (RTT) and c) A&E, (specifically Whipps Cross). There are also data quality concerns that present a further challenge for commissioners. This could: Threaten the long-term validity of the Risk ref: 5.4 a and c – (groups the Trust and put patients at risk and cause reputational damage. two performance risks together) Initial Assurances Current Gaps Target Risk Evidence for Controls I = internal risk Proposed actions Rating Rating assurance E = external rating Control Assurance 30/03/18 7/2014

1. Monthly Collaborative Commissioning 1. Minutes of the CCC . 1. Trust to produce 1. Programme BHR CCGs in Committee (CCC) meetings led by the meeting. (E) an initial return to Board to sign attendance at

lead commissioner, Newham CCG national reporting off trajectory Barts Health

Severe (Chief Officer) (CCGs only) trajectory and and road map improvement plan =

) roadmap for meetings for

4 2. Monthly A&E Delivery Board meeting, 2. Minutes of the A&E review at the RTT Whipps Cross as

led by BH Chief Executive, attended Delivery Board. (E) Recovery associated

by Newham CCG on behalf of Programme commissioner.

commissioners. Board by 9 June

2017

3. Bi-monthly Technical Sub Group 3. Minutes of the TSG (TSG) and monthly Contract Review and CRG. (E) Group (CRG) meetings, led by Newham CCG, attended by BH. Likelihood (3) x Impact (4) = High 12

Likelihood (4) x Impact (5) = 20 Severe Likelihood (4) x Impact ( 4. Monthly RTT assurance meeting, led 4. Minutes of the RTT by Newham CCG, attended by BH, assurance meeting. monitoring RTT performance and (E) recovery - site specific remedial action

plans (RAP) in place and monitored.

5. Monthly BH Internal (BHR CCGs) 5. Monthly BH Internal Escalation Review meeting receiving Escalation Review updates on performance (RTT, A&E, meeting report. (I) and diagnostics) and quality.

NB: please note the current rating for this risk is 20 (with a target risk rating of 12) as this is the rating for the higher of the two grouped risks – BH A&E. The risk rating for the RTT risk is 16 with a target risk rating of 8.

Page 3 of 9 43 Risk Description: If Barts Health do not achieve their quality indicators, (Never Events, serious incidents - recurring themes and the 4 harms, 1) Lead director: Jacqui Himbury Healthcare acquired Infections (HCAI), 2) Venous Thrombus embolisms, pressure ulcers and falls), patients may receive poor quality of care and suffer harm. More recently further concerns have developed around the management of serious incidents and complaints as well as compliance with Risk ref: 5.6 Regulation 20 – the Duty of Candour. Initial Assurances Current Gaps Target Risk Controls I = internal risk Evidence for Proposed actions Rating Rating E = external rating assurance Control Assurance 29/12/17 2/2015

1. Contract performance notice 1. Remedial action The Quality

issued. plans and recovery report provides 1. Remedial action 1. Remedial action BHR CCGs in 16 trajectory. (E) greater detail plans for SI and plans received attendance at Barts

2. BH Contract Review Group, on the Duty of Candour and reviewed by Health improvement 2. Minutes of monthly attend by the lead CRG (E) management of the lead plan and CQROA commissioner on behalf of this risk. commissioner meetings for Whipps BHR CCGs 5) = Severe 20 and the CCG and Cross as associated are non- commissioner. 3. Monthly system escalation 3. Letters of escalation compliance and to lead x Impact (4) = High and assurance route from the CCG has commissioners BHR CCGs (Redbridge as escalated to the (4) ) x Impact (

lead) to the Lead (March 2017) (E) 4 lead Commissioners AO – commissioner Newham.

Likelihood (4) x Impact (4) = High 16 Likelihood 4. Minutes of the

4. Barts Health (Whipps Cross) Likelihood ( monthly Clinical Quality CQROA meeting

Review and Oversight (E) Assurance (CQROA) meeting with NHSI and NHSE. 5. WX to self-assess 5. Performance enforcement to determine if any notices issued by the Care notices can be Quality Commission (CQC) closed following an inspection in July 2016.

6. Minutes of the Q&S 6. Quality reports to every Quality Committee and Safety (Q&S) Committee

detailing issues, actions taken

and impact. 7. Minutes of the SI panel meetings. (E) 7. Monthly SI panels including al NEL CCGs

Page 4 of 9 44 Collaborative objective 6: Continued focus on our development as an organisation and health system so that we can meet the challenges ahead and deliver better outcomes, quality and financial efficiency.

Risk Description: (Revised) Significant risks to the delivery of the CCGs' financial plan - legal directions on financial delivery of our QIPP requirements in year and management of any acute Lead director: Tom Travers over activity relating to underlying performance: a) Legal Financial directions, b) If we do not deliver against the CCGs' QIPP plans the CCGs will be in breach of Risk ref: 6.1 its financial control total and c) risk of over performance in acute, continuing care or prescribing activity. Initial Assurances Current Gaps Target Risk Proposed Controls I = internal risk Evidence for Rating Rating actions E = external rating assurance Control Assurance 29/09/17 8/2015

1 Weekly Financial Recovery Planning, 1 Minutes of FRPDM The Integrated 1. Further 1. Working with Delivery and Monitoring group (FRPDM) meetings and risk log and Contract schemes to providers and mitigations for all oversight of the QIPP development Management be identified STP partners schemes (I) process and monitoring delivery against report and the to cover the to identify plan. Work of the savings gap. additional 2 Minutes of the FRPB FRPB and schemes 2 Weekly Financial Recovery Programme Senior Executive ct (5) = Severe 20 Financial continues Board (FRPB) Senior Executive meetings (I) Recovery meetings (revised TOR). Programme 2. Fully 2. PMO project 3 Minutes of the bi monthly progress report functioning controls and 3 Formal escalation route to Finance and Finance and Delivery provides programme monitoring Delivery Committee (F&D) committee (I) greater detail management processes

on the office (PMO). have been

4 Minutes of the JEC (I) management strengthened.

Likelihood (4) x Impact (5) = Severe 20 4 Clinical engagement and leadership Likelihood (4) x Impa Likelihood (2) x Impact (5) = Severe 10 of this risk. Alignment of strengthening via the Joint Executive required Committee (JEC) monthly, FRPB and 5 Report of the independent resource is in F&D committee. review (E) progress and will be in 5 Independent review of finances jointly 6 Minutes of the NHSE place by commissioned with NHSE London assurance September meeting (E) 2017. 6 Monthly NHSE London Assurance 7 Minutes of bi monthly meeting Governing Body meeting (I)

Page 5 of 9 45

NHS Redbridge CCG Governing Body Assurance Framework - overall summary (2015 – 2017)

Current End of year Previous risk ratings Lead / rating forecast Target GBAF Risk description (summarised) risk ref. Aug Oct Dec Feb April June July Sept Nov Jan April June This Last level 2015 2015 2015 2016 2016 2016 2016 2016 2016 2017 2017 2017 time time L Mitchell Failure to deliver national performance 16 16 16 16 16 20 20 20 20 12 12 8 8 8 1.3 standards on cancer at BHRUT for 62 days. 20 A Failure to deliver quality improvement in Steward 16 16 16 16 16 16 16 16 16 16 16 16 12 12 12 urgent and emergency care at BHRUT. 3.1 L Mitchell Failure of Barts Health (BH) to meet a 5.4, number of operational standards, RTT & 16 20 20 20 20 20 20 20 20 20 20 20 12 8 12 a & c A/E, data quality and others. If Barts Health do not achieve their quality indicators, (Never Events, serious J Himbury incidents - recurring themes and the 4 20 20 20 20 20 20 20 20 20 20 20 20 8 12 16 5.6 harms, patients may receive poor quality of care and suffer harm.

T Travers (Revised) Risk of failure to deliver the 20 20 20 16 16 16 20 20 20 20 20 20 8 8 10 6.1 CCG’s budget plans.

Risk Summary Number Total risks last report 5 New risk(s) escalated 0

Risks de-escalated this report 0

Total GBAF risk this report 5

Page 6 of 9 46 NHS Redbridge CCG Governing Body Assurance Framework - overall summary (2013 – 2015)

Initial Previous risk ratings Lead / rating Risk Description May GBAF ref. (June Sept Jan Mar June Sept Nov Dec Feb 2013) 2013 2014 2014 2014 2014 2014 2014 2015 2015

L Mitchell Failure to deliver national performance standards on 12 9 9 9 16 1.3 cancer at BHRUT

A Steward Failure to deliver quality improvement in urgent and 16 16 20 20 20 20 25 25 25 16 3.1 emergency care at BHRUT

L Mitchell Failure of Barts Health (BH) to meet a number of 5.4, a, b operational standards, RTT and A/E, data quality and 20 20 16 20 20 & c others.

J Himbury Quality standards not being met at BH - for C.Diff, and 16 20 5.6 MRSA and FFT

Risks de-escalated from the GBAF

Risk rating Initial risk Target risk Risk description, ref and lead when rating level and date de-escalated

5 x 5 = 25 1 x 3 = 3 2 x 4 = 8 De-escalated April 2017: Failure to meet the 18 weeks referral to treatment times targets at BHRUT. June 2014 March 2017 April 2017

De-escalated April 2017: BH continues to fail a number of operational standard – risk 5.4b, cancer 62 days 5 x 5 = 25 3 x 4 = 12 3 x 4 = 12 target. (This was part of the grouped BH performance risks 5.4 a, b and c). July 2014 March 2017 March 2017

De-escalated in April 2017: If the acute contract activity is greater than planned (under payment by results 4 x 4 = 16 4 x 5 = 20 4 x 5 = 20 (PbR) this could result in higher costs. (This risk has been combined with risk 6.1). June 2016 March 2017 April 2017

De-escalated January 2017: Failure to deliver improved access to IAPT services. (Ref. 4.1) Lead S Morrow. 1 x 1 = 3 3 x 3 = 9 3 x 3 = 9 Sept 2014 31 Dec 2016 31 Dec 2016

Page 7 of 9 47

Page 8 of 9 48 How to interpret the CCG governing body assurance framework (GBAF):

Lead director Risk ratings: This is the executive lead The risk rating is derived from conversation between the lead director (or with responsibility for: nominated deputy) and the risk lead. The risk score is calculated using the risk - managing the risks to the grading matrix. There are three types of risk rating used in the CCG GBAF. corporate objectives and - initial risk rating: this grades the risk as if there were no remedial measures - liaising with the risk lead to in place. This is called the ‘inherent risk’. ensure the GBAF is up to - current risk rating: this grades the risk taking into account the remedial date measures. The remedial measures should aim to 1, reduce the likelihood of the Reporting to the CCG risk materialising, 2, reduce the impact of the risk if it does happen and 3, governing body or other reduce both. committee on progress - target risk rating: this is the level of risk that the CCG is prepared to accept and the level of risk that must be aimed for.

Initial Gaps Target Current Risk Lead Risk Control Assurance Proposed Risk – Risk Description Controls Assurances risk Ref Director Rating actions 1/4/1 rating (June 13) 4 Commissioning 15  Our current control is we have  A regular weekly report 15  A detailed  A regular  Develop 3 Risk ref organisations issued instructions to the CSU is being developed with process for report will new This is a risk Proposed actions are not able to not to pay un-validated the CSU to report on the non contract be validati identifier Where gaps have run patient level invoices. Where we have a progress. invoicing produced on attributed to the been identified, list validations for contract we will pay in line requires for the process the actions required risk by the CCG the first quarter with the contract and monitor  The audit committee urgent audit and to put them into risk lead 3.3 MS to validate non activity. will be updated on development. governance place. contract activity performance to only pay committee Ensure they have a which will  Where there is no contract we validated invoices. named lead and target date present a will develop an alternative financial risk validation process. Until the process is developed we will not pay the invoices.

Risk description Assurance Gaps in controls For each risk note down: Controls Assurances are inevitably ‘bits of What more can be done to Who can be harmed and how What is being paper’ that act as evidence the control the risk and what can they be harmed if the risk done to reduce controls are in place. Examples controls could be improved materialises. the likelihood and include: Gaps in assurance Areas to consider are: harm/ severity of the Job descriptions /organisation charts What associated injury, objectives, claims or risk. Regular reports documentation will litigation, service disruption, One specific risk Contracts / service level agreements demonstrate that the controls staffing and competence, may be mitigated Policies and procedures are in place? morale, financial, external by a number of Minutes / agendas / terms of assessment and adverse controls reference media interest

Page 9 of 9 49

To: Meeting of the NHS Redbridge CCG Governing Body

From: Conor Burke, Chief Officer

Date: 20 July 2017

Subject: Corporate Objectives

Executive summary Each year the CCG agrees corporate objectives that set out our aims for the coming year. We have made progress against a number of last year’s objectives, notably with tackling the delays for referral to treatment (RTT) at Barking, Havering and Redbridge University Hospitals Trust (BHRUT). However considerable challenges remain, particularly in relation to our financial position, for which we received legal directions from our regulator NHS England (NHSE) in March 2017.

There have been a number of system wide developments over the past year, with an increased focus on partnership working, both as part of the north east London (NEL) sustainability and transformation plan (STP), now the East London Health and Care Partnership (ELHCP) and within our local patch of Barking and Dagenham, Havering and Redbridge (BHR) through our Integrated Care Partnership Board, System Performance and Delivery Board and embryonic Joint Commissioning Board.

Our objectives last year focussed on three main transformation programmes: urgent and emergency care, mental health and planned care – specifically the referral to treatment (RTT) challenge. In addition, we also had a specific objective on primary care transformation, ensuring high quality care from services commissioned as well as continuing to develop our CCG and local system into one enabling us to deliver better outcomes, quality and financial effectiveness.

This year we recognise that in order to deliver any of the major improvements that we wish to, we must establish a more sound financial footing through meeting our control totals as directed by NHSE. We know that we cannot do this in isolation and to tackle the in-year and projected financial challenge in BHR that we must work even more collaboratively in future.

The objectives for 2017/18 build on those from last year, with an increased focus on a system approach. They have been revised as follows to cover: 1) financial recovery; 2) development of an accountable care system (ACS); 3) delivery of our transformation programmes for planned, urgent and emergency, complex and mental health care; 4) primary care transformation; 5) high quality safe and compassionate care from all commissioned services.

Recommendations The governing body is asked to:  Consider, discuss and agree the corporate objectives

1.0 Purpose of the report 1.1 To update governing body members on the CCG and system strategic direction and to seek approval for the corporate objectives, which are common across the BHR CCGs.

2.0 Introduction 2.1 This year is the most challenging for the CCG and neighbouring BHR CCGs since our inception. Havering CCG ended last year in financial deficit and collectively we have a £55m savings challenge this year.

2.2 In tackling our most pressing objective last year - addressing the backlog of patients waiting for more than a year for treatment (RTT) at BHRUT, for which Havering CCG received financial directions, the CCG committed significant staff and financial resources. This led to pressure on our budgets of up to £20 million in-year and contributed to the deterioration of the BHR CCGs’ financial position.

2.3 We should however be proud of the work led by the CCGs with BHRUT in successfully tackling the most wide-scale waiting time issue in the NHS. The CCGs were also recognised for our work in supporting BHRUT to exit special measures following their CQC inspection last year. It demonstrates that where we commit to working in partnership, positive results can be achieved.

2.4 The financial position remains the most challenging issue for the CCGs and system in 2017/18. Without a more sound financial foundation, we will struggle to implement the changes that will result in better health outcomes for local people. Conversely, we also know that by making changes and working in a more collaborative way with a ‘population based’ focus through an accountable care system that this will also support financial recovery and better use of resources in BHR.

2.5 The CCGs must demonstrate that we are competent commissioners and able to manage within our means if we are to gain the autonomy we want and need to progress our wider plans.

3.0 The new landscape for the NHS 3.1 In March this year, the refresh of the Five Year Forward View was published: Next steps on the NHS Five Year Forward View1. The plan makes it clear that there are no new funds above the limited increase in the NHS budget already identified.

3.2 There is a clear commitment to create genuine integrated care, putting in place population-based health systems to lead to better outcomes and improved efficiency. The plan also sets out the ambition and priority to improve A&E performance.

3.3 The refresh also makes it clear that the STP is a transitional vehicle, leading to the development of local accountable care systems with new care models and partners working in a more collaborative way. In this respect we are well placed in BHR given the work already underway and agreed through our successful bid for devolution and subsequent business case.

1 Next steps on the Five Year Forward View: https://www.england.nhs.uk/publication/next-steps-on-the- nhs-five-year-forward-view/

4.0 CCG corporate objectives for 2017/18 4.1 Through our positive work across the CCGs and system, we have made progress in a number of areas as outlined above. So it is proposed that the CCG’s objectives for 2016/17 build on last year’s and are as follows:

1. Secure financial recovery, meeting our control target agreed with NHSE, so that we begin 2018/19 on a sound financial footing.

This will be achieved through  Delivery of our system delivery plan and the initiatives within it, including making difficult decisions  Identification of new savings and efficiency initiatives for this year and next  Adhering to strict financial discipline and sound financial governance  Implementation of all recommendations within the well-led review linked to our directions, including further integration of our governance across the CCGs.

2. Development of our accountable care system, through a collaborative population based solution to our system challenges of quality and resources.

This will be achieved through:  Continued development of our joint commissioning approach with BHR local authorities, with a fully functioning and active commissioning board  Further strengthening relationships with our main providers, acknowledging our respective pressures and the incentives in the system that can currently mitigate against a system rather than individual organisational approach  Playing an active part within the STP, with functions released to the NEL level where it makes sense from a quality and economic perspective to operate at that scale (e.g. maternity)

3. Ensuring that we deliver on the objectives within our CCG and system wide transformation programmes to improve planned care, complex care, urgent and emergency services and mental health.  Implementation of the BHRUT/CCGs referral management system, to cover a range of specialties in areas such as gastroenterology  Continued focus on delivery of the national standards for A&E, meeting required trajectories for improvement – supported by creation of a joint senior role with a particular focus on the timely discharge of people from hospital  Improving care for patients with complex needs including pressure care, multiple long term conditions and end of life support  Deliver constitutional standards and QIPP requirements within each programme

4. Continued implementation of our agreed Primary Care Transformation Strategy, recognising primary care as the foundation of our accountable care system

This will be achieved through four key workstreams which underpin the delivery of the GP Forward View, namely:  Provider Development: ongoing development of primary care networks and resilience of individual GP practices, leading to a sustainable primary care model and improved CQC ratings  Primary Care Workforce: developing new roles and implementing support packages to address identified recruitment and retention issues  Quality Improvement (QI): developing skills and methods in QI, reducing variation between GP practices and monitoring improvements in patient outcomes, through

investments in long-term conditions such as diabetes, latent TB and atrial fibrillation  Reviewing the clinical leadership arrangements to enable a better alignment of talent and skills to deliver the required changes from a commissioner and provider perspective

5. High quality, compassionate and safe care for all commissioned services - delivering better outcomes.

This will be achieved through refreshing our Quality Strategy, confirming our quality priorities for 2017/20:  Implementation of the system pressure care improvement plan  Comprehensive quality impact assessments on all proposals/business cases forming part of the System Delivery Plan  Strengthening collaborative commissioning of care for people living in care homes  Addressing key quality concerns such as: reducing the number of people who die from treatable conditions, and improved infection and prevention control  Implementation of the SEND recommendations for children and the ‘Wood Review’ requirements for safeguarding (working with local safeguarding children boards)

4.2 Each objective and programme has a detailed plan for the year which has been quality assured and cross-referenced against others through the programme management office (PMO). The relevant committees and governing body will receive regular update reports so that members can be assured on delivery.

5.0 Resources/investment 5.1 There are no specific resource requirements arising from this report.

6.0 Equalities 6.1 There are no specific equalities implications arising from this report.

7.0 Risks 7.1 The CCGs cannot deliver this level of change alone. We rely on collaboration with our local partners and stakeholders, so our continued focus on developing relationships and a system rather than organisation first approach should help to mitigate this risk.

8.0 Conflicts of interest 8.1 There are no conflict of interest considerations arising from this report.

Author: Marie Price, Director of Corporate Services, BHR CCGs Date: 28 June 2017

To: Meeting of the NHS Redbridge CCG Governing Body

From: Louise Mitchell, Chief Operating Officer

Date: 20 July 2017

Subject: Community urgent care - case for change

Executive summary

Urgent and emergency care (UEC) has been a significant challenge for our health economy for many years with key performance targets, particularly in accident and emergency, not being met.

The Five Year Forward View refresh gives us a new set of urgent and emergency care key deliverables, which we need to address: − Achievement of the ‘4 hour target’ − Comprehensive front-door clinical streaming − Specialist mental health care in accident and emergency departments (A&E) − Integrated urgent care (IUC) - an enhanced NHS 111 service which means more people will speak to a clinician and receive a booked appointment where appropriate − An enhanced primary care offer - which will deliver a bookable general practice (GP) service from 8am - 8pm seven days a week − Standardise non-acute services - including urgent care centres (UCCs) and minor injury units (MIU) - to urgent treatment centres (UTCs)

Local services are inconsistent and fragmented and this confusion can lead to multiple attendances for the same need. Over the last two years we have undertaken several engagement exercises with stakeholders and patient representatives and the clear message from this is that all stakeholder groups view urgent care as complex and confusing and endorse the need to look at simplifying the pathway.

This report provides an update for the meeting on the development of a case for change for community urgent care, as the first stage in a process to review and update the existing model

Recommendations The Governing Body is asked to:  Agree the content of the paper  Agree to an engagement process on the community urgent care case for change  Agree to the development of a pre consultation business case  Agree to the timeline for the development of the commissioning plan

1.0 Purpose of the Report This report provides an update for the meeting on the development of a case for change for community urgent care, as the first stage in a process to review and update the existing model.

2.0 Background and context 2.1 Urgent and emergency care (UEC) has been a key challenge for our health economy for many years with a background that includes:  A complex urgent care system with duplication and fragmentation across services  Challenged health economies and challenged acute trusts  Key performance targets, particularly in accident and emergency, not being met

2.2 As part of the Five Year Forward View (5YFV) and subsequent Urgent and Emergency Care Review, NHS England have introduced a new set of urgent and emergency care key deliverables which include:  Achievement of the ‘4 hour target’  Comprehensive front-door clinical streaming  Specialist mental health care in accident and emergency departments (A&E)  Integrated urgent care (IUC) - an enhanced NHS 111 service which means more people will speak to a clinician and receive a booked appointment where appropriate  An enhanced primary care offer - which will deliver a bookable general practice (GP) service from 8am - 8pm seven days a week  Standardise non-acute services - including urgent care centres (UCCs) and minor injury units (MIU) - to urgent treatment centres (UTCs)

The General Practice Forward View outlines help for struggling practices, plans to reduce workload, expansion of a wider workforce, investment in technology and estates and a national development programme to speed up transformation of services.

2.3 The BHR health and wellbeing system is facing significant challenges and the CCGs financial challenge is to find £55m savings in 2017/18. Key to addressing this is the development of an accountable care system (ACS) in which we will further strengthen partnership arrangements. We are developing joint strategic commissioning, conditions for an integrated system provider response and our locality delivery model of care - all intended to best meet the needs of our people. Our jointly agreed new delivery model is comprised of 10 integrated place based localities based on existing GP networks and these are each developing at pace against agreed plans. In many cases UEC services do not align closely with this vision.

2.4 Over the last two years we have undertaken several engagement exercises with stakeholders and patient representatives to gather views on how we can transform urgent care services. This includes the Barking and Dagenham, Havering and Redbridge (BHR) urgent care conference held on 1 July 2015, engagement with the CCG patient engagement forums, a comprehensive UEC co-design research survey which included many patient events. The clear message from all of this engagement is that all stakeholder groups view urgent care as complex and confusing and endorse the need to look at simplifying the pathway.

The current urgent and emergency care landscape has a complex mix of service types delivered by multiple providers, with a large proportion of this activity being appointments with a GP. The services include:

 2 A&E departments provided by BHRUT (in addition some BHR patients use Whipps Cross and Newham hospitals)  NHS 111 service  4 walk-in-centres  7 GP access hubs Services in scope  3 GP out of hours sites  132 GP practices  Community treatment team  Minor ailments service

2.5 The current spend on our walk-in centres, access hubs and GP out of hours is a total of £10.64m per annum, for NHS111 and our UCCs there is a further £3.84m and in 2015/16 the cost of A&E activity was £23.087m at BHRUT and £4.74m at Barts Health - which is a total spend of £42.3m.

2.6 Significant population growth is projected for BHR. Over 143,000 extra people in the next 15 years which is a 19% increase - equivalent to the size of Basildon. There are also changes to the profile with significant housing developments planned such as Barking Riverside, expansion alongside the Elizabeth line and across Rainham within the current financial context.

2.7 A case for change has been developed as the first stage in a process to review community urgent care and transform the model to meet both the community urgent and emergency care Five Year Forward View requirements, to simplify the pathway in response to stakeholder feedback and to respond to the projected population growth within existing resourcing levels.

The case for change covers the following headings:  What is urgent care?  BHR vision  Executive summary  National and local context  Key urgent care research results  Current provision; complex and confusing  The case for change  Key themes for exploration  Next steps

2.8 The planned key milestones for this process are:

Community urgent care case for change to governing July 2017 bodies for agreement Engagement process on the community urgent care case July – August for change Development of a pre consultation business case July – August Pre consultation business case to governing bodies September Consultation September to December Decision making business case to governing bodies January 2018 Development of the commissioning plan January – March 2018

3.0 Resources/investment 3.1 There is no investment implication identified at this time and this will be need to be developed through the pre consultation business case and decision making business case developments.

4.0 Financial Implications 4.1 There is no investment implication identified at this time and this will be need to be developed through the pre consultation business case and decision making business case development.

5.0 Equalities 5.1 An Equality Impact Assessment (EIA) will be undertaken as part of the pre consultation business case and decision making business case development.

6.0 Risk 6.1 There is a risk of a growing level of demand for urgent and emergency care and a need to address the complexity in the system which this case for change can help to mitigate.

6.2 There are limited reputational and political risks associated with engagement on the case for change. Further risk analysis will be conducted alongside development of the pre consultation business case which will include option development; there is a need to avoid predetermining the outcome of a consultation process.

7.0 Managing conflicts of interest 7.1 There are no conflicts of interest considerations arising from this report.

Appendices: 1. Community urgent care case for change

Author: Carla Morgan Date: June 2017

57 Community urgent care Case for change

Barking and Dagenham, Havering and Redbridge (BHR) clinical commissioning groups (CCG) July 2017

58 Contents

1 What is urgent care? Slide 3

2 BHR Vision Slide 4

3 Executive summary Slide 5

4 National and local context Slide 6

5 Key urgent care research results Slide 7

6 Current provision; complex and confusing Slide 8-10

7 The Case for Change Slide 11-17

8 Key themes for exploration Slide 18

9 Next steps Slide 19

59 2 What is urgent care?

Urgent care is not emergency Urgent care is care needed the care which is provided in a same day. This could include medical emergency when life anything from cuts, minor or long term health is at risk. injuries, wound infections or This could include serious tonsillitis, urinary infections, injuries or blood loss, chest mild fevers etc pains, choking or blacking out

Definitions developed from Keogh with Healthwatch in 2016 as part of the urgent care co-design preparation

“When we need help urgently, we need to know exactly where to go to get the right treatment. Our time should be valued, and we should be treated and sent home as soon as possible”

60 3 BHR urgent and emergency care vision

Our vision for urgent and emergency care

We want local people to receive the right care in the right place, first time. If they do need to be admitted to hospital, we will get them home safely and quickly, with the right support to help them to recover their independence.

No time will be wasted.

Our ambition is to radically transform local urgent and emergency care services, removing barriers between health and social care and between organisations.

61 4 Executive Summary The current community urgent care system is complex and confusing • this is a clear and consistent message from all our engagement work (see slide 7) • there is lots of variation across our community urgent care services which includes: − multiple access routes − inconsistent assessment at first point of access − multiple services providing appointments with a GP − different times of provision (7am-11pm weekdays) − different staff types and diagnostics available in services with the same name (walk-in centres (WICs) and urgent care centres (UCCs)) − a range of providers and limited information sharing between them − variation in how much people use urgent care services across our local area • the complexity and variation within the system leads to: − duplicate attendances for the same health need − poor clinical outcomes − multiple transfers of care − wasted time and resources for both patients and staff − poor value for money − ultimately a poor patient experience

These are common issues across the country and ways to address them have been set out in the62 five year forward view next steps - summarised on the next slide 5 National and local context

The Five year forward view next steps set out the following key deliverables for urgent and emergency care in 2017/18 and 2018/19

The 5 year forward view key deliverables: BHR status

Improve ambulance triage/handover/conveyancing 

Achievement of the ‘4 hour target’ Plans in progress

Comprehensive front-door clinical streaming 

Patient flow which covers the process from admission through to discharge Plans in progress

Specialist mental health care in A&Es 

Integrated urgent care (IUC) - an enhanced NHS 111 service which means more people will speak to a clinician and receive a booked appointment where appropriate and will  support care homes

An enhanced primary care offer - which will deliver a bookable GP service from 8am –  8pm seven days a week This work will address Standardise non-acute services - including UCCs and Minor Injury Units - to Urgent / enhance  these Treatment Centres 63 6 Key urgent care research results

This involved: 10 focus groups & 966 one to one interviews 3,002 telephone interviews (1k per borough) conducted by Healthwatch over the three boroughs in March 2016

People are of people are aware Confusion around services available A&E is seen more than twice as likely 51% of NHS Choices as a as a reliable 24/7, information source B&D 34% 24/7 same-day service to use their GP than go to Hav 31% A&E People tell us they are prepared % of people who did not seek NHS/ Red 36% to wait for treatment in A&E professional advice before visiting: confused % because they are guaranteed to The most commonly used services A&E 39% were be seen and get treatment as UCC 44% Around 1 in 3 people told us they were quickly as possible. 72% GP confused about what NHS services were Long A&E waits are not a 69% Pharmacy available in their local area. deterrent 31% A&E The responses indicate that people 26% WICs of people we called had visited a with long term conditions, and so a walk in centre (WIC) in the last Only 6% said they went to A&E 26% greater need for services, are the six months most confused about what services because they thought they got of people said are available. better care there they had seen 37% their GP with the WICs are more commonly Parents with children aged same issue used by those aged 18-34 0-5 (41%), people with a before going to (34%) and 35-54 (29%). Summary long term illness or A&E. disability (35%) and carers (41%) are all significantly People are confused of people had . more likely to have visited There is a mix of awareness and been to A&E A&E than those who don’t People in Barking and Dagenham and understanding of what services are before with the Havering are more aware of walk in have these 26% available, what they offer and when roles/conditions. same issue centres than those in Redbridge they’re open. Where people knew of those who NHS services such as There is good awareness of the went to A&E said urgent care centres or range of non A&E services, but that they could WICs existed, they people are confused about what 33% were often didn’t know not get a timely each service offers. appointment with their exact location their GP It needs to be simpler 64 7 The BHR current urgent care system is complex and confusing - locations

Summary of the urgent and emergency care services which currently exist across Barking & Dagenham, Havering and Redbridge (BHR): Total of 19 services (across 7 providers): . 2 A&E departments (in addition BHR patients use Whipps Cross and Newham hospitals) . 2 urgent care centres . 4 walk-in-centres . 7 GP access hubs . NHS 111 service . 3 GP out of hours sites . 132 GP practices . minor ailments service . Mobile community treatment team

8 Access route key: route Access

Walk Weekend Weekday Hav Hav BHR BHR BHR BHR BHR BHR Red Hav B&D B&D Red Borough Hav Hav BHR BHR BHR BHR BHR BHR BHR Hav B&D Red Borough B&D Red - in Access via Access Access viaAccess The BHR current urgentcare system is complex and Access Hub: Southdene Access Hub: Fullwell Cross Access Hub: Park Newbury Medical Rosewood Hub: Access Street North Hub: Access Access hub: Broad Street Access hub: Upney Lane WIC Barking - community hospita Service WIC - Orchard Village Wood Harold - WIC UCC Queens - UCC KGH - Pharmacy GP OOHs Practice GP 111 NHS A&E WIC Loxford - WIC - Orchard Village Wood Harold - WIC UCC Queens - UCC KGH - Pharmacy GP OOHs 111 NHS A&E WIC Loxford - Access Hub: Southdene Access Hub: Fullwell Cross Access Hub: Park Newbury Centre Medical Rosewood Hub: Access Street North Hub: Access Access hub: Barking community WIC Barking - community hospita Service Various numbers / call centres centres /call Various numbers 8am - -01-111-12 10-11 9-10 8-9 - -01-111-12 10-11 9-10 8-9 8am -8am 12.30pm Weekends 10am - 2pm / Weekdays 10am - - 2pm Weekends 10am - from 5pm 10am times opening Sunday Various 11am - Weekends 4pm 11am 12-13 Various opening times from - - 10pm times 6am opening Various 12-13 8am -8am 6.30pm 8am - weekends 8pm 8am - weekends 8pm 8am - weekends 8pm 8am - weekends 8pm 8am - weekends 8pm 8am 12pm - Sunday 12pm 4pm 13-14 12pm - Saturday 12pm 5pm 8am -8am 8pm -8am 8pm 13-14 8am -8am 10pm -8am 10pm 14-15 8am -8am 10pm 14-15 call 111 and get a booked appointment slot where appropriatea bookedslot appointment get whereand call 111 15-16 15-16 3pm - Weekdays / 3pm 7pm 3.30pm - Weekends 8pm 3.30pm 61 17-18 16-17 61 17-18 16-17 2.30pm - 10pm - Thursday - 10pm - 2.30pm 6.30pm 18-19 18-19 6.30pm - 10pm Wkdays 6.30pm - 10pm Wkdays 6.30pm - 10pm Wkdays 6.30pm - 10pm Wkdays 6.30pm - 10pm Wkdays 6.30pm - 6.30pm - 10pm Wkdays 6.30pm - Mon/Tues/Weds/Fri 92 02 12 22 32 411223344556677-8 6-7 5-6 4-5 3-4 2-3 1-2 24-1 23-24 22-23 21-22 20-21 19-20 6.30pm - 10pm 6.30pm - 92 02 12 22 32 411223344556677-8 6-7 5-6 4-5 3-4 2-3 1-2 24-1 23-24 22-23 21-22 20-21 19-20 24/7 24/7 24/7 24/7 24/7 24/7 24/7 10pm 3pm -3pm / 7pm Weekdays 6.30pm - 8am confusing variation - 7am 7-8am 66 centres, walk in) walk centres, a majority being being majority a Lots of duplicate duplicate of Lots routes (111, call call (111, routes Multiple service Multiple names names Multiple access Multiple Lots of services services of Lots appointments opening hours attendances Variation in in Variation Variation in in Variation diagnostics connected with a a with but not - despite despite GP GP The BHR current urgent care system is complex and confusing - network area demand

All UEC excluding bloods & wound care - per 1000 population (raw) There is variation in the use of urgent 600 528 527 511 care services 452 478 500 444 446 425 383 across our 400 networks 288 300 200 Havering Phlebotomy and 100 B&D Havering Redbridge wound care are 0 B&D Havering Redbridge delivered by the

East WIC - this has West South North North Fairlop

Central been adjusted in & Loxford

Cranbrook the second graph Wanstead Seven Kings & Woodford Out of Hours NHS Barking & NHS Havering CCG CommunityNHS Redbridge WIC, CCG Community All UEC Raw list Weighted WIC (total AccessDagenham UCC CCG A&E All UEC UC: WIC, OOH & UC activity activity per OOH, Hub & per 1000 1000 CCG Networks size list size activity activity) Hub activity activity Total UCC Hub population population NHS Barking & East 73,929 69,770 6,280 4,699 3,590 6,193 12,075 32,837 20,762 14,569 281 444 Dagenham North 73,353 71,258 6,252 5,263 5,697 7,880 13,714 38,806 25,092 17,212 342 529 CCG West 73,796 67,050 9,620 3,889 6,950 5,645 11,622 37,726 26,104 20,459 354 511 Central 91,068 87,335 9,120 6,671 5,559 7,009 14,679 43,038 28,359 21,350 311 473 NHS Havering North 96,779 97,012 20,275 7,654 5,471 7,142 16,551 57,093 40,542 33,400 419 590 CCG South 86,859 84,649 11,371 5,891 4,575 5,236 12,597 39,670 27,073 21,837 312 457 Cranbrook & Loxford 101,624 88,050 6,966 4,570 8,306 7,862 15,458 43,162 27,704 19,842 273 425 NHS Fairlop 59,192 54,743 1,136 3,963 5,588 3,851 8,143 22,681 14,538 10,687 246 383 Redbridge Seven Kings 62,164 71,937 2,615 3,627 4,834 6,939 11,715 29,730 18,015 11,076 290 478 CCG Wanstead & Woodford 70,412 78,312 407 3,476 5,101 1,576 9,703 20,263 10,560 8,984 150 288 Unregistered 8,462 119 1,676 8,150 3,764 22,171 18,407 10,257 Out of Area 10,598 10,689 1,411 6,516 7,138 36,352 29,214 22,698 Total 718,764 691,804 93,102 60,511 58,758 73,999 137,159 423,529 286,370 212,371 67 Average 298 458 Activity 2016/17. Includes: ED (lowest 3 HRGs and UCC at Queens, KGH, Whipps Cross & Newham hospitals, WIC at Harold Wood, South Hornchurch, Loxford & Upney lane, all GP Out of hours (PELC and federations). 10 The case for change - local population growth projections

25000 21422 20000 18990 15904 16621 15136 15115 14597 15000 13865 11998 10000

5000

0 Growth 2017-22 Growth 2022-27 Growth 2027-32

Barking and Dagenham Havering Redbridge

BHR growth over the next 15 years

Over the next 15 years this is over 143,000 extra people - equivalent to the size of Basildon - 19% increase

68 11 The case for change - primary care

Primary Care . Primary care - the first place to consider for your urgent health needs as your practice provides care closest to home with the best continuity of care. This is beneficial especially for those with complex or long term conditions as a patient’s GP practice takes a more holistic view of care including preventative and other health services, such as immunisations and health checks . BHR commissioners agree that acute hospital care should be reserved for acutely ill patients with the majority of care delivered nearer to home.

Primary Care Capacity . The GMS primary care contract states that practices should provide care for long term condition and life limiting illness management, episodes of ill health and support people at the end of their lives. . None of the GP contracts state how many appointments are provided, however ‘reasonable access’ should be provided. . We know that general practice receive only 7% of the NHS budget - but they provide over 90% of NHS activity - pound for pound this is high value . Our co-design survey reported GPs as the most commonly used service (72%). . We also know that there is wasted capacity within primary care arising from people not attending their booked appointments - audits conducted with Redbridge practices in late 2014 saw this at between 11% and 13% at a cost of £1.2m . Establishing the access hub urgent evening and weekend GP appointment service has delivered significant improvement to access.

Friends and Family Test

GP Friends and family test London B&D Hav Red . BHR practices are consistent with national and London averages % would recommend 88% 85% 88% 90% % would not recommend 7% 8% 2% 5%

Primary Care Strategy . H owever primary care has challenges; and key themes for the development of general practice are that it should be accessible, coordinated and proactive (with a focus on prevention). . The CCGs’ vision for primary care is to combine general practice care (with other services such as community pharmacy, community optician, dentistry and community-based health and social care) into a locality or network care model with more productive general 69 practice at its foundation and GPs overseeing care for their patients. Locality-based care will be proactive, with a focus on prevention, support for self-care, active management of long-term conditions and the avoidance of unnecessary hospital admissions 12 The case for change - emergency care

Our emergency services are under pressure

. The Five Year Forward View refresh tells us ‘Each year the NHS provides around 110 million urgent same-day patient contacts. Around 85 million of these are urgent GP appointments, and the rest are A&E or minor injuries-type visits. Some estimates suggest that between 1.5 and 3 million people who come to A&E each year could have their needs addressed in other parts of the urgent care system. They turn to A&E because it seems like the best or only option.’

. High level of demand is seen at our A&E departments which is increasing (approximately 7% per year at KGH and 5% per year at Queen’s over the last four years). This rate is above demographic growth which has been at around 1.4%

. Despite considerable improvements, BHRUT has consistently failed to meet the 4 hour target over the last 3- 4 years

. Recruitment is a challenge within our ED departments leading to high use of locums . There is an establishment of 18 ED consultants - with 10 in post (46% vacancy rate) . There is an establishment of 223 ED nurses - with 170 in post (24% vacancy rate)

. At Queen’s and KGH hospitals - 16.6% of patients attending did not have any investigation or treatment

. The re-direction trial at Queen’s hospital has demonstrated that up to 30% of patients attending ED do not require a same day urgent care service

. A&E and ambulance services need to concentrate their skills on serious and life threatening conditions 70 13 The case for change - children There has been a significant increase in 0-5s using A&E services over last 2 years (19% increase - 8,000 patients). There is significant growth projected in the number of children within BHR - 47,400 in the next 5 years alone.

The emergency department lead paediatric consultant, conducted an audit from a sample of 100 attendances. This Source: ONS 2014 based sub-national population projections identified 32 children did not need emergency care at A&E. Three main conditions were: • Feverish symptoms (febrile) (does not include co-morbidity or complex health conditions e.g. diabetes, sickle cell) • Gastro - constipation, haemorrhage, abdominal pain and other • Respiratory including asthma Parents with children aged 0-5 (41%), people with a long Key items from the childrens services programme term illness or • Children are proportionately higher users of urgent and disability (35%) and emergency care carers (41%) are all significantly more • Often access more than one service for the same likely to have visited complaint A&E than those who don’t have these • Evidence that in some cases, parents are accessing roles/conditions.

multiple services for a ‘second opinion’ 71 14 Children – from new-born to 18 years of age The case for change - clinical Evidence of repeat attendances for the same health need (duplicate attendance) from our engagement work

of people said % of people who sought NHS/professional of people had they had seen advice before visiting: 37% 26% been to A&E their GP with the before with the same issue before A&E 39% same issue going to A&E UCC 44%

The clinical implications - duplication can lead to many negative clinical results: • No continuity of care • Delay in the patient journey • Increased clinical risk • Contribute to antibiotic resistance • Child or adult protection implications Quantification of duplicate attendances - we know that some NHS capacity is wasted due to repeat attendances for the same health need. This can be caused by the variation in services meaning people’s first choice service cannot meet their health needs due to the different staff types, diagnostics or technology in place; however some of this is also driven by patient behaviour to seek a second opinion Unconnected IT systems mean the full extent of duplication cannot be quantified - however, where we can compare datasets, the level of duplicate attendances was just over 5%; and most of these within 24 hours of the first attendance 3.3%. The highest number of attendances within a 72 hour period was 6 attendances Antibiotic prescribing • In recent B&D GP practice audit, attendances outside the practice were tracked for 1 week. The greatest number of patients attending different services on the same day had a final outcome of having been prescribed antibiotics. GPs anecdotally report patients seeking antibiotics outside of the practice as a clinical concern and a driver of duplication • There is clinical evidence to demonstrate that if patients take too many antibiotics they become resistant to the effects • BHR are amongst the highest prescribers in London with only 1 CCG above us Unregistered population - walk-in services can encourage patients to avoid registering with a GP - 9% of patients attending our 4 WIC services are not registered with a practice - with significant variation between 15% and 3%. The unregistered72 population miss the benefits provided by the GP practices such as continuity and holistic care 15 The case for change - common drivers of duplication

Patient expectation - this could be: A&E is the well known and trusted 24/7 . s eeking a prescription to ‘cure’ the illness, service and people know that they will be seen even though a similar medicine may be within 4 hours, so this can become a default available over-the-counter service for many people . expecting to receive antibiotics and

People tell us they are prepared accessing multiple services until these are to wait for treatment in A&E because they are guaranteed to prescribed is seen A&E be seen and get treatment as as a reliable 24/7, quickly as possible. . expecting to be seen on the same day 24/7 same-day service Long A&E waits are not a deterrent regardless of urgency

Dependence on clinical opinion or lack of confidence to self care. This could be: It’s confusing so people go to the wrong place . lack of confidence or understanding of the first time and need to be directed on to normal progress of symptoms (e.g. a cold another service by staff who may also find the can last up to 14 days) system confusing and therefore default to . r eassurance that nothing more serious is advising patients to go to ‘A&E’ wrong - particularly true for parents of young children 73 16 The case for change - value

Context: BHR CCGs have a 2017/18 in year financial challenge Funding and efficiency of £55m of savings. The system-wide budget gap is over £250m challenges over the next five years • The current spend on our walk-in centre, access hub, urgent care centres, NHS 111 and GP out of hours is a total of Local Authority £14.49m per annum and in 2015/16 the cost of A&E was funding £23.087m at BHRUT and £4.74m at Barts Health – which is a reduction total spend of £42.3m Public Health budget • There is lots of duplication in our urgent care system (approx. reduction 5% of all attendances) - clearly this represents poor value - financial, resources, quality and patient experience • Currently ‘Walk in’ services such as A&E, UCC and walk-in BHR CCG 17/18 centres do not have common assessments and therefore budget gap of over

patients may be seen in urgent care facilities when their need £ is not urgent. The re-direction trial at Queen’s hospital £55m demonstrated up to 30% of ED presentations do not require a same day urgent care services

• Inefficiencies in the patient pathway also arise from a lack of £ BHR UEC spend digital connectivity between these services and the GP record • Across our contracts there are variable contract and payment £42.3m terms. This is both expensive to manage and the unit price for these services can range from around £15 for an NHS 111 call 74 to £153 for an low acuity A&E attendance. 17 Key themes for exploration

 Simplify the system for patients - provide a clear and defined service structure so that patients can be confident about where to go for what e.g. illness/ injury… urgent or emergency and to reduce duplication and inappropriate attendances

 Move towards bookable appointments - the national requirement is bookable from 8am- 8pm daily

 Consistent assessment  consistent assessment and re-direction when booking and at the front door of services where people walk in such as A&E  appointments bookable through centralised systems (phone and online) to increase self care and remove inappropriate appointments

 Plan for the changing profile of population growth

 Provide more local services - this is an opportunity to review the location of where and how services are delivered

 Improved provision for children (newborn - 18 years) as they represent the greatest proportion of attendance growth

75 18 Next steps

 Community urgent care case for change to July Governing Bodies  Subject to outcome of Governing Body discussions, development of a business case for community urgent care in BHR including stakeholder engagement

Case for change key stages and timeline May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18

FRPDM 10/5/17 EMT proposal 11/5/17 UEC, Primary Care and Estates 19/5/17 workshop High level proposal to FRPB 25/5/17 Develop case for change Case for change to GBs Consultation plan and engagement on C4C Develop pre-consultation business case PC-BC to GBs Consultation Mid Sept - Mid Dec Consultation analysis

Decision making paper to GBs Late Jan Service alignment/ procurement IUC 111 go live Service go live 76 19

To: Meeting of the Redbridge Clinical Commissioning Group Governing Body

From: Tom Travers, Chief Finance Officer

Date: 20 July 2017

Subject: Integrated Contract Management Report

Executive Summary

This report follows the existing format but will be the last of its kind, as the recommendations of the Deloitte Well Led Review to create an integrated performance report including finance, activity, performance of services and Quality Innovation and Productivity schemes is presented to the CCG.

This current report concerns the CCG’s main providers - Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT), Barts Health NHS Trust (Barts Health), North East London Foundation Trust (NELFT), Partnership of East London Cooperatives (PELC) and the London Ambulance Service (LAS). Activity and performance data at Month 1 vary in their reliability upon which to base an accurate assessment or risk and develop sound mitigations: as data flows in subsequent months, in particular validated SUS data from acute providers, reliability and the ability to forecast, improve.

The main points of note are:  BHRUT has exited special measures, which is a key step forward for local patients and the health system as a whole.  BHRUT is also ahead of trajectory to return to RTT compliance.  The cyber-attack in May severely impacted on the operational capability of Barts Health NHS Trust.  The IAPT target was not achieved in the last quarter of 2016/17 by NELFT.  The achievement of the required performance trajectory in call answering by LAS remains a challenge.

BHRUT: Following the Care Quality Commission (CQC) inspection at the end of 2016, which found evidence of significant and transformational improvement at Queen’s and King George Hospitals, the CQC made a recommendation, endorsed by NHS Improvement, that the Trust be removed from special measures. Having been placed in special measures in December 2013, the CQC’s recommendation was accepted and the Trust was taken out of special measures in March 2017.

The agreed 2017/18 contract value with BHRUT is £346m (for the 12 CCGs within North East and North Central London), inclusive of CQUIN and agreed QIPP. The QIPP is balanced between that at commissioner and that at provider, financial risk. Redbridge CCG’s contract value is £91.5m. Joint working between the BHR CCGs and Trust on the development of QIPP schemes continues at both a local and STP level. Due to the expected data quality issues with month 1 data, the CCG has reported a breakeven plan. This is expected to be reviewed once the month 2 reporting cycle has been completed. CCG and BHRUT colleagues are working closely to come to a view on the likely risks inherent in the 2017/18 period, from the very earliest stage.

A key change for 2017/18 is the increased reliance on the achievement of the A&E performance

77 trajectory, in order for the System to gain access to STF funding, 30% is now linked to delivery against the trajectory.

Since recommencement of RTT data reporting in October 2016, BHRUT has consistently been ahead of the recovery trajectory and is expected to meet the national standard of 92% for 18 Weeks RTT Incomplete Pathways before September 2017. This therefore means the Trust is highly likely to have returned to RTT compliance ahead of schedule.

Following the issuing of Contract Performance Notices to BHRUT in 2016/17 regarding non-compliance with MRSA and Clostridium Difficile contract standards, the Trust has achieved compliance with the standards for the last 3 reported consecutive months.

The unprecedented global ransomware cyber-attack on 12 May 2017 resulted in approximately 120 elective outpatient appointments being cancelled at BHRUT in order to release capacity for non-elective activity. BHRUT took action to mitigate the impact of the attack including manually fixing all Trust PCs to ensure effective running of clinical systems. The CCG’s Quality Team has visited the Trust post attack and was assured by the steps taken by the Trust to minimise its impact. The Trust is also conducting a post-event review.

Barts Health: The agreed 2017/18 contract value is £93.5m across all BHR CCGs and the share for Redbridge CCG is £62m. No QIPP has been agreed at provider risk and significant further work is required to meet the requirements of the System Delivery Framework.

Due to the cyber-attack on 12 May 2017 and issues with the Trust’s IT systems, Barts Health has been unable to submit month 1 activity data. The Trust is addressing the issue and has agreed with the Co- ordinating commissioner (Newham CCG) that both month 1 and month 2 activity flex data will be available on 27 June 2017. The CCG has reported a breakeven financial forecast position at financial reporting period of month 2.

The May cyber-attack followed 2 previous IT incidents that took place in January 2017 (affecting Newham Hospital’s Pathology system) and April 2017 (affecting pathology and imaging services).

On 9 June 2017, BHR CCGs wrote to the Co-ordinating commissioner outlining concerns relating to the Trust’s resilience against IT system failures, and the impact on patient care and clinical risk. An extraordinary Contract Review Group (CRG) was held with the Trust on 16 June with a further CRG scheduled for 6 July 2017, at which further assurance will be sought from the Trust.

NELFT: NELFT is performing to Quarter 4 (Q4) contracted standards in their community services and mental health service contracts with the exception of the Improving Access to Psychological Therapies (IAPT) access target. The Care Quality Commission (CQC) published their inspection report and rated NELFT as “Requires Improvement” in September 2016. A quality summit has subsequently been held. The Commissioners’ response is being led by the Nurse Director.

PELC: Key activity trends experienced in this contract include an increase in 111 activity in Month 1 maintaining a trend set in 2016/17, a continuing reduction in activity in Out of Hours and relatively stable activity at King George UCC. 111 KPIs continue to be met.

LAS: The 2017/18 LAS contract is commissioned on a pan-London basis. BHR CCGs have yet to sign the contract. It is managed by Brent CCG as the host commissioner. A paper from the CSU has been presented to BHR CCGs on the 2017/18 LAS contract proposal, with details of the outstanding issues for agreement and the key implications linked to the proposed contract. These mainly relate to the contractual terms and the proposed application of contractual penalties for non-delivery of the commissioners’ LAS-related demand management initiatives. 2

The LAS contract value for Redbridge CCG is £10.1m and this is a £0.7m increase on the 2016/17 contract value which includes CQUIN. The month 1 2017/18 LAS performance for Redbridge CCG is reported at 66.2% of Category A calls responded to within 8 minutes against the 75% target. In order to achieve the LAS pan-London demand management reduction of 6.4% for both Categories A&C activities in 2017/18, Redbridge CCG has been allocated a planned demand management reduction figure of 1,831.

Recommendation

The Governing Body is asked to:

 Note the performance of contracted services, the risks therein and note the commissioner actions to address them.

1.0 Purpose of the Report The purpose of this report is to inform the Governing Body on the contract activity and performance for M1 2017/18 for acute where available, community, mental health contracts including the LAS contract, and agree any actions required.

2.0 Background/Introduction This is a report from Co-Director, System Delivery Framework, to inform the Governing Body of the position of acute, community and mental health contracts including the LAS contract at M1 2017/18.

3.0 Contract update

BHRUT – Contract Value for Redbridge CCG - £91.5m

The performance and constitutional standard data is Trust wide, whereas the activity and finance data is CCG specific.

All performance tables included in this report for acute services contain nationally published validated data. Where more up to date data is available, this is referenced in the commentary of the report.

BHRUT Activity Summary

Below is a summary of the BHRUT month 1 activity forecast at Point of Delivery (POD) level (for activity tables refer to Appendix 2)

Urgent Care  A&E forecast activity at month 1 is -4,267 (-7.9%) above plan.  However, Queen’s UCC activity is under plan by 1,362 (38.0%).  The 2016/17 A&E month 1 forecast activity was under plan at (1.9%) and UCC (53.2%) under plan.  This indicates there has been a year-on-year increase in A&E activity at month 1 in 2017/18 in comparison with same period in 2016/17.  There is also a year-on-year increase in month 1 UCC activity in 2017/18.  The monthly emergency attendances (all A&E and UCC at Queen’s) are over plan by -2,904 (-5.0%) at month 1 2017/18, compared with the same period in 2016/17, which was under plan by 2, 232 (3.9%).  This represents an increase in activity in 2017/18 compared with same period in 2016/17.  Non-elective non-emergency activity is also forecast over plan by -1,175 admissions (-30.5%) at month 1 2017/18, although this is partially offset by under performance in non-elective excess bed days which is 1,821 bed days (33.0%) under plan. Planned Care  The largest forecast activity variance from plan is in rehabilitation, which is forecast to under perform by 2,960 bed days (51.9%) in comparison with the same period in 2016/17 at a forecast over performance of -3,051 (-64.1%) at M1.  A change in recording of rehabilitation activity was agreed with the Trust and this has now resulted in the 2017/18 reported forecast under performance position.  The forecast under performance in rehabilitation in 2017/18 is slightly offset by forecast activity over performance in day cases at -1,220 (-14.0%). Outpatients  Outpatient forecast activity at month 1 in 2017/18 is over plan at a variance of -13,017 appointment (-12.8%) compared with the month 1 reported position in 2016/17 at an under performance of 5,190 (4.4%)  The majority of the over performance is seen in outpatient follow ups with a 4

80 forecast activity variance of -8,409 (-17.3%) and outpatient first appointments of -2,950 (-9.6%) over plan.  This has changed from the reported 2016/17 forecast under performance of 8,052 (12%) under performance at M1.

3.1 A&E

Current Position

A&E (all types): BHRUT reported a validated performance of 86.06% in April 2017 and unvalidated performance of 82.73% for May 2017. April’s performance shows that it is below the expected improvement trajectory of 86.30%.

Attendances at BHRUT in April 2017 compared with April 2016 have increased by 4.52%, while breaches have reduced by 22.05%. There have been persistent increases in daily A&E attendance. Over the last six months (October 2016 to April 2017), averaging 789 attendances a day, compared to 762 attendances for the six months prior to this period (April 2016 to September 2016). This is a comparative increase of 3.5% in daily attendance over stated periods.

Drivers for this growth can be identified as - increased attendances in late evenings, increased pressure on resus beds with potential impact on operational efficiency, increases in the proportion of ‘blue light’ ambulance conveyances as well as ambulance conveyances and this could be a driver for the increased demand on resus beds.

The leading causes of A&E breaches remain as follows - wait for the first clinician, wait for A&E triage and bed management.

It is noted that BHRUT continues to face challenges linked to increase in demand on A&E and the availability of a suitably skilled workforce in ED in 2017/18, as reported in 2016/17.

Risks to Delivery

Risks to the delivery of the A&E target are as follows:

• Higher A&E attendances compared to 2016/17. • ED staffing issues, in particular, low proportion of medical rotas (Consultant and Middle-Grade Doctors and bank nursing) that are filled with permanent staff. • Recruitment and development of staff to support appropriately skilled workforce for the enhanced urgent care pathway. • Delayed discharge from poor patient flow through the hospital. • High-acuity of patients and increase in blue light conveyances.

Mitigating Actions

The work streams of the Patient Flow Programme that support the improvement trajectory include Enhanced UCC (urgent care centre) & Redirection; Streamlining Complex Discharges & Discharge to Assess and Early Discharge Planning and Seven Day Services. Ongoing actions within the work streams include:

• Recruitment and development of ACPs (Advanced Clinical Practitioners) to support the non- admitted pathway/Enhanced UCC. • Continuation of redirect at the front door of Queen’s for patients not in need of acute care. • Maximising use of SAFER (Senior review, All patients to have an expected discharge date, Flow 5

81 of patients, Early discharge, Review) bundles of care on wards. • Standardising use of Expected Discharge Dates to proactively manage patients to discharge. • The trial of front loading therapies at the start of the patient journey to support early discharge. • Rehabilitation beds are available to flex up to 10%, with pilot underway to flex criteria to support flow. • Trust full capacity protocol in place to further support discharge where required, involving cancelling training/development and elective procedures to support the non-elective pathway. • Weekly and monthly (multi-agency) Length of Stay (LoS) reviews underway to challenge assessments for longer LoS patients. • In June the System Performance and Delivery Board for BHR agreed a sum of £400,000 to support improvement actions in ‘discharge to assess’ and BHRUT, under the direction and monitoring of the A&E Delivery Board.

The Table below shows the latest available A&E Performance position in 2017/18.

National 2016/17 Unvalidated 2017/18 KPI Site Performance Mar-17 Apr-17 Standard YTD May - 17 YTD

King George H Performance 89.08% 87.09% 89.72% 87.61% 88.60%

Queens Performance 85.24% 81.39% 81.41% 76.12% 78.67% A&E Type I Performance 95% Trust Performance 86.48% 83.25% 84.05% 79.99% 81.93% BHRUT Performance Vs Standard Performance Vs Trajectory King George H Performance 92.23% 90.90% 92.32% 90.99% 91.61% Queens Performance 85.89% 82.18% 82.19% 77.19% 79.60% Trust Performance 88.35% 85.65% 86.06% 82.72% 84.31% A&E All Types Performance 95% Performance Vs Standard BHRUT Trajectory 91.50% 86.30% 86.40% Performance Vs Trajectory No. of waits from decision to admit to Trust Performance 0 6 0 0 0 admission (Trolley waits) over 12 BHRUT 0 hours Performance Vs National Standard

King George H Performance 25.06% 25.76% 25.13% % Ambulance Handovers within 15 100% mins: KPI 1 Queens Performance 27.80% 26.92% 29.32% Trust Performance 27.14% 26.63% 28.22% BHRUT Performance Vs National Standard

King George H Performance 87.58% 89.23% 87.95% % Ambulance Handovers within 30 100% mins: KPI 2 Queens Performance 82.44% 85.83% 84.72% Trust Performance 83.69% 86.69% 85.57% BHRUT Performance Vs National Standard

King George H Performance 109 1434 91 117 Number of Ambulance Handover-30 Queens Performance 496 5568 360 415 0 minute breaches

Accident & Emergency and Ambulance Handover and Ambulance Emergency Accident & Trust Performance 605 7002 451 BHRUT 532 Performance Vs National Standard

King George H Performance 3 12 0 Number of Ambulance Handover-60 0 0 minute breaches Queens Performance 0 29 0 2 Trust Performance 3 41 0 2 BHRUT Performance Vs Standard

King George H Performance 88.52% 87.59% 90.23% % Patient records captured 90% electronically: KPI 4 Queens Performance 93.31% 90.98% 93.22% Trust Performance 92.10% 90.10% 92.41% BHRUT Performance Vs Standard

3.2 Referral to Treatment (RTT) and Diagnostics

Current Position

The latest RTT data available at the time of writing this report is shown and validated in the table below for March 2016/17. In April 2017, the reported performance for incomplete pathways was 89.11% against a planned recovery trajectory of 82.90%. BHRUT recommenced RTT data reporting in October 2016 and has consistently been ahead of the recovery trajectory and is expected to meet the national standard of 92% for 18 Weeks RTT Incomplete Pathways before September 2017. This means that the risk relating to 18 Weeks RTT Incomplete Pathways shifts from assuring delivery to ensuring the delivery in line with the agreed contract values, affordability within the contract sum and ensuring clear plans to stand down capacity within the provider in order for services to remain affordable.

The total number of patients waiting >18 weeks reduced to 3,803 in April 2017/18 from 4,351 in March 2016/17, as the RTT Programme continued to treat patients with long waits.

A total of 4 patients had waited >52 weeks on an incomplete pathway in April, representing a continuing reduction in the number of >52 weeks waiters. The Planned Care programme, following from the RTT Programme Board, will continue to monitor each patient who has waited >48 weeks (an indicator to inform of the potential risk of breaching >52weeks), to understand the reason for the delay and seek assurance that each patient has a plan to progress their pathway.

The Trust continues to be compliant on the diagnostics standard for April 2017.

Risks to Delivery

The key risks to delivery of the RTT Plan is:

 Activity and financial over performance against the agreed contract sums  Increased levels of system capacity that cannot be funded by the CCGs long-term

Mitigating Actions

 The commissioner and BHRUT are working closely to manage the demand for out-patient care. In June 2016/17, the System Delivery Board (SDB), approved the proposals of the two organisations joint Senior Responsible Officers (SRO’s) to establish a business case for whole system planned care demand management, building on the joint success of delivering the RTT backlog  The CCGs will track and manage treatment levels through the BAU contract management processes

The Tables below show the latest available performance positions for both RTT and Diagnostics in 2017/18.

National 2016/17 2017/18 KPI Site Performance Feb-17 Mar-17 Apr-17 Standard YTD YTD

18 Weeks RTT Admitted Trust Performance 60.28% 71.71% 65.61% 77.14% 77.14%

18 Weeks RTT Non-Admitted Trust Performance 81.05% 84.20% 71.64% 85.46% 85.46% BHRUT

18 Weeks Trust Performance 86.39% 88.20% 81.29% 89.11% 89.11% 18 Weeks RTT Incomplete Pathways 92% Performance Vs Trajectory Incomplete >52 week waits Trust Performance 19 3 4

83 National 2016/17 2017/18 KPI Site Performance Feb-17 Mar-17 Apr-17 Standard YTD YTD

Trust Performance 99.45% 99.88% 99.37% 99.53% 99.53%

6 Weeks Diagnostic Waits BHRUT 99% Performance Vs Standard Waits Trajectory 99.00% 99.00% Diagnostic Diagnostic Performance Vs Trajectory

3.3 Cancer Waits

Current Position

The latest cancer data available at the time of writing this report is shown and validated in the table below for April 2017. Validated March data shows that the Trust achieved 7 out of 8 cancer standards. The Trust failed the 62-day urgent GP referral to treatment standard, having met the standard in the previous month in line with the agreed recovery plan (achieving 81.99% against standard of 85%). The main driver for the non-compliance was urology.

As the standard was not met in April 2017/18, the commissioners, on 7 June 2017, wrote to BHRUT requiring:

1. Confirmation of the anticipated combined and specialty level performance positions for May 2017. 2. A full and comprehensive rationale for the reasons for failure to achieve the recovery positions at specialty level also setting out any interdependencies and associated risks, providing patient numbers for all.

On 12 June, BHRUT responded to the commissioner’s letter stating that urology will be compliant by September 2017. The commissioners and BHRUT are working closely together to agree on a feasible and sustainable solution which will deliver the standard at an aggregate and at speciality level.

In addition, the Planned Care Team meets fortnightly to review progress in delivery of the BHRUT cancer recovery plan.

Risks to Delivery

The key risks to delivery of this standard are:

• Lack of capacity within core specialties (urology, lower/upper GI, lung) to deliver additional activity to reduce existing backlogs. • Conversion of patients who have waited >62 days to be moved from the ‘suspected’ to ‘confirmed’ waiting list impacts on capacity at tertiary providers.

Mitigating Actions

• Daily performance reporting in place. • Ongoing, fortnightly operational teleconferences between BHRUT and CCG. • Additional support on MDT and histopathology to be provided via NHSE funding. • Independent clinical input for urology via NHSE is awaited. • Planned Care Programmer Board established across BHR health economy – first meeting on 29 June 2017.

Following the formal communications between the commissioners and the Trust relating to the non- compliance of the 62 Day GP Referral cancer waiting time standard, both parties are making arrangements to agree the terms for the recovery of the standard. Meeting set for 29 June 2017.

84 The Table below shows the latest available performance cancer position in 2017/18. National 2016/17 2017/18 KPI Site Performance Feb-17 Mar-17 Apr-17 Standard YTD YTD All Cancer Two Week Wait (2 Week Trust Performance 96.36% 95.74% 95.17% 95.66% 95.66% 93% Cancer Wait) Performance Vs Standard Two Week Wait for Breast Symptoms Trust Performance 95.52% 93.18% 93.94% 95.56% 95.56% (where cancer was not initially 93% suspected) Performance Vs Standard 31 Day Cancer Wait 1st Definitive Trust Performance 99.40% 99.59% 98.75% 99.40% 99.40% 96% Treatment Performance Vs Standard 31 Day Standard for Subsequent Trust Performance 100.00% 100.00% 99.58% 100.00% 100.00% 94% Cancer Treatments - Surgery Performance Vs Standard 31 Day Standard for Subsequent Trust Performance 100.00% 100.00% 99.80% 100.00% 100.00% Cancer Treatments - Anti cancer drug 98% BHRUT regimens Performance Vs Standard 31 Day Standard for Subsequent Trust Performance 100.00% 100.00% 99.47% 100.00% 100.00% 94% Cancer Waits Cancer Treatments - Radiotherapy Performance Vs NStandard Trust Performance 70.47% 86.22% 75.09% 81.99% 81.99% Performance Vs Standard 62 Day Cancer Wait GP Referral 85% Trajectory 84.00% 85.00% Performance Vs Trajectory 62 Day Cancer Wait Screening Trust Performance 100.00% 96.97% 94.52% 100.00% 100.00% 90% Service Performance Vs Standard 62 Day Cancer Wait Consultant No Trust Performance 89.86% 87.13% 87.54% 89.23% 89.23% Upgrade threshold Performance Vs Standard - - - - -

3.4 Quality

Current Position

The latest available data is for March 2016/17.

MRSA - There were no reported cases of MRSA bacteraemia occurrence in March. In total there were 7 reported cases in 2016/17. There were no cases reported in April 2017.

C.difficile - There were 2 reported cases of C.difficile reported in April 2017. It must be noted that in 2016/17, there were 29 reported incidents. The annual 2016/17 threshold was 30.

Mixed Sex Accommodation (MSA) - There were no MSA breaches in April. There were 7 cases reported in 2016/17.

Venous thromboembolism (VTE) The year-to-date performance in 2016/17 met the standard (95%) at 95.47%

Risks to Delivery

MRSA This standard has zero tolerance threshold. Any breaches at any point in the year would jeopardise the standard. All MRSA bacteraemia infections are subject to root cause analysis investigations to identify lapses of care, and these cases are reviewed at the monthly Joint Infection Prevention Committee (IPC) meeting and penalties applied where applicable. This risk has materialised, and the tolerance of 0 was surpassed for 2016/17.

C.difficile All C.difficile infections are subject to root cause analysis investigations to identify lapses of care, and these cases are reviewed at the monthly Joint IPC meeting. 9

Mixed Sex Accommodation (MSA) This standard has zero tolerance threshold. Any breaches at any point in the year would jeopardise the standard.

Venous thromboembolism (VTE) The standard for this indicator is 95%.

Mitigating Actions

Each case of C.difficile is reviewed via a multi-disciplinary Root Cause Analysis (RCA) meeting incorporating clinical, microbiology, pharmacy, CCG, IPC and nursing teams. An action plan is held by each ward to facilitate learning outcomes and ensure patient safety.

The Trust has implemented a plan to improve the performance of the 95% admission assessments for VTE.

The CQC improvement plan requires BHRUT to report on progress in reducing the risk of VTE in the hospital by ensuring that VTE prophylaxis is offered to patients at high risk and that patients are re- assessed when their clinical or mobility conditions change. This is reinforced by NICE Quality Standards and should be incorporated into BHRUT's VTE Prevention Policy.

3.5 Friends and Family Test (FFT)

Current Position

The Trust’s performance for A&E FFT experienced deterioration in April 2017 with a turnout of 78.13%. This is against the performance trend over the last 6 months which averaged above 81.20. During 2016/17, apart from the month of April, 80% or more of A&E patients responding to the survey would recommend the A&E service to their friends and family.

The Trust performance for inpatients has been maintained consistently through 2016/17, being above 92% of patients who would recommend the service for most of the year. Performance for April 2017 was 92.80%.

Risks to Delivery

The key risks to delivery of this standard are:

• Response rates of the FFT surveys. • Trust capacity to conduct surveys for the FFT.

Mitigating Actions

The Trust has been working in partnership with “I Want Great Care” for Friends and Family Test Surveys since April 2016, with the aim of providing:

• Real-time feedback. • Different ways for patients to provide feedback, either hardcopy or online. • New simpler booklet style surveys. • One set of questions across many areas to provide benchmarking capability.

This also includes initiatives such as recruitment of further patient experience volunteers to assist patients, the introduction of new electronic tablets to capture FFT responses and the introduction of new FFT feedback boards displaying monthly results in a user-friendly way.

The Trust also has a newly formed Patient Partnership Council (PPC) and acts as the patients’ forum which is a key mechanism to oversee patient and public involvement in the work of BHRUT.

FFT performance continues to be scrutinised at Divisional Performance Reviews, which are chaired by the Chief Operating Officer.

The table below shows the latest available FFT performance figures in 2017/18.

Row Labels Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Accident and Emergency Average of Percentage_Recommended 82.18% 81.88% 80.62% 80.03% 80.33% 78.13% %_Not_Recommended 7.46% 7.75% 8.03% 7.25% 8.37% 10.21% Inpatient Average of Percentage_Recommended 92.65% 92.41% 91.75% 90.85% 92.06% 92.80% %_Not_Recommended 1.52% 1.35% 1.76% 1.58% 1.63% 1.17%

3.6 Summary Level Hospital Mortality Indicator (SHMI) – September 2015 to October 2016 (latest reported data)

Current Position

The last nationally recorded information shows that BHRUT's Summary Level Hospital Mortality Indicator (SHMI) rate is 106.8 for the period September 2015 - October 2016 and Hospital Standardised Mortality Ratio (HSMR) is 109.34 for December 2016 for the last 12 months. This is latest data for both indicators. SHMI and HSMR should be interpreted with care and the data should be used as an alert to prompt further investigation rather than as a judgement tool in performance and practice.

The data at the time of publication will be six months in arrears and is published by the Health and Social Care Information Centre (HSCIC).

SHMI and HSMR are routinely monitored at the CQRM – detailed work on sepsis rates is in the planning stage.

Risks to Delivery

The key risks to accuracy and interpretations of these indicators and their values are : • Accurate reporting of data, which are always contested. • Staff recruitment, retention and training, which could adversely impact on patient care.

87 Mitigating Actions

The Mortality Assurance Group (MAG) have reviewed and rebuilt arrangements for mortality review within the Trust, restructuring the process to ensure:

• The identification of avoidable deaths. • Lessons learned from problems in care and contributory factors. • Mortality reviews are recognised as an untapped resource for quality improvement.

Progress to date includes:

• Quarterly mortality data reports to Trust Executive Committee, Clinical Quality Review Meeting, Quality Assurance Committee and Trust Board. • Mortality Review Checklist introduced June 2015 for ‘first cut’ reviews at the time of death. • Understanding avoidable mortality based on HOGAN score. • Established mortality database, over 2500 deaths recorded to date. • Progression of the Divisional Mortality Dashboards, shared with divisional teams August 2016. • Rebuild of MDT MAG – focused remit to review data and drive actions.

The Trust carries out reviews of and identifies learning from, all deaths within the organisation through the MAG, which updates the CQRM.

The Trust has introduced the mortality review checklist as this is an established method of data collection, which incorporates the Hogan Scoring System, to assess the quality of care and treatment being provided and to give an early warning signal if an avoidable death is suspected. Data accuracy is determined by Clinician Input. All pro-formas are reviewed weekly by the Clinical Outcome Manager and Associate Medical Director and escalated appropriately.

Barts Health Trust (BHT) – Indicative Contract Value for Redbridge CCG - £62.0m All reporting reflects the Trust wide position

There is no activity data on month 1 due to the cyber-attack and a financial breakeven position is forecast at month 2.

3.7 A&E

Current Position

A&E (all types): Barts Health Trust (BHT) did not achieve the A&E national standard in April 2017, achieving 81.81% and the reported final year-to-date position in 2016/17 was 86.06%. Barts Health has now resumed daily A&E performance reporting, this was suspended from 12 May 2017 to 11 June 2017, when the full data became available again.

This has resulted in twice monthly assurance meetings with regulators. Following a meeting with Steve Russell (Executive Regional Managing Director for London at NHS Improvement) and Anne Rainsberry (Regional Director for London, NHS England) in April, the Trust and WEL system have reviewed and consolidated the A&E Improvement Plans across the whole system. Building on the current governance structure of Urgent Care Working Group (UCWG) and A&E Delivery Board, a PMO approach is to be taken to managing the programme across both acute and community settings to deliver the required trajectory.

Progress in meeting that trajectory has been impaired by the IR35 (tax legislation designed to combat tax avoidance by workers supplying their services to clients via an intermediary, such as a limited company, but who would be an employee if the intermediary was not used) issues and difficulties in recruiting locums and both the diagnostics IT issue. Risks to Delivery

 The BHT and WEL system has been categorised as Group 2 in the National Groupings of Urgent and Emergency Care (UEC) systems, with a low level of performance and high breach volumes that require regional intervention and support.

 Progress in meeting that trajectory has been impaired by the IR35 issues and difficulties in recruiting locums and both the Diagnostics IT issue.

Mitigating Actions

 Twice monthly assurance meetings with regulators have been commenced.

 Building on the current governance structure of UCWG and A&E Delivery Board, a PMO approach is to be taken to managing the programme across both acute and community settings to deliver the required trajectory.

 Barts Health has reset the recovery plans for each of its sites and revised the STF performance trajectory for 2017/18 delivering 90% by September 2017 and with a more ambitious recovery trajectory to achieve and sustain 95% by March 2018.

Targeted actions with a national focus include freeing up bed capacity through:

89 • Improving access to home care or care home places.

• 7 day discharge capabilities including trusted assessor and discharge to assess.

• Comprehensive front door streaming.

• Improved support for care homes.

• Access to clinical advice within the 111 service.

• Reducing ambulance conveyances through hear and see & treat care.

• Standardising urgent care pathways.

• Rolling out increased access to GP appointment at weekends and evenings.

The national importance of this programme is demonstrated by the allocation of the 30% performance element of the STF for 2017/18 focused on the urgent and emergency care agenda. National funds have also been allocated to support improvements in social care, streaming and 111.

The revised trajectory has been signed off by commissioners and included in the operating plan submission uploaded on the 30 March 2017.

90 The Table below shows the latest available A&E Performance position in 2017/18.

National 2016/17 KPI Performance Feb-17 Mar-17 Apr-17 Standard YTD Trust 76.17% 80.46% 81.02% 77.99% Performance A&E Type I Performance 95% Performance Vs Standard Performance

Vs Trajectory Trust 82.58% 85.72% 86.06% 81.81% Performance Performance A&E All Types 95% Vs Standard Performance Trajectory 92.30% 90.30%

Performance

Vs Trajectory No. of waits from Trust 0 0 2 0 decision to admit to Performance 0 admission (Trolley Performance

waits) over 12 hours Vs Standard % Ambulance Performance 50.89% 48.60% 46.30% Handovers within 15 100% mins: KPI 1 Performance 31.16% 28.30% 30.47%

% Ambulance Performance 99.94% 92.81% 92.46% Handovers within 30 100% mins: KPI 2 Performance 86.23% 77.70% 78.49%

Performance 0 160 261 152

Number of Ambulance Performance 141 303 1645 266 Handover-30 minute 0 Trust 141 463 1906 418 breaches Performance Performance

Accident & Emergency and Ambulance Handover Ambulance and Emergency & Accident Vs Standard Performance 0 1 1 2

Number of Ambulance Performance 15 30 183 12 Handover-60 minute 0 Trust 15 31 184 14 breaches Performance Performance

Vs Standard % Patient records Performance 87.80% 89.98% 89.39% captured 90% electronically: KPI 4 Performance 84.87% 88.74% 87.81%

3.8 Referral to Treatment (RTT) & Diagnostics

Current Position

The Barts Health Trust Board took the decision to suspend national RTT reporting from October 2014 due to a lack of confidence in the quality of the data being submitted following the migration of the old

91 Whipps Cross site Patient Administration System (PAS) to Cerner. As a result of the cyber-attack the Cerner upgrade due at Newham Hospital was brought forward, resulting in an increase in the number of un-validated patients, delaying confirmation of the final PTL number.

As it stands, BHR CCGs cannot be clear on the total number of their patients, as is the case with all CCGs, waiting for care at Barts Health. This represents a significant quality of care and financial risk.

Risks to Delivery

A Phased Data Quality Plan was put into place, as part of which 4.2m pathways were extracted from the PAS system. Following the application of national and local rules as well as manual validation, a cohort of 25,000 patients remained whose pathway status was unknown. A patient contact exercise followed and of the 25,000 patients, 3,500 patients fed back that they were actively waiting for an appointment, however these pathways were not apparent on the PTL.

The Trust concluded that a full review of its electronic logic was required utilising alternative logic available through Cymbio applications and the Trust was required to undertake another significant validation programme of 69,831 pathways. Despite the IT Cyber-attack the Trust has been able to complete this exercise with only 2 weeks delay to the original timeline of end of May 2017, however resources allocated to validating the BAU Patient Tracking List (PTL) were diverted to supporting the backlog of paper records onto the Patient Administration System (PAS) and has resulted in an inflated PTL and a requirement for further validation.

The number of over 52 week waits has also significantly increased both as a consequence of the addition of validated pathways and the inability to validate due to lack of access to electronic patient records. In addition, the IT problem forced an early migration from the Newham black box resulting in a further 10k pathways needing validation.

Staff RTT training remains a risk and the Trust was asked by commissioners and NHSE on 30 May, to escalate this to the Director of Operations and to secure a date for the first training sub group meeting.

Mitigating Actions

All patients on both outpatient and admitted pathways affected by the IT problem have been rebooked on the Whipps Cross and Newham sites and partially on the Royal London and St Barts sites. Plans are in place to rebook all outstanding patients by July 2017.

A return to national reporting remains reliant on other interdependencies and actions within the RTT recovery action plan. The Trust aims to produce a trajectory and roadmap to national reporting for sign- off with internal and external stakeholders. Due to the dependency against actions relating to data quality, validation and training, a completion date can only be set once these project elements are complete.

Demand and capacity modelling has been received for orthopaedics and this is currently being reviewed by the CSU. Specialty and site level recovery trajectories are still to be clarified and understood.

As part of the joint Trust/IST PTL assurance process, the Trust plans to carry out a series of sampling exercises equivalent to approximately 3k validations to ensure the integrity of the data.

92 Current Position

The national standard for 6 weeks diagnostic waits was achieved in March 2017 (M12) with performance of 99.59%. This represented achievement of the standard for the ninth month in succession.

Barts Health has not submitted diagnostic data for April 2017. Due to the cyber-attack, the Trust is in a process of recovery and has agreed a later submission of this data with UNIFY.

The Table below reflects the latest available diagnostics data position in 2017/18

National KPI Performance Jan-17 Feb-17 Mar-17 2016/17 YTD Standard

Trust Performance 99.21% 99.42% 99.59% 99.21%

6 Weeks Diagnostic Waits 99% Performance Vs Standard

Waits Trajectory 99.17% 99.17% 99.17%

Diagnostic Diagnostic Performance Vs Trajectory

3.9 Cancer Waits

Current Position

The latest available data as shown in above table is for M12 2016/17.

At Barts Health:

The cancer 2 week wait performance for March was 97.85% compared to the standard of 93% and this has been met consecutively for the last 22 months.

The 62 day urgent referral performance for March was 85.99% compared to the standard of 85%. Overall year view shows that this standard was met for 9 out of 12 months.

At the Whipps Cross site:

The cancer 2 week wait performance for March was 98.1% compared to the standard of 93% and this has been met consecutively for the last 23 months.

The 62 day urgent referral performance for March was 93.8% compared to the standard of 85%.

Risks to Delivery

Risks to delivery continue to include:

 Diagnostic delays.  Capacity delays.

93  Late referrals from other providers.

Mitigating Actions

In response to the sustained poor performance in 2014/15 and 2015/16, Commissioners took a number of actions to turn around the cancer delivery at the Trust in 2016/17 and these included:

• Serving a Contract Performance Notice (CPN) which required the development of a Remedial Action Plan (RAP) for Cancer, RTT and Diagnostics. These are reported to the BH National Standards Performance Committee where senior level representation from WEL CCGs, NHS Improvement, NHSE Specialised Commissioning and the CSU hold the Trust to account.

• Many of the actions in the RAP have been completed and those that weren’t, were rolled forward into the Service Development and Improvement Plan in the 2016/17 Contract.

To oversee the Cancer Improvement Programme the Trust has put in place permanent senior clinical and managerial resources; a Clinical Director of Cancer Performance & Improvement, a ‘managerial’ Director of Cancer Performance & Improvement, a General Manager for Cancer Performance and Data Analysts.

The SDIP programme includes a number of service developments and enhanced quality requirements:

• GP direct access or ‘straight to test’ diagnostic tests with targets for reduced reporting times. • Reducing variation within pathways. • Implementation of the Macmillan/NCSI ‘Recovery Package’. • Adoption of stratified follow-up and self-management programme.

The 62 day trajectory for 2017/18 and 2018/19 continues to profile a non-compliant position for two months, based on actual outcomes, these months are now August and January where the highest impact of patient choice delays are expected.

Barts Health is working with BHRUT to improve late inter-provider transfers.

There are monthly Contract Technical Sub-group meetings, led by the WEL CCG collaborative, where performance is scrutinised.

The WEL CCG collaborative has engaged in NCEL sector fora with other commissioners, providers and other regional partners to improve inter trust referral transfer performance.

The Trust continues to mitigate the impact of the IT problem and is working to compliance and the agreed STF trajectory for Q1.

94 The Table below show the latest available performance positions for cancer wait in 2017/18.

National KPI Performance Jan-17 Feb-17 Mar-17 2016/17 YTD Standard All Cancer Two Week Wait (2 Week Cancer Trust Performance 98.34% 97.64% 97.85% 97.75% 93% Wait) Performance Vs Standard Two Week Wait for Breast Symptoms Trust Performance 98.36% 100.00% 99.05% 99.27% 93% (where cancer was not initially suspected) Performance Vs Standard Trust Performance 96.07% 96.64% 98.62% 97.38% 31 Day Cancer Wait 1st Definitive Treatment 96% Performance Vs Standard 31 Day Standard for Subsequent Cancer Trust Performance 94.51% 96.97% 95.06% 96.53% 94% Treatments - Surgery Performance Vs Standard 31 Day Standard for Subsequent Cancer Trust Performance 100.00% 100.00% 99.42% 99.73% 98% Treatments - Anti cancer drug regimens Performance Vs Standard 31 Day Standard for Subsequent Cancer Trust Performance 97.41% 99.12% 100.00% 98.94% 94% Treatments - Radiotherapy Performance Vs Standard

Cancer Waits Trust Performance 84.72% 86.21% 85.99% 85.69% Performance Vs Standard 62 Day Cancer Wait GP Referral 85% Trajectory 83.50% 85.71% 86.46% Performance Vs Trajectory Trust Performance 94.74% 92.59% 95.83% 93.95% 62 Day Cancer Wait Screening Service 90% Performance Vs Standard Trust Performance 86.17% 85.37% 88.73% 87.53% 62 Day Cancer Wait Consultant Upgrade No threshold Performance Vs Standard - - - -

95 North East London Foundation Trust (NELFT)

3.10 Community Health Services (CHS) – 2017/18 Contract Value for Redbridge CCG £20.5m

Current Position

This section focuses on the latest quarterly performance data. Monthly review of performance occurs within the quarterly business cycle and significant exceptions will be reported to Governing Body when they occur.

NELFT Key Performance Indicator (KPI) and CQUIN performance is reported quarterly in line with contractual targets and the quarterly service and performance review (SPR) closedown process.

Performance Management (Q4)

Q4 performance data has been received with an initial review of performance data undertaken at SPR on 26 May 2017. The highlights are set out below:

KPIs:

• All KPI targets have been achieved in Q4. • Community Treatment Team (CTT) numbers of new patients referred and conversion rate targets met. Number of referrals is 34% above the required target for new patients referred in the quarter, with acute conversion rate of 7% against maximum of 12%. • Intensive Rehabilitation Service (IRS) numbers of patients referred continues to over-perform across BHR, in Redbridge this represents 81% above target to date. • No reported cases of MRSA or Clostridium difficile.

CQUINs:

• NHS Staff health & wellbeing – NHS staff survey (based on 3 staff survey questions on health and wellbeing, MSK and stress). The required 5% improvement based on 2015/16 results was not achieved with relevant partial payment and withholding rules applied. • NHS Staff health & wellbeing – Achieving an uptake of flu vaccinations by clinical frontline staff by 75%. Initial review highlights 50% of front line staff had been vaccinated. This CQUIN was not achieved with the relevant financial withholding applied.

RTT:

• No reported breaches of the 18 week Referral to Treatment (RTT) complete/incomplete pathways across NELFT paediatric and adults services.

Other Highlights:

• Patient experience and satisfaction across CTT in Q4 was 100% based on 5x5 survey results. • Patient experience and satisfaction across IRS in Q4 was 100% based on 5x5 survey results. • Patient experience and satisfaction across Community beds in Q4 was 93% based on 5x5 survey results. • Looked After Children (LAC) Initial Health Assessments (IHAs) completed with 4 weeks = YTD average 87%. • Child Protection Medicals completed with 48 Hours = 100%. • CTT / LAS attended 337 calls and kept 238 (70%) of patients at home against plan of 260. • Admission avoidance at Queen’s Hospital via CTT acute hub remained high with 251 referrals against a plan of 132, with 95% of referrals preventing an acute admission. • IRS inreach into orthopaedic and geriatric wards at BHRUT identified and managed out of the acute 326 suitable patients for community support against a plan of 325 in the quarter. • Percentage of Community Matron Care plans that have been agreed by patient /carer remains 20

96 high during the quarter, at 99%. • Community Rehab Average Length of Stay (ALoS) remains within the benchmark position of 21 days with average Q4 position for Foxglove at 17 days and Japonica at 19 days. • Occupancy rates for the general rehab beds remains high and consistent with previous years, averaging 93% across both Foxglove and Japonica wards.

North East London Foundation Trust (NELFT) 3.11 Mental Health Services (MHS) – 2017/18 Contract Value for Redbridge £24.7m

Current Position

The Q4 performance for selected KPIs is set out below. It should be noted that the Redbridge IAPT service has still not quite achieved its quarterly improving access to psychological therapies (IAPT) access target, although current performance is much improved compared with last year. The Recovery target performance has been achieved.

KPI Name Borough Target Q3 Performance Q4 Performance IAPT Access Redbridge 3.75% 3.24% 3.62% IAPT Recovery Redbridge 50% 48.24% 50.55% IAPT Waiting times: Redbridge 75% 96.70% 97.80% percentage of people referred to the IAPT programme begin treatment within 6 weeks of referral IAPT Waiting times: Redbridge 95% 100% 100% percentage of people referred to the IAPT programme begin treatment within 18 weeks of referral

All other mental health KPIs have been met including the important new EIP target of 50% of people experiencing a first episode of psychosis being treated with a NICE approved care package within two weeks of referral. Q4 performance is 90.9%

Q4 performance:

As reported at Q2 and Q3, high pressures on inpatient occupancy of the psychiatric acute wards at Goodmayes Hospital continue. Rising demand on NELFT beds to levels consistently above 100% occupancy occurred during 2016 until remedial actions were taken by NELFT (above 100% occupancy means that patients who are on trial home leave have their beds used by other patients).

Whilst the mitigating actions have moderated the bed pressures, the occupancy does still remain high. This persistent high demand for inpatient beds reflects trends across London. At times this requires placements by NELFT with alternative providers. Commissioners are in active discussions with the provider on necessary steps to support the Acute Mental Health Services pathway and deadlines have 21

97 been agreed for the detail of demand and capacity information to support decision making.

CQUINs:

NHS Staff health & wellbeing – NHS staff survey (based on 3 staff survey questions on health and wellbeing, MSK and stress). The required 5% improvement based on 2015/16 results was not achieved with relevant partial payment and withholding rules applied.

• NHS Staff health & wellbeing – Achieving an uptake of flu vaccinations by clinical frontline staff by 75%. Initial review highlights 37% of front line staff had been vaccinated. This CQUIN was not achieved with the relevant financial withholding applied. • Improving physical healthcare to reduce premature mortality in people with severe mental illness - Cardio metabolic assessment and treatment for patients with psychoses: The NELFT Q4 performance on this element of CQUIN is to be determined by a national audit; the results of which are still awaited.

Risks to Delivery

a) There remains a key risk in relation to the IAPT Access and Recovery targets.

b) The Early Intervention in Psychosis (EIP) is a new target, with a high risk of achievement failure due to small numbers in patients in the service, which can be fewer than 10. This small demand can have a significant impact on provider percentage performance achievement, for only one patient breach.

c) Pressures on occupancy in the psychiatric acute ward beds are posing significant operational challenges.

Mitigating Actions

a) IAPT: The CCG clinical lead continues to support work to achieve IAPT targets with the provider and GPs

b) EIP: There is an applicable contractual penalty in the event of quarterly failure. In order to develop an understanding of the reasons why targets may be missed, we require NELFT to report on all cases where EIP patients were not seen within the specified standard timescale. This enables us to identify whether entering treatment after two weeks is a data recording issue, service delivery issue, or whether the specific circumstances of the particular cases suggest valid clinical reasons for delay.

c) Under the leadership of the Nurse Director, commissioners are supporting NELFT and seeking assurance that the requirements to improve quality and safety identified in the CQC report are being met. Placements into out of area hospitals if required due to capacity constraints are paid for by the provider trust (NELFT) rather than the CCGs. Such placements are reported for quality assurance purposes to commissioners. Detailed discussions continue with NELFT to ensure that the pressures in the acute care pathway are understood and a plan to mitigate them agreed.

The PELC contract covers GP Out-of- Hours (OOHs), 111 and Urgent Care Centre (UCC) King Georges Hospital (KGH)

Following the ‘Well Led Review’ and Action Plan in 2016/17 PELC has achieved a level of financial sustainability based on the contract agreed for 2016/18. Enhanced support to the WLR Action Plan ended in 2016/17 and PELC have taken forward actions including recruitment to senior posts, including a new Chair. Further development of WLR themes e.g. of internal governance is continuing.

Key activity trends can be summarised as; increase in 111 activity in Month 1 2017 maintaining trend set in 2016/17, continuing reduction in activity in Out of Hours and relatively stable activity at King George UCC.

3.12 PELC Performance

Current Position

111

111 call volumes have increased by 34% in April 2017 compared to the same time last year. In part this increase reflects telephony developments which now allocate mobile network calls correctly to BHR but there is an underlying increase in 111 usage.

Selected KPI: PELC’s performance for calls answered within 60 seconds at 96.8% comfortably met the 95% target. Call abandonment rates are within target.

The percentage of calls disposed to Green Ambulance despatch which have been clinically re-triaged has been consistently improving and has been achieving over 65% in recent weeks as it continues to support LAS and prevent non-essential attendances to ED.

Out of Hours (OOH)

The activity has again decreased in OOH in April 2017 by -5.37% in Redbridge CCG, compared to same period in 2016/17 (note that whilst OOH calls are routed through 111, they are only a proportion of 111 calls and changes in overall 111 activity can occur in a different trend compared with OOH).

Performance against KPIs has improved in April and all KPIs were reported Green or Amber. Amber KPI relate to ‘call backs’; calls are prioritised based on clinical acuity and any delays in call backs to patients are risk assessed.

UCC

Activity at King George Hospital (KGH) has increased by 3.16% in April 2017 compared to the same period in 2016/17. However achieving a sustained increase in patients directed to UCC rather than A&E is proving challenging. Overall utilisation at King George Hospital (KGH) UCC was 30.33% in April 2017.

Patients attending UCC are streamed by PELC at point of entry. A CCG led audit of streaming has been undertaken and opportunities to improve streaming and UCC utilisation have been jointly explored with the provider.

Risks to Delivery

• Maintaining organisational development required by the Well Led Review may prove challenging 23

99 now that external support has ceased • Improving activity within UCC and increased direction of patients following screening to UCC rather than A&E is stalling and risks failing to support A&E improvement sufficiently • Integrated Urgent Care Procurement may potentially lead to a change in provider (dependent on outcome of bidding process for the contract) and will require a different delivery model; both circumstances will raise risk to service continuity. This is a medium term risk, new service due on April 2018.

Mitigating Actions

• Assurance in respect of provider governance underpinning service delivery is within scope of SPR/CQRM • Commissioners are working closely with provider on service improvement, potentially further incentivising increases in activity to UCC • Robust mobilisation plan will be developed with NE London procurement project

100

London Ambulance Service (LAS)

Contract Value for Redbridge CCG – £10.1m (2017/18)

3.13 LAS performance for Redbridge CCG

Current Position

LAS Performance Pan-London

The 2017/18 LAS contract is commissioned on a pan-London basis. BHR CCGs have yet to sign the contract. The lead CCG remains Brent. BHR CCGs’ allocation of the pan-London 2017/18 LAS contract value is £28,539,368. A paper from the CSU was presented to the BHR CCGs on the implications linked to the proposed contractual terms. The contractual terms relate firstly to the STP rejecting the LAS proposed billing arrangements for over/under performance being sent to the STP rather than individual CCGs directly and secondly, to improve patient care, the commissioners’ proposal for the transfer time to the preferred place of death for patients on an End of Life (EoL) pathway to be undertaken by LAS within the patient’s last 48 hours, instead of 24 hours in the 2016/17 contract.

LAS performance pan-London continues to underperform against the national target at month 1 of 2017/18. Category A performance in April 2017 is reported at 73.7%. The LAS is aiming to achieve the pan-London national standard of 75% by 1 October 2017.

The 2017/18 pan-London contract activity plan is based on 2016/17 activity with 6% uplift for growth. A further 3% growth will be paid at 75% marginal rate on a cost / volume basis reconciled by STP area on a quarterly basis and cost applied to individual CCG at the rate of demand generated. Cost per case is payable at £211 for activity above the baseline (2016/17 + 6%). CQUIN is not payable on over performance. Over- performance is capped at 9% total (the 6% plus the 3%). If activity exceeds this then all parties commit to formally renegotiating the contract to determine the causes and assess the full range of potential options to address. Should activity fall below the funded 6%, up to 2% (reducing the 6% to 4%) will be withdrawn at the 75% marginal rate. Again, this is payable on a cost per case basis or £211. If activity is lower than 4% then both parties commit to contract renegotiation as above.

In order to facilitate the change in billing, freeze data submission dates and quarterly closedown dates have been agreed.

101

LAS and Redbridge CCG The LAS contract value for Redbridge CCG is £10.1m and this is a £0.7m increase on the 2016/17 contract value and includes CQUIN. The April 2017/18 LAS performance for Redbridge CCG is reported at 66.2% of Category A calls responded to within 8 minutes against the 75% target (see graph above). There has been a 3.4% decrease in total demand in April 2017/18 (inclusive of incidents, Hear & Treat and Surge) when compared to the same in 2016/17. In month 1 of 2017/18, Redbridge CCG actual activity positions for both Categories A and C activities are 1,410 and 1,372 respectively (the phasing for the activity plan is in the process of being finalised).

In order to achieve the LAS pan-London demand management reduction of 6.4% for both Categories A&C activities in 2017/18, Redbridge CCG has been allocated a planned demand management reduction figure of 1,831 (943 for Category A and 888 for Category B respectively).

Risks to Delivery

The key risks to delivery of this standard are:

• Non-delivery of commissioners demand management plans resulting in increase in LAS activity. • Delivery against the pan-London 6.4% demand management target. • 111 conversions to 999 calls across London • Increase in ambulance handover times / job cycle time. • Use of different UCC protocols used in the 2 UCCs at Queen’s Hospital and KGH.

Mitigating Actions

BHR CCGs Demand Management

The CSU’s June 2017 paper serves to inform and support decision making.

LAS NEL Demand Management

The second NEL Demand Management meeting with the LAS was held in April 2017 to discuss challenges in the footprint and plans to reduce activity. The following areas were covered at the meeting and at subsequent forums:

Care Homes

• A number of schemes are underway in the STP to reduce call-outs to the LAS and unnecessary conveyances to A&E. • Educate and training of Care Home staff on best practice taking place e.g. ‘Significant Seven’ training programme in BHR CCGs.

Frequent Callers

• Ensuring that CCGs have the required forums for discussing and managing frequent callers via the Urgent Care Network. • Awaiting details of NEL Stakeholder Engagement Managers to obtain latest data.

ACPs

• Work underway to improve the utilisation of Alternative Care Pathways (ACPs) across the STP, which includes reviewing access criteria and failed referrals.

102 • MiDoS will be the platform to host the ACPs and the NEL CSU Directory of Services Team is working on developing the tool and familiarising the LAS Clinical Hub (CHUB) with its functionality. • The initial plan is to promote the top ACPs per CCG e.g. Rapid Response and GP Out of Hours, and get these on the home page of the MiDoS tool, and eventually in ambulances via mobile devices. In the interim, the STP is looking at producing ‘business cards’, which captures this for ambulance crews. • The STP is also looking at placing ACP representatives (possibly with an LAS manager) at A&E to greet arriving ambulances and discuss whether the patient could have been treated by the ACP.

111

• The PELC services in the STP aim to monitor and re-triage green ambulance dispositions, where a target of 60% is taken through enhanced assessment. • Also, in the STP, 111 callers are asked whether they have contacted other urgent care services including LAS services within the previous 24 hours. PELC is the only 111 provider that currently captures this data. Between April and August 2016, 1,282 calls were received by PELC that had been previously in contact with 999 services. When LAS is operating under surge Red currently, it is recognised that LAS redirects identified callers to 111 for assessment where appropriate.

Analysis by the LAS is also underway to understand the case mix of patients that are conveyed to EDs in the STP.

Addressing hospital handover delays continue to be a key focus for the Trust, and an action plan has been developed to address issues relating to the Trust’s handover to green performance. The Trust continues to be involved and participates in discussions with system wide partners to improve overall hospital handover performance.

The BHR health economy continues to have in place services that support demand management and prevent conveyances. These schemes include the Community Treatment Team (CTT), the CTT/LAS Falls Car, and service developments at A&E to support resilient ambulance handover times.

4.0 Resources/investment

4.1 Resources/investment in each service/provider are highlighted for each individual provider as required, under the relevant sections of this report.

4.2 There are no financial, social or environmental impacts arising from this report.

5.0 Equalities

5.1 There are no equalities implications arising from this report.

6.0 Risk

6.1 Risks and mitigations for each service are highlighted for each individual provider, under the relevant sections of this report.

7.0 Managing conflicts of interest

7.1 There are no conflicts of interest to note, related to this report.

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Appendix 1

BHR CCGs Open Contract Performance Notices in 2017/18

Provider CPNs/AQNs/ Issue Current Status Exception notice BHRUT RTT Percentage of service An update on performance will be reviewed at the July Incomplete users on incomplete 2017 CQRM meeting between the Commissioner and pathway - CPN pathway waiting no the Trust. more than 18 weeks, Trust not achieving Recommendations from the CQRM will subsequently target. be made to the next SPR meeting.

BHRUT A&E - CPN Trust non- An update on performance will be reviewed at the July achievement of the 2017 CQRM meeting between the Commissioner and national target the Trust.

Recommendations from the CQRM will subsequently be made to the next SPR meeting.

BHRUT Cancer 62 day Trust continued failure A 2nd Contract Exception Report Notice was issued to – Exception to achieve the 62 day the Trust in January 2017 for failure to meet the Notice standard within recovery trajectory for 62 day cancer standard. A agreed timescales urology specific recovery plan was agreed with the Trust (approved and monitored via the Cancer Performance Recovery Board).

A letter was issued to the Trust on 7 June 2017 requesting recovery plans and trajectories for specialties which are at risk of not meeting the standard from April 2017 onwards. Trust plans are awaited.

The Exception Report Notice will remain open pending Trust achievement of the 62 day standard.

BHRUT Cancelled Trust breached the A Contract Performance Notice remains open for operations - zero tolerance Trust performance below the national standard. CPN threshold for the number of Service Following a request at SPR in January 2017, the Trust Users who have provided a report to SPR in April 2017 on the work operations cancelled being undertaken by the Trust to reduce the rate of who have not been cancelled operations. SPR further agreed that treated within 28 days cancelled operations would be routinely reported via the RTT Programme Board going forward.

Latest data (Q4 of 2016/17) indicates Trust achievement of 99.64% against the 100% standard.

The Contract Performance Notice will remain open pending Trust achievement of the standard. 28

104

BHRUT MRSA Trust has breached Commissioners and the Trust agreed at SPR in (Methicillin- the zero tolerance March 2016 that the CPN relating to MRSA Resistant thresholds for performance would remain open until such time as the Staphylococcu incidences of MRSA. Trust achieve 3 consecutive months of achievement s Aureus) - against the threshold. CPN April 2017 data indicates 3 months consecutive achievement with 0 cases reported in February 2016 - April 2017.

Pending formal recommendation from CQRM, the CPN will be recommended for closure by SPR.

BHRUT Mandatory Provider failing An update on performance will be reviewed at the July Training - CPN monthly targets for 2017 CQRM meeting between the Commissioner and Mandatory Training in the Trust. the following areas; Safeguarding (Adults Recommendations from the CQRM will subsequently and Children), be made to the next SPR meeting. Information Governance, Appraisals. BHRUT Clostridium Monthly cumulative Commissioners and the Trust agreed at SPR in difficile (C-Diff) breaches above the March 2016 that the CPN relating to C-Diff would agreed trajectory. remain open until such time as the Trust achieve 3 consecutive months of achievement against the threshold.

April 2017 data indicates 3 months consecutive achievement with 0 cases in February 2016 and 2 cases each in March and April 2017 (below the threshold of 2.5 cases).

Pending formal recommendation from CQRM, the CPN will be recommended for closure by SPR.

Barts Serious Serious Incidents A CPN was issued to the Trust in February 2017 for Health Incidents - investigated and consistent failure to achieve to standard at the Whipps CPN closed on STEIS Cross site, with a monthly average of 19 overdue SI within 60 working reports throughout 2016/17. days threshold of 90% The CQRM is monitoring the status of this performance notice. Barts Complaints - Complaints A CPN was issued to the Trust in February 2017 for Health CPN responded to within consistent failure to achieve to standard at the Whipps 25 working days or Cross site. the timeframe agreed with the complainant - The CQRM is monitoring the status of this 80% threshold performance notice.

Barts Duty of Duty of Candour A CPN was issued to the Trust in February 2017 for Health Candour - threshold of 100% consistent failure to achieve to standard at the Whipps CPN Cross site.

105 The CQRM is monitoring the status of this performance notice.

Appendix 2

Month 1 Activity Summary Tables

BHRUT

Urgent Care

Planned Care

Outpatients

Other

106

To: Meeting of the NHS Redbridge Clinical Commissioning Group Governing Body

From: Tom Travers, Chief Financial Officer

Date: 20 July 2017

Subject: Finance Report Month 2

Executive Summary

The Month 2 Finance Report should be read in conjunction with the report from the Chair of the Financial Recovery Programme Board (FRPB).

In Month 2 Redbridge CCG reported a year to date deficit of £0.41m and a forecast deficit of £2.48m. This is in line with the CCG’s operating plan.

At Month 2, there is £5.6m QIPP slippage reported in the forecast position. This has been mitigated by the use of acute reserves and the release of contingency.

The likely level of risk that the CCG is facing at Month 2 is £9.9m. These are mitigated by opportunities totalling £2.4m, resulting in a net risk of £7.5m. If these risks materialise this will result in the CCG’s deficit increasing to £10m.

The major risks are further slippage on QIPP and acute SLA over performance.

A further risk identified is that there is limited acute data available at Month 2 and the data received has some data quality issues. Prescribing data is received two months in arrears, which means that no data is available until Month 3 reporting. CHC data is also limited at the start of the financial year. This is not unusual at Month 2 reporting and means that the CCGs have reported to plan for Month 2. This position may be revised in future months when more data becomes available.

Recommendations The Governing Body is asked to: Agree the financial position noting the risks within it.

1 Purpose of Report

The purpose of this report is to brief the Governing Body on the overall financial position as at the end of May 2017 (Month 2).

2 Background/Introduction

As at the end of Month 2 the CCG reported a deficit of £0.41m with a forecast year end deficit of £2.48m against resource limit. These deficits are in line with the plan.

3 Report

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MONTH 2 FINANCIAL INDICATORS Indicator Target Actual Variance Rating Key Messages this £'000 £'000 £'000 month

At month 2 BHR CCGs have reported an in year deficit of £0.4m, which is in line with plan. Month 1 flex data received from BHRUT has a number of errors Financial position year to date (413) (413) 0 Amber which have been raised with the trust. A number of associate trusts (including Barts Health) have not submitted a full set of data. These data issues pose a risk at month 2 reporting.

The forecast outturn deficit remains in line with plan as a £2.5m deficit. However this position includes a forecast savings slippage of £5.6m. An over Financial position forecast outturn (2,476) (2,476) 0 Amber spend of £0.3m is also forecast within the IT directorate. This slippage has been negated by the release of the commissioning reserve and the majority of contingency. Any further slippage or contract overspends will result in the CCG not delivering its planned deficit position

The year to date savings position shows an over achievement of £29k. The Savings Year to date 670 699 29 Green position has been calculated using proxy data given the issues raised with regard to acute data.

Savings forecast outturn 15,245 9,690 (5,555) Red The savings forecast outturn projects a £5.6m slippage. This position is broadly in line with the level of assured savings schemes Net Risks and Opportunities (7,539) Red The likely risks facing the CCGs at month 2 amount to £9.9m; these are Opportunity mitigated by opportunities of £2.4m, resulting in a net risk of £7.5m Worst Case Forecast outturn (2,476) (10,015) Red If the risk position fully materialises the CCGs will record an in year £10m deficit.

108

REVENUE POSITION

Annual YTD YTD YTD Forecast Variance Budget Budget Actual Variance Outturn to FOT £'000 £'000 £'000 £'000 £'000 £'000

BHRUT 91,539 14,263 14,263 0 91,662 (123) Barts Health NHS TRUST 61,939 10,050 10,050 0 63,966 (2,027) Homerton 4,502 710 710 0 4,502 0 Other Acute Trusts 20,420 3,174 3,193 (19) 20,498 (78) Other Acute 28,718 4,783 4,800 (17) 28,734 (17) Acute Reserves 3,765 37 0 37 1,016 2,749 Acute QIPP Commitments (2,713) 0 (66) 66 (763) (1,950) Acute Commissioning Total 208,169 33,017 32,950 67 209,615 (1,446)

Mental Health 29,545 4,852 5,015 (163) 30,375 (829) Community 23,323 3,988 3,890 98 23,587 (263) Continuing Care 23,275 3,872 3,902 (29) 23,593 (318)

Primary Care & Prescribing 45,491 7,697 7,692 5 45,539 (48) Primary Care Co-Commissioning 36,599 6,100 6,100 0 36,599 0

Other Programme Services 12,403 1,645 1,598 47 12,741 (338) Programme Reserves 4,191 53 53 0 906 3,285 Other QIPP Investments / Disinvestments 231 (25) 0 (25) 274 (43)

Running Costs 6,510 1,085 1,085 0 6,510 (0)

Total BHR CCGs Expenditure 389,739 62,284 62,284 (0) 389,739 0

2017/18 Allocation (387,263) (61,871) (61,871) 0 (387,263) 0

2017/18 Control Surplus / (Deficit) (2,476) (413) (413) 0 (2,476) (0)

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MAIN EXPENDITURE VARIANCES

Acute Contracts

 Due to the limitations of acute data at Month 2 the variances reported against BHRUT and Barts Health relate to QIPP slippage. The most significant being £2.0m QIPP slippage reported against Barts Health.  The lead commissioner for Barts Health has reported that Barts will provide Month 1 and Month 2 activity and cost data in time for Month 3 reporting.  There is also forecast QIPP slippage of £1.95m against other acute QIPP commitments. The QIPP slippage is partly mitigated by an acute reserve generated as a result of contract agreements being less than the operating plan assumptions. This has released £2.7m into the forecast position.

Mental Health

 There is a forecast overspend of £0.8m. This relates to slippage on the Meadowcourt QIPP.

Community

 There is a year to date underspend of £0.1m. This relates to the final 16/17 CQUIN reconciliation with NELFT.  The annual QIPP target with NELFT is £0.6m. It is assumed that there will be slippage against the QIPP, resulting in a forecast overspend of £0.2m.

Continuing Care

 There is a forecast overspend of £0.3m. This relates to slippage against the Care UK, Meadowcourt AQP placements element of the QIPP.

Other Programme Services / Reserves / QIPP Investments and Disinvestments

 The main budgets held under “Other Programme Services” includes budgets for Better Care Fund (BCF), 0.5% uncommitted risk reserve, Property Services and other programme services. This area is reporting a £0.3m overspend against the IT directorate.  There has been £3.3m released into the financial position as a result of the partial release of contingency and savings shown against QIPP investments.

Further detailed information across all contracts is found in the Performance Report.

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RISK ANALYSIS

Probability of risk Potential Full Risk being Risk Value realised Value £000s % £000s

RISKS Acute SLAs 6,237 50% 3,119 Continuing Care SLAs 473 50% 237 QIPP Under-Delivery 7,077 75% 5,329 Prescribing 1,215 50% 608 Other Risks 691 100% 691

TOTAL RISKS 15,693 9,983

MITIGATIONS Uncommitted Funds (Excl 1% Headroom) Contingency Held 1,753 100% 1,753 Mitigations relying on potential funding 691 100% 691

TOTAL MITIGATIONS 2,444 2,444

NET RISK / HEADROOM (13,249) (7,539)

Forecast Outturn Underspend / (Deficit) 0 (2,476) RISK ADJUSTED CONTROL TOTAL (13,249) (10,015)

Acute SLAs

 The risk relates to acute pressures in excess of the agreed contracts. This encompasses baseline, demographic and non demographic growth.

Continuing Care and Prescribing

 The risk reflects the risk of demographic growth and price increases above plan.

QIPP Under Delivery

 Outstanding risk is based on the RAG rating from the latest System Delivery Framework report.

Other Risks

 Increases in market rent. It is assumed this risk will be fully mitigated by national funding. If this funding isn’t received it will represent a risk to the CCGs.

Mitigations

 Due to the financial position the CCG is facing, the only mitigation available to offset the risk is release of the contingency.

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UNDERLYING POSITION

Remove Non 2017/18 2018/19 2017/18 Non Other Non recurrent exit FYE of FYE of opening Forecast at Recurrent Recurrent QIPP underlying QIPP Investments underlying M02 Budget / Spend Schemes position position Spend £000 £000 £000's £000 £000's £000's £000's £000's

Total Allocation 387,263 1,274 0 0 388,537 0 0 388,537

Total Spend 389,740 -1,214 -4,289 2,907 387,144 -5,162 468 382,450

Surplus / (deficit) -2,477 2,488 4,289 -2,907 1,393 5,162 -468 6,087

Purpose  The underlying position details the recurrent spend against the allocation received – this is different to the forecast position at Month 2.

Methodology

 The start point is the Month 2 forecast. Non recurrent budgets and spend are removed, including the impact of the Identification Rule (IR) changes, HRG 4+ changes and non recurrent investments.  Non recurrent QIPP is added into the position to give an exit underlying position for 2017/18 – at Month 2 this is forecast to be a surplus £1.4m.  The full year impact of 17/18 QIPP schemes and investments are reflected post the exit 17/18 position to give the opening underlying position going in to 2018/19. At Month 2 it is expected that this will be a surplus of £6m

Risk to the Underlying Position  The underlying position is based on Month 2 data. Overspends reported against acute and other contracts will impact on the underlying position.  Further QIPP slippage will negatively impact the underlying position.

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OVERVIEW

No Indicator Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 1. Financial position year to date Amber 2. Financial position forecast outturn Amber 3. Savings Year to date Green 4. Savings forecast outturn Red 5 Risks and Opportunities Red 6 Worst Case Forecast outturn Red

The table above shows the Financial dashboard on a month by month basis. This will be further developed in future months and will be used to make comparisons against historical performance.

Information relating to the Statement of Financial Position, Invoice payment metrics and the cash position can be found in the appendices.

113

Financial Summary

The financial position of the CCG is extremely challenging. The forecast QIPP slippage at Month 2 means that the CCG has released available contingencies into the position to enable the reported position to be at plan.

Clearly this means that any acute or other over performance and any further QIPP slippage represents a high risk to the CCG and will result in the financial position moving away from plan.

4 Resources/Investments n/a

5 Equalities n/a

6 Risk

Financial risk is detailed in section 3 of the report.

7 Managing conflicts of interest n/a

Attachments: 1. Appendix 1 – Statement of Financial Position 2. Appendix 2 – Invoice Payment Performance Measure 3. Appendix 3 – Cash to Income and Expenditure Reconciliation 4. Appendix 4 – Cash Position and Forecast Year End Value

Author: Tom Travers, Chief Finance Officer Date: June 2017

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Appendix 1

Redbridge CCG

Statement of Financial Position

Position as at 31st May 2017

£000 £000 £000 £000 Mar May Mar Annual 2017 2017 2018 Change

Non-current assets

Property, plant and equipment 2,911 2,268 3,599 688

Intangible 726 514 871 145

Other financial assets - - - -

Trade and other receivables - - - -

Total Non Current Assets 3,637 2,782 4,470 833

Current Assets

Inventories - - - -

Trade and other receivables 7,756 9,066 7,047 (709)

Other financial assets - - - -

Cash and cash equivalents 11 (256) 50 39

Total Current Assets 7,767 8,810 7,097 (670)

Total Assets 11,404 11,592 11,567 163

Current Liabilties Trade and other payables (34,818) (36,508) (34,188) 630 Provisions (606) (606) (386) 220 Borrowings - - - - Total Current Liabilites (35,424) (37,114) (34,574) 850

Net Current Assets/(Liabilities) (24,020) (25,522) (23,007) 1,013

Trade and other payables - - - - Provisions (46) (46) (61) (15) Borrowings - - - - Total Non-Current Liabilites (46) (46) (61) -

Total Assets Employed (24,066) (25,568) (23,068) 998

Financed by:

Taxpayers Equity

General Fund (24,066) (25,568) (23,068) 998 Revaluation reserves - - - -

Total Taxpayers Equity (24,066) (25,568) (23,068) 998

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Appendix 2 Redbridge CCG Invoice Payment Performance Measure Position as at 31st May 2017 Apr-17 May-17 Cumulative Number Value Number Value Number Value £'000 £'000 £'000

Non-NHS Creditors

Total Bills paid in the year 1,145 6,935 1,182 8,570 2,327 15,505

Total Bills paid within target 1,116 6,869 1,093 7,790 2,209 14,659

Percentage of Bills paid within target 97.5% 99.0% 92.5% 90.9% 94.9% 94.5%

NHS Creditors

Total Bills paid in the year 93 19,389 268 20,814 361 40,203

Total Bills paid within target 93 19,389 255 20,499 348 39,888

Percentage of Bills paid within target 100.0% 100.0% 95.1% 98.5% 96.4% 99.2%

All Creditors

Total Bills paid in the year 1,238 26,324 1,450 29,384 2,688 55,708

Total Bills paid within target 1,209 26,258 1,348 28,289 2,557 54,547

Percentage of Bills paid within target 97.7% 99.7% 93.0% 96.3% 95.1% 97.9%

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Appendix 3

Redbridge CCG Cash to income and expenditure reconciliation Position as at 31st May 2017 £000 May 2017

Cashflows from Operating Activites Net operating cost before interest operating surplus/deficit (61,588) Depreciation and Amortisation 159 Impairments and Reversals - (Increase)/decrease in trade and other receivables (1,310) Increase/(decrease) in trade and other payables 1,690

Provisions utilised -

Net cash inflow/(outflow) from operating activities (61,049)

Cash flow from investing activities Interest received - (Payments) for property, plant and equipment - (Payments) for intangible assets - (Payments) for other financial assets - Proceeds of disposal of assets held for sale (PPE) - Proceeds of disposal of assets held for sale (Intangible) - Proceeds from disposal of other financial assets - Net cash inflow/(outflow) from investing activities -

Net cash inflow/(outflow) before financing (61,049)

Capital element of payments in respect of finance leases and On-SoFP PFI and LIFT - Net parliamentary funding 60,782 Net cash inflow/(outflow) from financing activities 60,782 Net increase/(decrease) in cash and cash equivalents (267) Cash and cash equivalents (and bank overdraft) at beginning of the period 11

Cash and cash equivalents (and bank overdraft) at YTD (256)

Reconciliation of Cash Drawings to Parliamentary Funding Total cash received from DH (Gross) 54,800 (Less)/plus: transfers (to)/from other resource account bodies - Plus: cost of Co-Commissioning (central charge to cash limits) - Plus: drugs reimbursement (central charge to cash limits) 5,982 Parliamentary funding credited to General Fund 60,782

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Appendix 4

Redbridge CCG Cash position and Predicted Year End Value Position as at 31st May 2017 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 April May June July August September October November December January February March Total 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018 Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast

Receipts

Balance bfwd 11 1,623 308 235 233 317 259 262 246 288 291 275 11

NCB Drawdown 27,400 27,400 27,400 28,400 28,200 27,400 27,400 28,100 27,500 27,400 28,100 26,600 331,300 Other 1,137 1,208 2,345 PCS Payments Reimbursements 0 0 0 VAT 101 193 294

Total 28,650 30,424 27,708 28,635 28,433 27,717 27,659 28,362 27,746 27,688 28,391 26,875 333,951

Payments

Creditors NHS 19,389 20,820 18,227 19,822 20,291 19,572 19,572 20,291 19,572 19,572 20,291 18,716 236,137 Creditors BACS 6,948 8,389 8,645 7,979 7,224 7,285 7,224 7,224 7,285 7,224 7,224 7,285 89,935 Creditors CHAPS 12 191 ------203 Salary CHAPS - 5 ------5 Cleared Payable Orders 1 1 ------2 Salaries & Wages 361 387 320 320 320 320 320 320 320 320 320 320 3,948 Pensions 119 122 112 112 112 112 112 112 112 112 112 112 1,361 Tax & NI 197 200 169 169 169 169 169 169 169 169 169 169 2,087 Standing Orders/Direct Debits - 0 ------Foreign Payments - 0 ------Other 0 1 ------1

Total 27,026 30,116 27,473 28,402 28,116 27,458 27,397 28,116 27,458 27,397 28,116 26,602 333,678 Balance cfwd 1,623 308 235 233 317 259 262 246 288 291 275 273 273

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To: Meeting of the NHS Redbridge Clinical Commissioning Group Governing Body

From: Jacqui Himbury, Nurse Director

Subject: Quality Report

Date: 20 July 2017

Executive summary

This report provides assurance to the governing body that the Clinical Commissioning Group (CCG) continues to measure and monitor the quality of the services we commission from all providers.

The report is divided into two sections. Section 1 provides a system wide overview of specific quality indicators that underpin and assure all the CCG commissioning activities, such as assurance on the robustness of the quality impact assessment process to ensure the system delivery plan is safe to implement.

Section 2 focuses on the priority operational quality issues and challenges that the CCG continues to manage to ensure patient safety and that also support a positive patient experience.

Recommendations The governing body is asked to:

 Discuss and review the quality matters outlined in this report  Suggest any additional actions that are required for further improvements or assurance

1.0 Purpose of the Report

1.1 This report is presented to the governing body to ensure that members are fully briefed and assured on all the quality challenges and issues that the CCG is addressing through our range of commissioning activities.

1.2 This covers both strategic and operational quality issues and details how they are managed so that the people we commission services for receive the best possible care, delivered in a way that is safe and effective while providing value for money and a positive patient experience.

2.0 Introduction

2.1 Improving experience for patients continues to be a CCG priority, and many of our specific quality improvement and assurance activities are aimed at doing this, particularly our actions that deliver improved provider quality performance, which we assure and monitor through our established contract monitoring processes.

2.2 This report is divided into two sections:

 Section 1 - System wide quality performance which includes the CQC provider quality performance concerns and assurance of the robustness of our Quality Impact

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Assessment (QIA) process and that we continue to implement our care home (with nursing) strategy.

 Section 2 – The quality performance of our main providers and the issues we are currently reviewing and addressing at the Clinical Quality Review Meetings (CQRM).

3.0 Section 1: System Quality Performance

3.1 CQC Provider Quality Performance Challenges

3.1.1 NELFT CQC inspection. NELFT has reported the current status of the Strategic Quality Improvement Plan to the June Trust Board meeting and confirmed that there are fourteen exceptions remaining, with nine improvement actions recently closed. NELFT has recently established locality CQC meetings which will focus on preparation for re-inspection and to guarantee sustainability into the future. These locality meetings will ensure that there are audit checks and assurance processes in place.

3.1.2 NELFT reports that they have a solution around monitoring and reporting against care planning and risk assessment which is under discussion with their IT department to ensure that the solution is embedded and maintained. We have sought assurance at the June CQRM on the Clinical Risk Training Programme, both in terms of the content of the training and the expected level of participation. NELFT has advised that their biggest change since the CQC inspection is an improvement in staff culture in terms of understanding the consequences of actions and risk awareness.

3.1.3 We have also continued to improve the service performance review/CQRM process and can assure the governing body that the quality team and CSU contracting colleagues will continue to work together to monitor the performance and quality of the services provided by the Trust.

3.2 BHRUT CQC inspection. As reported in previous papers, BHRUT exited “Special Measures” in March 2017 following the publishing of the recent CQC report which rated the Trust as “Requires Improvement” overall.

3.2.1 The Trust’s improvement programme provides the detail on implementation of the next steps with the aim of improving the CQC rating from ‘Requires Improvement’ to ‘Good’ within the next 18 months. To achieve this current “Must Do” and “Should Do” actions from the March 2017 CQC report are aligned to the existing improvement programmes. Where no immediate concerns, risks or issues exists these areas will be moved to business as usual systems and processes overseen by the improvement portfolio leads with oversight by commissioners through the CQRM.

3.2.2 The current enhanced surveillance level of contract monitoring and quality assurance processes we have in place will remain, until we are assured that the required improvement the Trust has achieved is sustained. We will continue to support the Trust with all the quality improvement plans and initiatives to ensure the pace of improvement does not slow down.

3.3 Bart’s Health NHS Trust CQC inspections. As reported in previous papers, the CQC issued the Trust with seven requirement notices because of the breaches to the fundamental standards that were not being met. Included within the regulations are twelve “Must Do” and twenty one “Should Do” recommendations that the Trust must meet.

3.3.1 The Trust reports progress against the Whipps Cross improvement plan, including discharge improvements linked to better transport arrangements, a focus on reducing cancelled operations, some recent senior appointments and roll out of the SAFER bundle at each CQRM. At The Royal London Hospital, there had been work to address staffing ratios and consistency of security arrangements in maternity services while improving high dependency contingency arrangements. All ‘Must Do’ actions following the Newham Hospital inspection have now been implemented.

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3.3.2 A quality summit will be held to formalise a related improvement plan and the Trust has been encouraged by positive media coverage following the CQC report publication that reflected the progress made. The Quality and Safety Committee (QSC) will review the emerging improvement plan in more detail in due course.

3.3.3 The Trust Board papers notes forthcoming CQC inspections ahead of an overall CQC provider report being issued: A review of St Bartholomew's Hospital in May 2017, followed by a 'Well Led' domain review in early June, which will focus on the effectiveness of 'ward-to-Board' governance and processes.

3.4 PELC CQC Inspection. PELC have recently undergone a CQC inspection and have received verbal feedback. They are awaiting imminent publication of the report and when this is available a detailed update will be included in this report.

4.0 System Quality Improvement Actions 4.1 Care Homes (with nursing) Strategy 2017 – 2020. As reported in previous papers, the CCG has been performance managing three different care homes where quality risks have been identified. All three have had ongoing enhanced quality assurance monitoring by Multi Agency Surveillance Groups, and all three have now had their restrictions lifted. These three return to routine surveillance and quality monitoring.

4.2 The care home CQRM process is currently being established with appropriate representation from Continuing Healthcare and CSU colleagues. This will provide a report to the QSC at each meeting to assure members that the issues and challenges we identify are being managed safely and proactively. This process will include the routine monitoring of all performance information including attendances at emergency departments, number of reported falls and pressure ulcer prevalence.

5.0 Quality Impact Assessment (QIA) process. As reported in previous papers, due to the significant scale of our financial challenge and the development of the System Delivery Plan, each cost reduction project and investment business case goes through an initial QIA process, and if indicated a comprehensive QIA is completed. Since March 2017, approximately 30 project plans have been reviewed by the quality team following this process. The QSC are assured that the process is robust and that if any quality/patient safety issues are identified appropriate action is taken to mitigate or reduce the risks.

6.0 Section 2: Operational Quality Improvements and Challenges

6.1 Provider quality performance improvements and challenges addressed through the CQRM

6.2 BHRUT Mortality Outlier Status. As reported in previous papers, BHRUT was flagged as a mortality outlier by the Dr Foster Unit in December 2016, February and March 2017, for urinary tract infections (UTI), patients admitted with septicaemia (except in labour) and more recently deaths caused by biliary sepsis. In response, the CQC have issued three alerts requesting that the Trust take action to understand and explain why the actual number of deaths for these conditions is greater than the expected number of deaths. The CQC requested that the Trust explore potential common factors which might explain the apparent raised mortality. The Trust was required to review the groups of patients coded with these primary diagnosis between specified dates, and evidence analysis undertaken on a sample of at least 30 individual cases for each alert. The reviews of sepsis and UTI have been completed.

6.2.1 The findings reported at the June CQRM noted one case of probably avoidable UTI mortality, which represents 3% of cases which is in line with the national average. This case related to failure to remove an indwelling catheter for a care home resident with resultant immediate admission to hospital with sepsis. The case requires wider review in respect to planning for

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catheter change, referral and detection of deterioration within the care home. The Trust have indicated that the avoidable mortality scoring is subjective and have cited concern from the Royal College of Physicians who feel it is better to extract learning points from mortality reviews. However, the Trust continues to build their Mortality Faculty to deliver extensive detailed reviews by Q3 to meet the NHSE publication date. This work builds on the current checklist review established in 2015 which has reviewed 3700 deaths and reported across a range of quality indicators.

6.2.2 The Trust has identified three key findings from their mortality reviews:

 That patients are presenting in a considerably poor condition and often have significant comorbidities. Deterioration is clear prior to admission and this suggests earlier clinical intervention may have halted progression of the condition. Identification of people who are approaching the end of their life if they are able to communicate this on admission, however communication and planning from community care settings could be improved. The engagement of commissioners, GPs, community providers and care homes is needed in this area and is being pursued.

 In the mortality review timeframe (June 2016), the use of bundles of care was poor. A number of examples show excellent senior review, however evidence of delivering all key tasks required in sepsis varied. Weekly testing and reporting on care bundles was established in May 2017 to drive improvement, and now shows >90% compliance. Performance is being monitored monthly at the CQRM.

 Documentation of patient condition and assessment was variable in the review. This relates to care bundle use and accurate clinical coding. Clinicians and the coding team have been presented with the results and have been involved with improvement actions. Consultant sign off on primary diagnosis and comorbidity is now in place.

6.2.3 BHR CCGs have been invited to participate in the new Mortality Faculty which will closely monitor actions to reduce mortality and ensure compliance to the ‘Learning from Death’ reviews. BHRUT has requested support from the CCG in respect to care provided outside of the Trust, and proposes engagement with GPs and the community provider in this work.

6.2.4 Commissioners have requested that the Trust produce an improvement plan with a recovery trajectory that will reduce mortality to ensure the Trust return to the expected Summary Hospital- leveI Mortality Indicator (SHMI) baseline of 100. The Trust have given commissioners assurance that the plan will be presented to the July 2017 CQRM for commissioner sign off. Enhanced quality surveillance will continue for this indicator at each CQRM and a report on progress will be presented to each QSC meeting.

6.2.5 A clinically led meeting has been arranged between the CCG and the Trust to review the draft improvement plan and to agree the next steps for implementing total pathway reviews.

6.3 BHRUT. Safer Staffing. As noted in previous papers, recruitment and retention of staff, across all disciplines continues to be a risk that the Trust are managing, and this risk is reported monthly to their Board through an escalation process from their Quality Assurance Committee.

6.3.1 In June 2017, the Trust presented the current status of the recruitment for the nursing workforce, particularly at band 5 level, which remains one of the Trust’s key risks and challenges. The Trust has refocused their recruitment from EU and international campaigns to developing a “grow your own” programme to recruit more locally; by developing and embedding a strong and identifiable

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employer brand that is visible in the local community, setting out how BHRUT manages its people in line with their PRIDE values.

6.3.2 The Trust will continue to commission the maximum number of places on pre-registration courses with partners, and will introduce the Nursing Associate role to support the development of a future professional workforce.

6.3 BHRUT – Never Event. BHRUT reported their third Never Event in May. This was a retained swab which was discovered two days after surgery. An initial investigation notes that the swab was retained following the formal counting process, and an immediate safety action was put in place to hold observation audits of theatre practice on 3-5 June. The Never Event has been reported to NHS Improvement. The Investigation report on the previous SI (retained dental micro-drill bit) was reviewed at the April 2017 SI Panel and approved. The actions from this report will be monitored to completion through the SI Panel process, and the final report will be noted at CQRM.

6.4 NELFT - Safer Staffing. As reported in previous papers, the Trust has reported that vacancy rates are showing significant improvement across the Trust, with a reasonably static rate of 17% against a target of 10%. Staff turnover increased in March 2017 from 15% to 17%, and this continues to be a cause of concern for commissioners, as the target is 10%. The Trust has a trigger point for safe staffing; where vacancy factors of 30% or above are reported, a quality visit is conducted by the Director of Nursing to assess the safety of the service. As of March 2017, no new wards have hit the trigger for a quality visit. The Trust has a watch list for wards at risk for staffing issues, as identified by incident reports for red flag staffing events such as, where bank/agency staff do not arrive or are cancelled late. These incidents are closely monitored and used as a risk measure. In March 2017, out of approximately 2,100 shifts, 11 (0.52%) were reported as ‘adverse events that affect staffing levels’ incidents.

6.4.1 The Trust has established an agreed reporting and quality assurance framework to ensure all quality and patient safety risks are reported to their board on a monthly basis. This reporting mechanism demonstrates an improvement in the way the Trust manage quality risks, escalating as necessary. Improvements are still required and this is evidenced in their recent well led review conducted by KPMG, which is with the commissioners for review.

6.5. Bed Occupancy. The ward occupancy rate for adults of working age has risen again (reported as >99% in February 2017). Older adults’ ward occupancy has risen for men and women. Older women remain within target while older men are above the target. 93.4% and 86.8% respectively. This shows that despite the remedial actions taken by NELFT to relieve pressures, the demand for inpatient care remains high.

6.5.1 Adult average length of stay (ALOS) has fallen for each borough for the third month and are within the 25 day threshold. This reflects the actions that NELFT has been taking to ease the pressures on beds. However, older adult (ALOS) in B&D and Havering are no longer within the threshold.

6.6 Bart’s Health. The Trust continues to progress slowly in improving their performance across a range of quality indicators and continue to be contractually and supportively managed by the lead commissioners. This report focuses on exception reporting for Whipps Cross Hospital (WXH) as this is our main local hospital site. The quality indicators that we are supporting the Trust to improve are:  A high number of Never Events with repeated incidents and poor evidence of learning. Following Redbridge CCG escalating concerns to the lead commissioner contractual action has been taken. BH have now developed and implemented a

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remedial action plan which includes a standardised risk assessment process for Never Events. The Trust reported at the April 2017 CQRM that during 2016/17 there were 13 Never Events reported, 2 of these events occurred at Whipps Cross Hospital. There were no Never Events reported at WXH between November 2016 and March 2017, however, a Never Event was declared in April 2017. This was a Redbridge CCG patient.  Non-compliance with the National Framework for the management of serious incidents. In December nineteen serious incident (SI) reports were overdue, which was a deteriorating position compared to the November data. Whipps Cross Hospital have confirmed that the governance team lack the capacity and capability to ensure all the serious incidents are closed on time. The Medical Director is now leading the improvement plan and a revised compliance trajectory has been agreed. Data reported at the June CQRM shows 14 open SIs (within the deadline) with only 3 overdue. This is a significantly improved position.  Inadequate complaints management and little evidence of organisational learning. As above a remedial action plan has been submitted by the Trust and was reviewed in January 2017 by commissioners. Commissioners were not assured that the plan would deliver the required improvements and escalated this quality risk to the Contractual Review Group. The Trust has subsequently shown significant improvement in reducing the number of overdue complaints from 62 in Q3 to 34 in Q4, with 3 complaints overdue in April. The governance team are reviewing complaints at day 15 to determine any risks to achieving the deadline and appropriate escalation for issues related to lack of response. The Trust have assured commissioners that the performance target of 80% of all complaints responded to within 25 working days will be delivered by the end of Q1 2017/18. Year to date performance at the time of writing this report was 64%.  Friends and Family Test rate for the emergency department. The Trust has submitted an amended improvement action plan with a revised trajectory for compliance. This has been accepted by commissioners. The Trust has recruited a lead for patient experience and commissioners anticipate this could support improvements. Work has been ongoing to improve the response rate in the Emergency Department at Whipps Cross to achieve the improvement trajectory agreed with the CCG. Data presented at the June CQRM provides a trajectory to improve FFT rates for the ED to 20% by August 2017. The Trust’s reported response rate is 3% as of February 2017. The CCG is offering additional support to this provider working collaboratively with NHSI.  Non-compliance with regulation 20 the Duty of Candour (DoC). The requirement is 100% compliance and for November 2016 the Trust reported 65% compliance. This breach of contract has also been escalated by Waltham Forest CCG to the Contract Review Group as a breach of regulation. Data reported for January 2017 shows the overall Trust at 69.2% compliance, with the WXH site at 54.5%. The improvement plan includes a daily review of incidents to ensure level of harm is correct and escalation for review at compassionate care and patient safety meetings is timely. Additional governance resource has been dedicated to support staff to ensure all elements of DoC are completed, and to ensure that performance reports are accurate. Further training to increase awareness around DoC, medical and nursing staff priority groups is planned to be completed before the end of June 2017. 6.7 Bart’s Health IT Disruption. In January 2017, Barts Health IT service became aware of failures in their IT systems at Newham University Hospital which suggested a computer virus had affected their pathology and imaging systems, making them inoperable, and also affected file share systems which prevented user access to documents and files. The effect of measures to protect from further infiltration was that planned cardiac cases were cancelled and pathology results were reported manually. This was declared as a Major/Serious Incident, which was due to report on 12 April 2017 although the report has not yet been submitted.

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6.7.1 On April 20 2017, Barts Health IT service reported a Major/Serious Incident into simultaneous failures of a number of hard drivers storing clinical data, which affected diagnostics systems and chemotherapy systems. This incident appeared to reach deeper into Trust clinical systems, again affecting pathology and imaging systems across the Trust, although it has not been confirmed that this was caused by similar malware. An immediate response was to advise GPs to send requests for fracture and chest x-rays to the Royal London Hospital, rather than the Mile End Hospital until further notice. This incident appears to have similar features to the January IT disruption, which raises concerns about the IT system’s resilience. It also raises concerns that organisational learning across sites requires improvement.

6.7.2 On 12 May 2017, the global cyber-attack caused major disruption to Barts Health pathology and diagnostics systems. A Major/Serious Incident was declared. Barts Health reported that 80 operations were cancelled, 30 of these at Whipps Cross Hospital, and that all of these patients had been rebooked. The immediate impact of that was that current patients had their operations cancelled to accommodate these cancellations.

6.7.3 In addition 980 screening mammograms were delayed, with 5 cancers diagnosed, 300 surveillance mammograms were delayed, and all reported initially without access to archive scans for comparison (as archives were not accessible). No cancers in this group have been reported to date and films for second reporting have been taken as historic archives are restored. BH reported that 3,000 screening mammograms appointments were delayed. As these are rebooked, new cancer diagnosis will be assessed for clinical harm potentially caused by the delay. The Trust anticipates that this would be a low number.

6.7.4 For Maternity, the IT systems failure had less impact, as patients’ paper records were available. However, some mothers had their foetal anomaly screening delayed, and maternity follow-ups post-delivery were pushed back. The Clinical Harm Team undertook a review to assess any clinical harm in maternity services and to date, have found no evidence of patient harm. A specific focus was on delays to foetal anomaly screening; to date, none have been identified.

Impact on RTT 6.7.5 Barts Health reported a major impact on their ability to validate their RTT/PTL following the cyber- attack, and that they could not report a validated position from March 2017. At the Clinical Harm Review Panel in June, it was noted that 167 patients had been waiting longer than 52 weeks, but that this could not be substantiated until data was fully restored. Barts Health anticipated having an accurate PTL by the end of June.

6.7.6 Barts Health plan to return to RTT reporting in October 2017, but were identifying risks to this as: the upgrade to the Newham system, further cyber-attacks, data quality issues and training for clinicians on RTT rules.

Clinical Harm Process 6.7.7 Barts Health clinicians explained at the External Clinical Harm Review Panel in June 2017 that reviews for potential clinical harms would be carried out on patients impacted by the cyber-attack in a similar manner to the RTT clinical harm review process. A Quality Assurance Triumvirate has established a task and finish group to identify and review clinical harm caused by the global cyber-attack. The clinical harm reviews will focus on the following:  Inpatients – patients who required repeat diagnostics/imaging, with higher risk of ionising radiation; and patients who may have suffered an adverse outcome related to a delay.

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 Accident & Emergency – patients who suffered delays to treatment, with focus on delayed fracture management and cardiac procedures; where revisions of treatment were made consequent on delayed diagnosis  Cancer Patients – patients who had cancer operations cancelled; administration of chemotherapy and treatment delays; delays related to deferred MDT discussions and the potential impact on the 31 and 62 day cancer constitutional targets.  RTT and Outpatients – Treatment cancellations and impact on 18 week pathways; where surgery was delayed or deferred, or where interventional procedures were delayed of deferred.  GP Alerts System – review of the dedicated email inbox (which was closed for a time following the attack) where local GPs had raised concerns of possible harm from delays.  Additional areas for review – The Trust will also review the impact of delays on breast cancer screening, the prolonged impact on Cancer MDT and 52 week breeches. A maternity review will be conducted to assess the impact on maternity patients, to include post-delivery follow ups.  Radiology Safety Netting – The Trust has put in place a Radiology Safety Netting process. To date, 1,100 MRIs and 600 CT scans have been recovered from the recent archives and are being reported. Further imaging recovery is on-going. A log is being kept within Radiology for all patients from this period, who are being monitored for new diagnoses and/or repeat ionising radiation. A clinical harm review will take place for all of these patients. 6.7.8 Comprehensive oversight and risk management will be maintained through the use of the Trust’s Datix reporting tool. Where Incidents were recorded on paper, these are being added to the electronic system. The Trust will present information on any clinical harm from the IT disruptions via the Clinical Harm Review Panel. IT Resilience Recovery Plan - June 2017 6.7.9 The Managing Director of Whipps Cross Hospital, provided an overview of the current status of the IT resilience recovery plan at the Whipps Cross CQRM on 15 June 2017. The recovery plan which was being tracked daily is now at a point where weekly tracking is required and 96% of the actions are complete. In terms of risk, the ability to rebook the backlog of patients should be complete by the end of July. Barts Health has commissioned an external review into the IT disruptions. BHR CCG Actions 6.7.10 BHR CCGs have written to the lead commissioners asking for assurance that Barts Health has mitigated the risks. BHR CCGs has expressed concerns that despite moving to manual paper systems during the IT disruption; that data restored from backups may be incomplete, so cases of potential clinical harm may not be immediately identified. It is clear that the Trust has found it challenging to restore imaging archives, and that data required for reporting has also taken some time to restore. The Trust have agreed to review the process and will provide additional assurance as requested by commissioners at the July CQRM.

7.0 Resources/investment

7.1 There are no additional resource implications/revenue or capitals costs arising from this report.

8.0 Sustainability

8.1 If we achieve the quality improvements detailed in this report the positive impact will be on sustained quality improvement and an improvement in patient experience.

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9.0 Equalities

9.1 This report has considered the CCG’s equality duty and where relevant has identified relevant actions which address any likely impact on equality and human rights.

10.0 Risk

10.1 Failure to ensure that there are improvements to the quality performance of commissioned services may result in a failure to manage and mitigate risks with potential harm to patients and reputational damage to the CCG. The CCG quality surveillance and management system provides mitigation to this risk. The management of this risk is assured by the Quality and Safety Committee.

10.2 Some patients may not be receiving the quality of care at the level which the CCG commissions, and therefore may have a poor experience of using the services we commission.

10.3 Mitigating actions for the above risks have been specified in the body of the report.

11.0 Managing conflicts of interest

11.1 There are no conflicts of interest raised in this report.

Author: Jacqui Himbury, Nurse Director and Christine Kane, Deputy Director Quality Date 26 June 2017

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To: Meeting of the Redbridge Clinical Commissioning Group Governing Body

From: Marie Price, Director of Corporate Services

Date: 20 July 2017

Subject: Finance and Delivery Committee – Update to Terms of Reference

Executive summary The CCGs have been revising arrangements for governance of financial decisions and risk given the deterioration in the financial position and recent finance/governance review.

The Barking and Dagenham, Havering and Redbridge (BHR) governing bodies have agreed to consolidate the functions of the Investment Committee into the Financial Recovery Programme Board (FRPB) and its terms of reference (TOR) have been amended.

A number of further changes to finance and delivery committee arrangements were recommended as part of the recent Deloitte review and were proposed to the Finance and Delivery Committees (FDC) which met (in common) on 28 June and considered and agreed the following changes to the TORs:  Additional member: One of the recommendations of the review was that the FDC include an additional member. It was agreed that one of the lay members be included as a member. The lay members across the three CCGs currently act on behalf of each other with respect to some decisions – such as investments where there is a conflict of interest for other members. It was proposed and agreed that the lay member invited to join this committee in common is also able to act for all three CCGs. The Accountable Officer will also attend meetings of the committee as appropriate.  Chairing: It is suggested that the Chair of Havering CCG act as the FDC Chair, with the lay member for governance as deputy chair.  Procurement Oversight Group (POG): The revised TORs also outline that the POG will report to this committee.

Additional changes have been made to reflect the name of current plans – i.e. System Delivery rather than QIPP and senior responsible officer (SRO)/clinical responsible officer (CRO) in line with the leadership arrangements for programmes and projects.

The revised TORs are attached.

Recommendations The Governing Body is asked to:  Approve the revised terms of reference

Author: Marie Price, Director of Corporate Services Date: 04 July 2017

128 Clinical Commissioning Group Governing Body

Finance and Delivery Committee Terms of Reference

Meeting Finance and Delivery Committee

Constitution The Clinical Commissioning Group (CCG) governing body (‘the governing body’) hereby resolves to establish a committee of the governing body to be known as the Finance and Delivery Committee (‘the Committee’).

NB: This committee is specific to the CCG and retains individual decision making authority, but meets in common with fellow BHR CCGs.

Role of the The Committee shall provide assurance that all aspects of financial committee management are operating effectively, through focus upon key financial risk areas. The Committee will ensure that CCG is delivering its financial targets within the System Delivery Plan (SDP). It will review and agree mitigating actions, for projects escalated to the committee as high risk.

Membership Members:

 Two clinical directors (CD), including the CD finance lead  Lay member, governance  Chief finance officer  Transformation programme directors  Lay member (PPI) from one of the BHR CCGs and able to represent all three CCGs

Regular attendees

 CCG Deputy Chief finance officer  CCG Director of Delivery and Performance

Additional Attendees

 All clinical directors will be invited to attend. Individuals may be invited to attend all or part of the meeting, as and when appropriate. These are expected to include SROs, CROs and assurance leads for areas such as contracting, finance and analytics. Other individuals may be invited to attend all or part of the meeting depending on the specific range of risk areas identified. The accountable officer will also attend meetings as appropriate.

Chair The Committee shall be chaired by the Havering CCG Chair with the lay member for governance as the deputy chair.

Quorum The quorum of the Committee is three of the six members, to include at least one lay member or the chief finance officer and one clinical director.

A duly convened meeting of the Committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee.

129 Decision- The chair of the Committee will work to establish unanimity as the basis for making decisions of the committee. If, exceptionally, the committee cannot reach a unanimous decision, the chair will put the matter to a vote, with decisions confirmed by a simple majority of those voting members present, subject to the meeting being quorate.

The Committee will ensure that any conflicts of interest are dealt with in accordance with the CCG standards of business conduct policy.

Duties of the The Committee shall provide assurance to the governing body that there Committee are robust and integrated mechanisms in place to ensure detailed review and oversight of the CCG’s financial position.

The Committee shall:

 Review and consider the financial and delivery plans and make recommendations to the governing body.

 Review significant risks identified by the Committee, the Chief Finance Officer, Executive or Governing Body. Facilitate deep dives into finance and activity data where required.

 Report to the governing body on the overall status of financial and operational performance, assessing potential shortfalls and risks and recommend governing body level mitigating actions to address them.

 Review plans and progress reports on the delivery of SDP initiatives and ensure that plans are supported by robust activity and financial information. Review in detail SDP schemes that have been escalated to the group as high risk, and ensure that mitigating actions are in place to enable recovery.

 Receive reports on progress against action plans already in place.

 Review and consider detailed monitoring reports and year end forecasts relating to financial performance and performance of the CCG against core standards, national and local targets and the operating plan as required.

Frequency of Meetings shall be held bi-monthly and not less than five times a year. meetings In accordance with standing orders the Chair may call an extraordinary meeting of the committee at any time.

The Committee also has the right to meet with another CCG Committee if there are matters of common concern for discussion e.g. the audit & governance committee

Notice of Meeting dates are set by the company secretary for each financial year in meetings advance. Changes to meeting dates or calling of additional meetings

130 should be provided to members and attendees within five days of the meeting.

A minimum of five working days’ notice and dispatch of meeting papers is required. Notice of all meetings shall comprise venue, time and date of the meeting, together with an agenda of items to be discussed and supporting papers.

Administration The company secretary, or whoever covers these duties, shall be and minutes of secretary to the Committee and shall attend to take minutes of the meetings meeting and provide appropriate support to the chair and Committee members.

Reporting The Committee shall: responsibilities  submit a summary of key points and recommendations to the governing body.  submit to the governing body complete copies of minutes of all meetings;  submit an annual report of its work to the governing body.

The pan BHR Procurement Oversight Group will report to the Committee.

Authority The Committee is authorised by the governing body to investigate any activity within its terms of reference. It is authorised to seek any information it requires in this regard from any employee and all employees are directed to cooperate with any request made by the Committee. The Committee is authorised by the governing body to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

The Committee will be responsible for determining any additional or reconfigured sub-structural arrangements to support fulfilment of the Committee’s remit.

Other The Committee shall at least quarterly, review its own performance and terms of reference to ensure it is operating at maximum effectiveness and recommend any changes it considers necessary to the governing body for approval.

Agreed at Barking & Dagenham CCG’s Finance & Delivery Committee May 2015.

Approved at Barking & Dagenham CCG’s Governing Body meeting June 2015.

NB: This will be updated following consideration at July GBs

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To: Meeting of the NHS Redbridge Clinical Commissioning Group Governing Body

From: BHR CCGs Finance & Delivery Committee Vice Chair

Date: 20 July 2017

Subject: Feedback report from the June 2017 BHR CCGs Finance & Delivery Committee meeting

Summary The Finance & Delivery Committee meeting minutes are provided to each of the 3 CCGs Governing Body meetings.

To provide additional assurance to the Governing Bodies, this brief feedback report provides key highlights from the meeting:-

Finance risk report - Committee members were given an update on the financial risks and it was noted that the financial position of the CCGs remains extremely challenging.

System Delivery Framework - Committee members received an update report which outlined the current status of QIPP savings.

Contracts position / deep dives An update on the RTT national standard was provided along with an update on the NHS Standard Contract and the changes affecting the interface between primary and secondary care. Committee members also received a deep dive on ENT, Gastroenterology and Urology referrals.

Locality/Network updates The Lead CDs from each borough provided updates on the areas they are focusing on.

Recommendation:  The Governing Body is asked to note this feedback report and the June committee minutes which provide more detail on all the matters considered.

3 July 2017

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Draft Minutes of the BHR CCGs Finance & Delivery Committee held on 28 June 2017 at Imperial Offices, Romford

Members: B&D CCG Havering CGG Redbridge CCG Dr Atul Aggarwal (AA) CCG Dr Jyoti Sood (JS) Clinical Chair and F&D Committee Director Chair Dr Gurkirit Kalkat (GK) Dr Alex Tran (AT) Clinical Dr Muhammad Tahir (MT) Clinical Director Director Clinical Director

Kash Pandya (KP) Kash Pandya (KP) Kash Pandya (KP) Lay Member, Governance Lay Member, Governance Lay Member, Governance

Tom Travers (TT) Tom Travers (TT) Tom Travers (TT) Chief Finance Officer Chief Finance Officer Chief Finance Officer

Sharon Morrow (SM) Alan Steward (AS) Chief Operating Officer Chief Operating Officer

Attendees: Dr Ann Baldwin (AB) Clinical Director, Havering CCG Dr Gurdev Saini (GS) Clinical Director, Havering CCG Dr Anil Mehta (AMe) Chair, Redbridge CCG (Dialled in) Dr Syed Raza (SR) Clinical Director, Redbridge CCG Conor Burke (CB) Chief Officer, BHR CCGs Tracy Welsh (TW) Deputy Chief Operating Officer, representing LM Ali Kalmis (AK) Director, Acute Contract Management- CSU Frank O’Neill (FO) Interim Director Finance – CSU Jeremy Cridland (JC) Associate Director, Business Intelligence - CSU Anna McDonald (AMc) Business manager, BHR CCGs

Apologies (members) Dr Waseem Mohi (WM) Chair, B&D CCG and F&D Committee Dr Maurice Sanomi (MS) Clinical Director, Havering CCG Dr Mehul Mathukia (MM) Clinical Director, Redbridge CCG and Chair of F&D Committee Dr Sarah Heyes (SH) Clinical Director, Redbridge CCG Louise Mitchell (LM) Chief Operating Officer, Redbridge CCG Apologies (attendees) Dr Kanika Rai (KR) Clinical Director, B&D CCG Dr Ravi Goriparthi (RG) Clinical Director, B&D CCG Dr Anju Gupta (AG) Clinical Director, B&D CCG Dr Ashok Deshpande (AD) Clinical Director, Havering CCG Dr Anita Bhatia (AB) Clinical Director, Redbridge CCG Rob Adcock (RA) Deputy Finance Officer, BHR CCGs

1.0 Welcome and apologies Action The Chair welcomed everyone to the meeting and apologies were noted.

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1.1 Declarations of interests The Chair reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of BHR CCGs.

No additional declarations of interest were declared. The register of interests held for BHR CCGs Governing Body (GB) members and staff is available from the Company Secretary.

1.2 Minutes of the last meeting The minutes of the meeting held on 27 April 2017 were agreed as an accurate record with one minor amendment.

1.3 Matters arising/actions log The open actions were reviewed:-

Ref 2.1 Clarity on the RTT national standard – AK confirmed that the national standard for RTT is still included in the standard national contract. The target is achievement of 92% by 2020 which providers are expected to meet. AK confirmed there isn’t a financial penalty attached and that her team are working with BHRUT to achieve the target. CB reiterated that the CCGs have agreed with our providers that they are contractually obliged to meet the target. Action Closed.

Ref 2.2 Review other CCGs ToR for clinical cabinets – The Chair confirmed that BHR CCGs clinical cabinet has now been established. Action closed.

AK to invite SH to attend a meeting with Barts Health re their QIPP – AK has contacted SH to agree a convenient date. Action closed.

The remaining actions related to items on the agenda.

2.0 Finance reports / risks

2.1 Finance risk overview report TT presented the month 2 report based on month 1 data. The financial position of the CCGs remains extremely challenging. A £12.9m QIPP slippage was reported which has been mitigated by the use of acute reserves and the release of contingency. The likely level of risk that the CCGs are facing at month 2 is £26.8m and if the risks materialise, it will result in the deficit increasing to £29.8m. TT stressed that this is not a position that the CCGs can be in. The major risks are further QIPP slippage and acute over performance. There is limited acute data available at month 2 and the data that has been received has some quality issues which has been identified as a further risk. KP raised his concerns about the lack of data and about the quality of the data received and asked when the CCGs could expect to receive more reliable data. AK said she understands the concerns raised and explained that the data received for months 1&2 is in the process of being validated and there are a number of processes to go through before assurances can be given. It was acknowledged that the recent cyber attacks have had an effect on coding at the Trusts. KP asked for assurance that NHS England (NHSE) has been sighted on the data

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issues and TT confirmed that it was specifically mentioned at the assurance meeting with NHSE on 21 June 2017. CB reminded Committee members of their responsibility to determine what action needs to be taken and when adding that a positive steps need to be have been taken by September 2017 to inform any change to reported outturns. KP suggested this should be focus for the finance sub-group TT/KP/ meeting on 27 July 2017. WM/AA/AMe

AB raised concerns about the QIPP target for NELFT and TT explained the action that is being taken.

Dr Mehta joined dialled into the meeting.

Committee members noted the risk overview report and the monthly dashboard.

2.1.1 Finance risk register SM presented the risk register and reported that there are currently 12 red rated risks mostly relating to finance. The highest rated risks to the CCGs are:

-Risks to the delivery of the CCGs’ budget -Risk to the delivery of the CCGs’ QIPP plans -Barts Health A&E performance -Co-commissioning - Personal medical services (PMS) contracts -Re-basing PMS to general medical services (GMS) contracts

SM explained that each risk is being reviewed by the risk owner and the register will be reviewed at EMT on a monthly basis. KP said he found the new format very useful but added that he would like to see a timeline/numbers included in the narrative. SM to feed back to Pam SM Dobson (PD).

AB raised the issue in regard to hospital appointment letters not being received etc that has been in the news recently which she said could have caused a high number of DNAs (did not attend). AK to contact AB AK outside of the meeting to establish the severity of the problem. TW added that DNA rates are being looked at and said she would TW include this issue too. It was agreed that Trusts should be looking at others ways to communicate with patients such as SMS text messages rather than just relying on letters. KP referred to the risk regarding the NELFT IT funding transfer. TT explained the mediation process that is taking place and what the next steps will be if the issue remains unresolved. AMe referred to the BHRUT radiology risk and asked if the quantity is known. AMc to ask the risk owner and respond back to AMe. AMc

The Committee reviewed the risks and agreed that the actions are appropriate to reduce the impact to the CCGs. No additional risks were added.

2.2 System delivery framework The Committee noted the report and the assurances conveyed on the 21 June 2017 position and also the key differences since the report was last presented.

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3.0 Contracts position / deep dive reports

3.1 Payments made to GP Federations TT presented the report that had been requested at the last meeting. The report provided a summary of the payments made to the Federations during 2016/17 and the Federations performance. TT drew particular attention to the final paragraph on ‘year-end reconciliation’ which informed members that as at the end of May 2017, it has still not been possible to fully reconcile the year-end payments. In order to do this the CCGs are reliant on data that details the amount of capacity and activity that was provided from December through to the end of March. Some data has been received from the Federations but it is incomplete so the year-end reconciliation cannot be finalised. This is being picked up with the Federations directly. TT confirmed that the Federations are on the same tariff and explained the reasons for the variations in the totals. AS confirmed that the CCGs are working with the Federations, looking at the current patterns of activity at the hubs and ways to increase it. Contract meetings with the Federations are being set up and quarterly reviews will be undertaken with the first is scheduled for July. AS confirmed that payments to the Federations are made on a monthly basis. Concerns were then raised about the risks associated with payments being made when the full data has not been received. CB said we need to be looking at whether the service is effective and if it’s delivering its primary objectives. AMe said he feels there is a lot of duplication that needs looking into as patients are seen in the evening at the hubs and then going to their GP practice the next day. AS confirmed that the Community Urgent Care group is already looking at these issues. AA asked TT when he expected to receive the missing data and TT responded saying he will bring an updated report back to the next TT meeting.

3.2 BHR CCGs contracts position FO presented the report which included key message for each CCG. However, he explained that not all the activity has been received and that some of it is inaccurate. He gave assurance to the Committee that meetings with BHRUT are taking place regarding activity and the meetings will be on-going through the year. KP said it was difficult to comment on the report knowing that the data is not accurate and this was acknowledged by other Committee members. AK said her team are currently looking at month 1 freeze data. KP said one of the key things for the Committee is to decide when to escalate concern about the data issues.

3.3 2017/19 NHS Standard Contract – changes affecting the interface between primary and secondary care AK presented the report which provided information on the six changes introduced in the 2017/19 NHS Standard contract (fit notes, out-patient clinic letters, patient queries, discharge summaries, out-patient prescribing and shared care protocols) and the actions taken by BHR CCGs’ and BHRUT to implement the changes. AK reported that a meeting with BHRUT had taken place earlier in the day where she reiterated the importance of these changes to primary care. AA asked AK how she will know if the Trust is delivering on the new changes and AK assured the Committee that working groups will be set up. AA suggested this is something that should go to the CCGs Clinical Senate followed by

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a report back to the Committee to provide the necessary assurance. AMe said this needs to be prioritised as GPs are continuing to receive more and more requests for diagnostics. AT added that there isn’t the capacity in general practice to keep up with the number of requests received each day. AK asked if there is a forum where GPs and Trusts can discuss their issues and AA replied that is the purpose of the new Clinical Senate. AK suggested that service level discussions need to take place there. AA raised the question of how the issues can be quantified and suggested that AK could work with one CD from each CCG on this.

AK to bring a follow-up report back to the next meeting. AK

3.4 ENT, Urology and Gastroenterology referrals - deep dive JC presented the analysis report that was requested at the last meeting. The key messages in the report were:- ENT: The total GP referred outpatient first activity has reduced in 2016/17. The majority of this decrease is seen at BHRUT with some activity moving into the other providers. The timing of these changes in activity suggests that these shifts are due to the redirection of referral activity that commenced in May 2016/17 as part of the RTT System Recovery plan. As of Feb-March 2016/17 GP referred activity has not returned to the levels previously seen. Urology: The total GP referred outpatient first activity has reduced in 2016/17. As with ENT the majority of this decrease is seen at BHRUT. The largest increase in activity is seen within NHS providers (particularly the Homerton). The independent sector is showing a decline in activity as two providers have stopped the Urology service. Similarly to ENT, as of Feb-March 2016/17 GP referred activity has not returned to previously observed levels. Gastroenterology: Both GP and consultant referred ‘outpatient first’ activity has increased in 2016/17. This change in activity was seen earlier and occurred from July 2015/16 with decreases at BHRUT initially being balanced with activity at other NHS providers and the independent sectors but not Barts Health. GP referred activity has shown higher levels at all providers from July 2016/17 although this may be for different reasons. The new Gastro Virtual Pathway (Medefer) appears to have had an effect on BHRUT referrals but more time is needed to see if this is disproportionate to the effect on other providers.

TW added that the Planned Care Transformation team has requested a piece of work on consultant to consultant referrals. AA thanked the CSU for the helpful report and added that he would like to know how many patients are being seen in the community for ENT. AK agreed to circulate AK the information after the meeting a ‘post meeting note’. It was acknowledged that we don’t have a community urology service. In regard to gastroenterology it was noted that referrals though Medefer are low. TW added that a survey has been undertaken to determine why GPs aren’t referring through Medefer yet.

Conor Burke left the meeting.

3.5 BHR joint delivery arrangement review – draft PwC report TT explained that PwC had been commissioned to undertake this piece of work to get an independent view of the joint delivery arrangements between the CCGs and BHRUT in order to address the 2017/18 financial

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challenge. TT talked though the main highlights in the interim report and explained that it would be updated following the board to board meeting with BHRUT that took place on 22 June 2017 and the conclusion of the equivalent piece of work with NELFT. KP said that an action plan is now required which will be jointly managed by the CCGs and BHRUT. TT confirmed that an action plan will be drawn up based on the recommendations which will be agreed with the Trust and he advised the Committee that PwC has started the scheduled piece of work with NELFT. He added that the interim report has been shared with BHRUT but not with NSHE or NHSI as they will receive the final report. AA gave his view that the System Delivery Performance Board (SDPB) should take this forward. KP said he would like the recommendations and the outcome brought TT back to the next meeting. He added that he is in the process of trying to set up a meeting with the Audit Chairs from BHRUT and NELFT.

4.0 Update to the Committee Terms of Reference (ToR) TT explained that the ToR have been re-drafted based on the Deloitte Well-led review. The main changes suggested are:-

-One PPI lay member be invited to join as a member from one of the BHR CCGs and who is able to represent all three CCGs -Lay member for Governance to be the Chair of the Committee -Accountable Officer to attend as appropriate - Review of Committee effectiveness to be carried out quarterly instead of annually.

KP proposed that AA be the Chair and said he would be happy to act as vice-chair in AA’s absence.

AB asked if the issue of conflicts of interest and clinicians needing to leave meetings could be reviewed. It was agreed that it isn’t an issue for this Committee and relates more to the Financial Recovery programme Board (FRPB).

The Committee agreed to the proposed changes with the exception of the suggested Chair which the Committee proposed should be AA.

TT to take discuss with Marie Price in advance of the ToR going to the TT July Governing Body meetings for final approval.

5.0 Locality/Network updates

B&D CCG – GK reported that the initial focus has been setting up the network. They held their second council meeting on 27 June. A plan of action is being drawn up and they have a dashboard in place. They are looking at setting up a community minor surgery service. One of the main problems is funding for locality developments. AK asked how they propose the minor surgery services service will fit in with PoLCE and the service restrictions and GK responded that this is being worked through. SM added the Integrated Steering Group is looking at how services are being aligned at locality level.

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Havering CCG – AB gave an update on their network progress so far. Their areas of focus are diabetes, Atrial Fibrillation (AF) and workforce/back office. They are also exploring moving to a single clinical system across Havering as well as working on a number of other projects but are still unclear about project support, who makes the decisions and what the networks can and can’t do. AS confirmed there has been a good level of engagement from the networks into the localities. Locality work is focussing on how people are discharged into the community and there has been good support on this from NELFT and the Local Authority. AB added they are also working closely with the Federation and AA reported that there is a Locality/Federation meeting scheduled for 6 July.

Redbridge CCG – MT reported they have had two leadership meetings and are starting to see individual development of the localities. He said it is very encouraging that the leads are taking advantage of the opportunities and are starting to review services. They are getting more and more data from the acute sector but are struggling with the data sets received from community services and there are still boundary issues. AK asked MT to send her an e-mail about the issues with the MT data sets from NELFT.

6.0 Items for noting

6.1 Procurement Oversight meeting minutes The Committee noted the minutes.

7.0 Any other business

KP referred to a new consultation on the proposed new charging systems to replace PbR which he said the Committee needs to respond to. AK said it is only in draft at the moment and confirmed the consultation runs from 3 July until 25 August 2017. She agreed to circulate the consultation document via AMc. AA asked for it to be AK/AMc circulated to the LMC as well.

8.0 Dates of next meetings:

F&D Sub- group - 27 July 2017

F&D Committee – 29 August 2017

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To: Barking & Dagenham, Havering and Redbridge CCGs

From: Kash Pandya, Chair of Audit & Governance Committees

Date: July 2017 Governing Body meetings

Subject: Feedback from the 24 May 2017 Audit & Governance Committee meetings

The Governing Body’s (GB) attention is drawn to the following key matters discussed at the Audit and Governance Committee meetings on 24 May 2017:

 The Committee considered reports from the both internal and external auditors on the governance arrangements and the financial statements for 2016/17. The Committee noted that unqualified audit opinions were proposed by the external auditor for all the three CCGs, though for Havering a qualification to the regulatory opinion was also proposed as the CCG's spend in 2016/17 had exceeded its resources limit. All three CCGs were also to be given qualified value for money conclusions because of the Legal Directions issued against them by the NHSE. The Committee were pleased that the auditors had not identified any errors in the accounts and the annual reports and thanked all staff involved with their preparations for their efforts. The Committee recommended that the BHR CCGs approve and adopt their accounts and annual reports for 2016/17. (This was subsequently done at the BHR GB meetings on 26th May and the external auditors completed their audit on 30th May).

 The Committee approved both a revised conflicts of interest policy (that incorporated gifts, hospitality and sponsorship) and a raising a concern (whistleblowing) policy for the BHR CCGs based on new guidance. Mandatory training on the new conflicts of interest policy and briefing arrangements for all GB members and staff is currently being finalised.

 The Committee welcomed the proposed improvements to the BHR CCGs risk management arrangements. The Committee decided that it would review the risk register every 6 months.

 The Committee recommended that a report be prepared for the BHR CCG's GBs on the benefits secured from their Better Care Fund investments with local authorities and the learning points for the future, where necessary.

Kash Pandya

BHR Audit & Governance Committee Chair

05.06.17

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DRAFT Minutes of the Joint Barking & Dagenham, Havering and Redbridge CCGs Audit &Governance Committee held on 24 May 2017 at Becketts House 9.30-12.00

Present –Members

Kash Pandya (KP) BHR audit chair, lay member for Audit & Governance Khalil Ali (KA) Lay member PPI Redbridge CCG Charles Beaumont (CBe) BHR co-opted member for Audit & Governance Sahdia Warraich (SW) Lay member PPI Barking & Dagenham In attendance-Officers

Tom Travers (TT) BHR chief financial officer Rob Adcock (RA) BHR deputy chief financial officer Nick Christolides (NC) NELCSU interim financial controller Pam Dobson (PD) 1 item Deputy Director of Corporate Services Angela Ward (AW) BHR company secretary In attendance-auditors

Kevin Suter (KS) External auditor, Ernst & Young Stephen Bladen (SB) External auditors, Ernst & Young John Elbake (JE) Internal auditors , RSM Apologies

Richard Coleman (RC) Lay Member PPI Havering Marie Price (MP) BHR Director of Corporate Services Conor Burke (CB) BHR Chief Officer Nick Atkinson (NA) Internal Auditor RSM

Action 9.00- Committee Members held a short private meeting and IA and EA then joined for a 9.30 short private session.

26/17 Welcome and Apologies for absence Apologies for absence were received from Richard Coleman, Marie Price, Conor Burke and Nick Atkinson.

27/17 Declaration of Interests (DOI) No further declarations of interests were declared other than those on the three registers presented.

28/17 Minutes of meeting held on 14 February 2017. The minutes of the previous meeting were agreed and would be signed by the Chair as a correct record.

29/17 Matters Arising The log indicated a number of completed actions and updates that were being provided at the meeting, in addition;

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05.4/17 Well Led Review-attention was drawn to a briefing from MP that advised there was a working group looking at the recommendations next week and an action MP plan would come to the next committee.

10/17 IG Toolkits- Training was being arranged for June (PD) and there would be a KP/TT/ meeting to discuss further, including the costs. MP/PD

18/17 IA- TT and RM had met and the Directorate Risk Register was now in place and the request for a review be completed before the July deadline noted. An update on the recent ransome-ware Cyber-attack from RM was provided and members were pleased to note that the CCGs were not impacted bar a potential server patch issue where there was a decision not to switch off due to loss of clinical data. The team were congratulated on a well managed incident. SW raised the impact on our patients from Barts Health IT issues particularly those receiving critical care and the Q& S Committee would request if any SIs had arisen. TT advised that such impacts and AW/JH power outage were also picked up by review of the Business Continuity Plan and resilience testing and these new issues would be picked up at the next exercise. Although systems were in communication with each other the firewalls would prevent MP/LW spread.

18.2 /17 IA CSU Report- The Chair could request a copy of the WF CHC personal MP/KP budgets report via their audit chair if necessary.

21.1/17 Tender Waivers- Due to the time constraints at this meeting the procurement strategy was deferred to the next meeting.TT confirmed a final review was in hand by TT GS.

30/17 Havering CCG TT provided a short summary of the annual report that included some new mandated requirements. He confirmed it was a comprehensive cover of a number of necessary statements and there had been work with EA on the content and alignment with the financial statements. CBe pointed out an error on P16 around the year end position NC/MP which was to be corrected immediately after this meeting. The other two CCG reports would be checked for accuracy.

For the financial statements TT confirmed the core numbers and bottom line had not changed since the draft financial statements although there had been a classification change around the CSU across all CCGs and formatting changes. Member’s earlier feedback had been accounted for.

Internal Auditors Annual Report/HOIAO JE confirmed that all reports for the three BHR CCGs included the same Head of Internal Audit Opinion for this financial year - ‘The organisation has an adequate and effective framework for risk management, governance and internal control. However, our work has identified further enhancements to the framework of risk management, governance and internal control to ensure it remains adequate and effective’. This included work on QIPP and CSU work undertaken on IT controls and Cyber Security. The status of management action against IA recommendations was commended, noting 100% achievement by year end. Areas for partial opinion were highlighted.

The findings of the interim Service Auditor Report (Deloittes) had been reviewed and a draft bridging letter had been received for the final month with no significant issues to report.

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The report covered IA’s own performance and added value achieved that included the sharing of Health Matters bulletins. Also provided was a summary of performance indicators, agreed with the Committee, and their achievement.

The Chair in noting the challenging year and a light management structure, congratulated staff on achieving the 100% response by year end. KA requested a piece of work in year to review the impact of the BCF, both on health and social care, to determine VFM. The Chair questioned specific reporting on BCF/S75 agreements and delivery of objectives. TT said there were elements reported eg. BCF figured in the Urgent & Emergency Care QIPP and referred to reducing elective activity/holding TT back further growth and work could be done to strip out more direct impact and this would be considered further with leads.

Noting the current amber/red status of QIPP and partial assurance, there would be a further update at the July meeting.JE would check whether the CSU IT security issues JE had been sorted.

The Chair noted the April 2017 edition of Health Matters and asked TT to run through the sections to determine if any issues impacted the CCG noting many areas had been TT covered already by the CCGs.

The Internal Auditors were thanked for their report.

External Auditors results report KS reported on a good set of accounts in a challenging year by the finance team with the ambition to complete the work by Friday 26th May. An unqualified opinion was proposed..

On the financial statements there were just a few further areas to complete but the key challenge was completing the work on co-commissioning. Although a national process had been agreed and we submitted information in January there had been slow progress in clarifying responsibility for accruals. Although these were delegated budgets they were not in our control. It was confirmed this had been escalated at a number of levels including the NAO but communications did not appear to be working with for example, London finance. The Chair agreed to raise with the national Audit Chair if necessary as the account closures were being delayed. The Chair was reminded of a similar delay on Service Auditor reporting some years back. It was confirmed RA and TT had escalated this issue a number of times and KA added that the PCC had found the paucity and quality of information difficult to work with.

KS drew attention to the usual key areas of audit focus covering risk of fraud in revenue and expenditure recognition and management over-ride of controls. Testing was on reasonableness of estimates, journals and general satisfaction with evidence to provide assurance on a unqualified, true and fair, opinion.

Havering had overspent against its resource limit. KS stated that, whilst understanding the progress made in mitigating the RTT backlog clearance, he had no option but to issues a S30 referral to the SoS on 8 May. This reflected the factual position that led to a qualified regulatory opinion being given as monies were spent without statutory powers to do so.

Under VFM responsibilities it was clear that good progress had been made that led to the RTT Legal Directions being removed this year. This was a very positive message, However the CCG had to incur additional spend under these Directions to retrieve the 3 Draft Minutes BHR Audit Committee 24 May 2017 v1 143

RTT position, leading to the £4.76m overspend. Therefore the auditors were planning on giving a qualified VFM conclusion.

On reviewing the CCG’s Operating Plan for 2017/18, a significant level of QIPP was noted for the year ahead and looking at the whole health economy there was a very large issue, so the CCGs were not alone in their challenge. It was noted that not all QIPP areas appeared fully supported by full project plans yet and the CCG were advised to keep going, keep producing replacement ideas for areas of non-delivery, look ahead for opportunities for next year. Areas such as Prescribing coded blue were to be kept under review as whilst processes were in place there was no assurance until figures came through. TT confirmed it was coded blue due to the planning process and was in provider contracts and therefore risk was with the provider. Planning assurances vs delivery assurances was key. TT highlighted a difference with auditors on one point under the conclusions. It related to reference to weakness in financial arrangements rather than the CCG view of it being performance. KS stressed the need to use regulatory wording. KA again raised the importance of gaining evidence to review outcomes as commissioners we needed to ensure our money was well spent.

The Chair questioned impact of the S30 referral and KS did not expect it to raise any further issues as the CCG was in Legal Directions and therefore it aligned. Members discussed the need for reference in the annual reports to turnaround referencing strong strategic direction and commitment, Board to Board meetings on the £35m and clinician to clinician work on 13 specialties.

The Chair added that the VFM conclusion was disappointing but understandable due to the Legal Directions but asked that the Management Letter emphasise the positives not a lack of effort. KS would reflect on this further before finalising his letter. KS added that he was completing testing that day and was preparing for the Friday sign-off by TT and KP.

Finalised Annual Reports Apart from the issue raised by CBe, there was little further to add to previous drafting. MP and her team were thanked for the finalised reports.

Finalised Financial Statement The Chair firstly thanked the Finance Team and both the Internal and External Audit teams for their very good work.

The Chair would recommend to the Havering GB that they adopt the Annual Report and the Annual Accounts for the year 2016/17, highlighting that all observations of the CFO, Audit Committee Members, Internal Audit and External Audit had been considered in the documentation, subject to a change of one sentence on P16 of the Annual report that would be corrected after this meeting (since completed).

31/17 Barking & Dagenham TT provided a short summary of the annual report that included some new mandated requirements. He confirmed it was a comprehensive cover of a number of necessary NC statements and there had been work with EA on the content and alignment with the financial statements. NC would check the statements in the annual report were correct on the year end position.

For the financial statements TT confirmed the core numbers and bottom line had not changed since the draft financial statements although there had been a classification

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change around the CSU across all CCGs and formatting changes. Member’s earlier feedback had been accounted for.

The findings of the interim Service Auditor Report (Deloittes) had been reviewed and a draft bridging letter had been received for the final month with no significant issues to report.

The Chair in noting the challenging year and a light management structure, congratulated staff on achieving the 100% response by year end.

The Internal Auditors were thanked for their report.

On the financial statements there the same issue applied around co-commissioning information and this was currently being chased and would be escalated if necessary as outlined above.

A qualified VFM conclusion was being proposed. The Letter of Representation will refer to an accrual, referred to last year, of a provision made for R & D ‘Life Study’ work involving the CCG, NELFT and BHRUT. There was lack of clarity of ownership TT of the debt between NELFT and BHRUT and the CCG was taking a prudent approach with holding a provision. The Chair noted this was not material and supported the CFO in making this provision and requested an update in September of the position.

The significant level of challenge on QIPP was again repeated and the need for completed project plans and advice given on focus for the CCG.

Finalised Annual Reports There was nothing further to add on the annual reports but the summary line on year end position would be checked for accuracy (since complete). MP and her team were thanked for the finalised reports. 5 Draft Minutes BHR Audit Committee 24 May 2017 v1 145

Finalised Financial Statement The Chair firstly thanked the Finance Team and both the Internal and External Audit teams for their very good work.

The Chair would recommend to the Barking & Dagenham GB that they adopt the Annual Report and the Annual Accounts for the year 2016/17, highlighting that all observations of the CFO, Audit Committee Members, Internal Audit and External Audit had been considered in the documentation.

32/17 Redbridge CCG TT provided a short summary of the annual report that included some new mandated requirements. He confirmed it was a comprehensive cover of a number of necessary statements and there had been work with EA on the content and alignment with the financial statements.

The findings of the interim Service Auditor Report (Deloittes) had been reviewed and a draft bridging letter had been received for the final month with no significant issues to report.

On the financial statements there were just a few further areas to complete but the key challenge was completing the work on co-commissioning as referred to above. KS drew attention to the usual key areas of audit focus covering risk of fraud in revenue and expenditure recognition and management over-ride of controls. Testing was on reasonableness of estimates, journals and general satisfaction with evidence to provide assurance on an unqualified, true and fair, opinion.

A qualified VFM conclusion was proposed and there were no specific references in the Letter of Representation. However, the resultant accruals arising from co- commissioning, referred to as delayed above, would sit with Redbridge CCG as the host of the delegated co-commissioning so therefore there was risk of delay in these accounts sign off to meet the deadlines. The Chair questioned the penalties and TT confirmed this could be counted against the CCGs performance assessment

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framework. The Chair requested TT escalate to David Slegg if there was a continued risk of delay and KS was to keep the Chair informed.

Finalised Annual Reports There was nothing further to add to previous comments other than a request to ensure plain English (e.g. Deep Dives was not an understood term).

Finalised Financial Statement The Chair firstly thanked the Finance Team and both the Internal and External Audit teams for their very good work.

The Chair would recommend to the Redbridge GB that they adopt the Annual Report and the Annual Accounts for the year 2016/17, highlighting that all observations of the CFO, Audit Committee Members, Internal Audit and External Audit had been considered in the documentation.

33/17 Update on GBAF and risk in 2017/18 PD attended and confirmed she had taken account of comments from the last Audit Committee and the IA review. She had now met with all risk owners, and questioned if the risk description was correct and the impact of the risk. The mitigation was reviewed and tangible actions sought and target dates set of when reduction of risk was expected. The risk registers would be updated to align with the agreed corporate objectives and CD responsibilities. A summary would be added to list risks in severity order against the corporate objectives. Work was ongoing to keep pace with changes to the management structure and transfer of risks.

The Chair welcomed the risk review and requested a twice yearly report to the Committee, beginning July. KA questioned whether a learning element to share risk and remedial action could be incorporated to avoid repetition. PD would consider this further. The Chair was pleased to note that all Directorates had a risk register and that MP/PD EMT were discussing it the following week. He requested a July review of the register.

As agreed earlier there would be a meeting to discuss and scope the June risk training. KS added that the key to good risk management was management behaviour and gaining continuity in a challenged environment.

The Chair thanked PD for her update.

34/17 Policy Approval Conflicts of Interest, Gifts & Hospitality and Sponsorship Policy This new policy had taken account from recent guidance and was based on a useful national template. It had also taken account of the IA recommendations from their February review. IA supported the policy and added it was important to record refusal of gifts etc.

Under COI, KA suggested that consideration could be given to including co-opted patients/public involved in the procurement processes. It was noted there was a separate declaration form around procurement, and that process should be referenced in the procurement policy and to whom was included, but this would be checked. The AW policy was required to be in place by 1 June and there would be communication to all listed as affected by the policy. A national training module was being developed and this would be rolled out to staff in the autumn and become part of CCG mandatory training. It was confirmed that the Audit Chair remained the COI Guardian.

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The policy was approved by the Committee.

Raising a Concern Policy This was the new term for Whistle-blowing and again the policy took account of new guidance. LCFS had received a copy and were satisfied with the content. Again the Guardian, was the Audit Chair and there were details of reporting to LCFS in the policy. SW raised the consequences if staff saw something and did not report this and CBe referred to references to ‘don’t do nothing’. The Chair welcomed any further additions that members offered and added that training would be important for full understanding. Communication of the policy would be rolled out to all concerned during June. It was noted that an annual report was required and this would be to the Remuneration and Workforce Committee by year end.

The Committee agreed the policy.

35/17 Update on Financial position At month 1- There was no actual data yet but everything was on plan. A focus of the system delivery performance board was ensuring QIPP remained on target. A risk model was being developed and he was able to report on very positive partnership work. The letter of engagement required PWC to provide their analysis by month end and a draft had been received for comment. This Committee would receive that next TT time.

KA raised the impact of purdah on decision-making and TT confirmed that the timetable was affected for only one procurement. The Chair advised that the CCG had received directions that the annual reports and accounts could not be made public until purdah was lifted and the website had been adjusted and GB papers would be received at a Part 2 meeting. KA asked for consideration to be given if there was the easing of 18 week wait targets as reported on and flagged impact on finance.

Tender Waiver- Home-Start Havering-The Committee noted this had been considered by FRPB and this was a sole provider issue. KA asked that good VFM should be captured in all procurements at the outset.

36/17 CSU Quality Assurance Plan JE provided the Plan that indicated that the CCG’s risk management processes had been evaluated to inform the Plan. Priorities had been discussed with a number of leads and SLAs reviewed. The Plan had 4 sections  Information Technology  Clinical Systems  Data/Analytics/Performance  Operational Processes

The main focus areas for the CCGs were cyber-security, provider quality management, GP IT services, CHC.

The Quality Assurance Group had recommended the plan to the Audit & Governance Committee for approval. There had been three key considerations for the Assurance Group laid out in the report. This had also been reviewed by the CFOs group. The £77k costs were to be divided between the 12 CCGs served by the CSU dependant on usage not equally. The Chair asked the CFO to consider if the CSU had adequate workforce resources to deliver and JE confirmed that it had included a recruitment review. 8 Draft Minutes BHR Audit Committee 24 May 2017 v1 148

KA referred to the current consultation on spending wisely and whether there could be a process to capture any impact e.g. on IFRs, finance, quality & safety and the patient response. It was noted all such plans had an equality impact assessment and TT would consider further.

The Committee approved the CSU Quality Assurance Plan

37/17 Any Other Business There was no other business.

38/17 Chairs Key Messages to GB The Chair would be referring to completion of the Annual Reports and Annual Accounts for 2016/17, the issuing of qualified VFM conclusions for all three CCGs, a provision made in Barking & Dagenham accounts, agreement of two policies, review of risk management processes, approval of the CSU Assurance Plan and a request for a review of BCF value for money.

39/17 Items for Information The Committee noted the minutes of the Assurance Group meeting held on 3 March 2017.

40/17 Date of Next Meeting The next meeting was arranged for 11 July 2017.

Signed………………………………………………..Date………………………….

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To: Meeting of the Redbridge CCG Governing Body

From: Tom Travers, Chief Financial Officer Chair of Financial Recovery Programme Board (FRPB)

Date: 20 July 2017

Subject: Work of the FRPB and Financial Recovery Programme Progress Summary

Executive summary During 17/18 BHR CCGs are required to deliver £45m of savings in year. As of 9 May over £33m of savings scheme opportunities have been approved by the CCG. A pipeline of new opportunities has been identified and a series of workshops to develop further opportunities is in progress.

Recommendations The Governing Body is asked to note the report

1.0 Purpose of the Report 1.1 To update the Governing Body on the progress of the 2017/18 Financial Recovery Programme and work of the FRPB.

2.0 Background/Introduction 2.1 The financial challenges facing the BHR health system, following agreement of 2017-19 NHS contract values, are now significant, requiring BHR CCGs to save £45m to deliver a planned £10.2m deficit across BHR. Work is continuing under the direction of the Financial Recovery Programme Board (FRPB) to deliver savings schemes to meet this target.

2.2 Under the FRPB’s terms of reference a high level summary of the progress on the financial recovery will be regularly provided to the governing bodies.

3.0 Progress to date 3.1 Significant progress continues to be made on the savings programme: 47 savings schemes are now approved by the CCG and the total assured savings figure is £33,173,000.

3.2 Work is continuing within the CCGs and with providers to identify new savings opportunities. A program of workshops involving CCG clinical directors and provider clinicians to develop the identified opportunities into viable projects is ongoing, as is work to identify new opportunities via the NHS RightCare program which benchmarks CCGs’ performance against comparator CCGs. Following a joint executive meeting with colleagues from BHRUT in April, three system wide initiatives are being developed: Discharge to Assess, Pressure Ulcer Avoidance and Management and Referral Management. Each is reported through the System Delivery and Performance Board and monitored through the weekly Joint Delivery Meeting between the CCGs and BHRUT.

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3.3 Work is being undertaken to review current and planned investments to ensure that where possible investment funds deliver an optimal financial return on investment given the competing pressures of immediate financial recovery and sound long term investment in the health of our population. In addition work has begun to review the CCGs’ contract portfolio and procurement pipeline to identify any areas for potential saving.

4.0 Resources/investment 4.1 There are no additional resource implications/revenue or capitals costs arising from this report.

5.0 Equalities 5.1 There are no additional equalities implications arising from this report. All savings schemes are required to have an equalities impact assessment completed as part of the approval process.

6.0 Risk 6.1 There are no risks arising from this report. Risks to project delivery are held in individual project risk registers.

7.0 Managing conflicts of interest 7.1 There are no conflict of interest in regards to this paper.

Author: Jeremy Kidd, Head of PMO Date: 26.06.17

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Primary Care Transformation Programme Board 16 January 2017 Becketts House Present: Councillor Mark Santos, Chair (MS) Cabinet Member for Health and Social Care, London Borough of Redbridge Conor Burke (CB) Chief Officer, BHR CCGs Dr Gurkirit Kalkat (GK) Clinical Director, Barking and Dagenham CCG Sahdia Warraich (SW) Lay Member, Barking and Dagenham CCG Dr Shabana Ali (SA) Clinical Director, Redbridge CCG Khalil Ali (KA) Lay Member, Redbridge CCG Cathy Turland (CT) Healthwatch Redbridge Dr Anil Mehta (AM) Chair, Redbridge CCG Rob Adcock (RA) Deputy Chief Finance Officer, BHR CCGs Alison Goodlad (AG) Head of Primary Care, North East London, NHS England Dr Daniel Weaver (DW) Chair, Havering Health Ltd Sarah See (SS) Director, Primary Care Transformation, BHR CCGs Dr Arun Sharma (AS) Chair, Together First Ltd Dr Imran Umrani (IR) Director, Redbridge GP Alliance Ltd Gladys Xavier (GX) Deputy Director of Public Health, London Borough of Redbridge Paul Roche (PR) Primary Care Programme Manager NEL STP Karen Stubbs (KS) Director & COO, HealthBridge Direct Ltd In attendance Sarah Perman (SP) Deputy Director, Primary Care Transformation, BHR CCGs Natalie Keefe (NK) Head of Primary Care Transformation, BHR CCGs Ross Graves (RG) Prederi, Programme Support Paul Olaitan (PO) Programme Manager, BHR CEPN Jordanna Hamberger (JH) Senior Localities Lead, Havering CCG Jenny King (JK) (minutes) Business Manager, Primary Care Transformation, BHR CCGs Apologies Anne-Marie Dean (AD) HealthWatch, Havering Dr W Mohi (WM) Chair, Barking and Dagenham CCG

Item Title Action 1. Welcome and introductions After a hiatus due to the ‘refresh’ of the programme, MS welcomed all to the meeting and introductions were made. Apologies were noted. 2. System financial delivery CB gave an update on the BHR financial position and the plan to deliver financial sustainability. He outlined the financial challenges facing the BHR health care scheme and highlighted that good headway is being made. The main hurdle relates to next year’s financial position and the saving of £55m identified as a result of the arbitration from the contract negotiations.

The challenge is to draft a plan for delivery of the £55m by 28 February 2017 as required by our regulators. It is important to note that the plan needs to be signed off by system commissioner & providers; £35m of the plan needs to demonstrate how that value will be taken out across BHRUT. The plan will require input/agreement from all the providers, evidence continuous impact for the next 12 months starting 1st April, incorporate schemes associated with transformation, decommissioning and the cessation of services currently in the system.

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In order to reach the 28 February deadline, a mechanism will be established to facilitate arrangements, identify priorities and develop robust business cases. It was agreed at a recent meeting of all the BHR Chief Executives to recommend to the Integrated Care Partnership Board (our overarching system governance arrangement) to establish a BHR System Delivery and Performance Board (SDPB). The Board will be comprised of representatives providers and commissioners and will be responsible for system level delivery, planning and implementation of the financial recovery programme.

This is a new way of working and will inevitably require further discussion regarding board members, terms of reference, decision making criteria and how workstreams and providers will be held to account. To this end a programme director has been engaged to facilitate arrangements and liaise with members to take the objective forward, adhering to the very tight timescale.

CB stated that it will be the responsibility of the SDPB to oversee the work that is being carried out across the system and to support, enable and develop primary care. One of the critical enablers to this relates to the primary and community response to handling the demand management.

AS queried whether London Ambulance Service (LAS) will be included in the board. CB stated that LAS is represented through the A&E delivery arrangements which would in effect report into this board.

AS had a concern regarding the need for primary care to focus on demand management as he felt that this was a piecemeal way of dealing with what is a much bigger issue. CB understood the sentiment but reiterated that there is a requirement for all the organisations to make savings.

MS thanked CB for an informative update. 3. Governance and delivery structure Governance and delivery structure Given the ‘refresh’ of the programme, MS gave an overview of the governance and delivery structure. As the strategy is now approved, the focus of the board has changed from developing the strategy to implementing the strategy. Going forward the role of the board would be to implement the GP Forward View and supporting programmes (e.g. SCF), collaborative arrangements for STP Primary Care QI programme board and system financial recovery. MS indicated that there are three overarching worksteams under the programme; workforce, provider development and quality improvement.

SS clarified that in terms of governance, provider networks have their own accountable boards and are not managed by the Primary Care Transformation Programme – that is they are part of the delivery models, such as GP Federations, but are independent provider units (not managed by CCGs). Terms of Reference SS stated that there had been slight changes to the membership in order to support attendance at meetings across the system. Feedback from the local authorities is that they would prefer a representative for each borough – this is likely to be the Director, Public Health.

A representative from CEPN was now included in the membership.

A suitable meeting date/time needs to be identified as Monday afternoon is not convenient for many GPs.

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DW queried whether it would be beneficial to have individual federation representative rather than the three areas. SS agreed this was the intention and will make the necessary amendments to the TOR so that this is clear to all.

AS suggested linking the objective settings to financial recovery so that the results of projects incorporated both financial and quality.

CB confirmed that GPs, NELFT and voluntary sector organisations are expected to put forward joint propositions relating to how they will deliver planned health and wellbeing. Commissioning for outcomes and integrated solutions will be on a place based geographical basis.

The terms of reference was agreed, subject to incorporating the comments made above.

Action: Update TOR accordingly. SS 4. Programme overview SS presented the BHR Programme Overview Slides which set out the objectives, role of the GP Networks, current network status, approach and priorities for quarter 4 2016/17 and financial year 2017/18.

Each of the networks will have a non-commissioning chair and a vice-chair who will sit on a council/board at borough level, this group will steer the work undertaken in this programme within the respective boroughs. The chair of the council/board will join this programme board and ensure the flow of information between the practice networks and federations with the transformation programme board. They will also be representative of the NEL Quality Improvement Programme Board.

Discussion took place and it was recognised that the saving of £55m was a huge task during 2016/17 but ultimately that is what is required. It was agreed that the Board needs to have a clear focussed message to encourage GP engagement and ensure the challenge is met in a confident manner. Providing practices with training, information and support to enable them to do more for themselves has proved successful in other boroughs.

GX stated that this is an excellent opportunity to work together as public health commission services from primary care too.

SA queried whether the arbitration process would provide BHRUT the ‘higher ground’ to challenge primary care in future. CB responded that there will be challenging times ahead and there needs to be a move to develop joint plans relating to capacity, activity and managing demand in a better way. 5. Agree summary PIDS and review delivery highlights for each workstream NK presented the summary PIDS for each workstream providing further detail; namely provider development, quality improvement and primary care workforce.

Provider development has 4 workstreams: GP network development, sustainable GP practice, pathway redesign and patient access.

Discussion on Urgent Primary Care needs ensued and KA suggested that it would be helpful to have a mechanism in place to measure patient feedback to ensure the service they are visiting is adequate. Taking on board patient comments would impact patient design with maximum effect and prevent historic mistakes being repeated. SS reassured that positive patient feedback had been received from the hubs and will be taken into account when redesigning Urgent Primary Care Services going forward.

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There was also a concern regarding high levels of DNAs. NK confirmed this was an issue, in some practices DNA rates were higher than the national average, and was an area that could be looked at through the text messaging service.

SS pointed out that the hub model had a much lower rate of DNAs than practices, possibly due to the fact that appointments were made/available on the day.

KS suggesting making patients aware of the actual cost of a DNA and the general cost of using a NHS health service; there is evidence that this strategy has been effective in other areas.

SP advised that as part of the Urgent and Emergency Care Programme, there is a review of the OOH provision access across BHR which is going to be taking place with the final report being available at the end.

SP provided an update on the Quality Improvement Programme, rollout access across the patch, recruitment for training local QI facilitators, working with UCL partners and the Clinical Effectiveness Group (CEG). All agreed it is also important to involve non clinical staff in QI. SP confirmed that there will further opportunities for non-clinical staff in future via Care City / CEPN.

SP confirmed that the CCG is working closely with Community Educational Provider Network (CEPN) to ensure coherence in terms of the way we work noting their Programme manager is now part of the Transformation Programme Board. 6. Budget SS presented an update on budget and investment. In response to a query from KA relating to the Primary Care Investment Fund, SS clarified that as per the December Operating Plan submission, investment per head would remain at £5 inclusive of £3ph required under the GPFV.

KA felt it would be beneficial to financially reward patient representatives for attending meetings as patient input was key. SW agreed with this sentiment as well as the provision of refreshments at meetings. SS stated it was the decision of individual practices if they wish to invest in the PPG. 7. STP Primary Care Approach PR presented a paper relating to the STP Primary Care Quality Improvement Care Approach across North East London.

In brief, he reported that there are 2 main areas in terms of the STP plan; one relating to the strategic frameworks; access to care and proactive care and the other delivery of the GPFV.

He further advised that there are 3 main workstreams:-

 QI – sharing learning and examples of good practice  Workforce  Provider development

PR then went through the TOR for the North East London Primary Care Quality Improvement Partnership Board. It is intended to have representation from both commissioners and providers for all 7 CCGs and he reiterated the importance of building on our knowledge and developing common views.

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KA & GX would like patient representative to be included as these were not currently involved. PR acknowledged that thought should be given to how practices are represented on the Partnership Board as it develops.

Action: Draft patient engagement strategy for next meeting. PR 8. Review risk register The risk register was presented and noted. 9. A.O.B. None Date of next meeting: 5th April 2017

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Joint Executive Committee 20 April 2017 MINUTES

Present Title Dr Waseem Mohi Chair – Barking and Dagenham CCG (meeting Chair) Dr Gurkirit Kalkat Clinical Director – Barking and Dagenham CCG Dr Kanika Rai Clinical Director – Barking and Dagenham CCG Dr Rami Hara Clinical Director – Barking and Dagenham CCG Dr Ravi Goriparthi Clinical Director – Barking and Dagenham CCG Dr Jagan John Clinical Director – Barking and Dagenham CCG Dr Anju Gupta Clinical Director – Barking and Dagenham CCG Sharon Morrow Chief Operating Officer – Barking and Dagenham CCG Dr Atul Aggarwal Chair – Havering CCG Dr Maurice Sanomi Clinical Director – Havering CCG Dr Ann Baldwin Clinical Director – Havering CCG Alan Steward Chief Operating Officer – Havering CCG Richard Coleman Lay Member – Havering CCG Dr Anil Mehta Chair – Redbridge CCG (meeting Chair) Dr Mehul Mathukia Clinical Director – Redbridge CCG Dr Shabana Ali Clinical Director – Redbridge CCG Louise Mitchell Chief Operating Officer – Redbridge CCG Conor Burke Chief Officer – BHR CCGs Tom Travers Chief Financial Officer - BHR CCGs Marie Price Director of Corporate Services – BHR CCGs

In attendance James Gregory Interim Director - Programme Management Office Christine Kane Assistant Director – Quality – BHR CCGs

Apologies Dr Sarah Heyes Clinical Director – Redbridge CCG Dr Shujah Hameed Clinical Director – Redbridge CCG Dr Muhammad Tahir Clinical Director – Redbridge CCG Dr Jyoti Sood Clinical Director – Redbridge CCG Dr Syed Raza Clinical Director – Redbridge CCG Dr Anita Bhatia Clinical Director – Redbridge CCG Khalil Ali Lay Member – Redbridge CCG Ah-Fee Chan Secondary Care Consultant – Redbridge CCG Kash Pandya Lay Member – BHR CCGs Dr Alex Tran Clinical Director – Havering CCG Dr Ashok Deshpande Clinical Director – Havering CCG Dr Gurdev Saini Clinical Director – Havering CCG Jane Gateley Director of Strategic Delivery Jacqui Himbury Nurse Director – BHR CCGs Sarah See Director of Primary Care Improvement – BHR CCGs

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1.0 Welcome, Introduction and apologies The Chair welcomed members to the meeting and apologies were noted.

2.0 Declarations of interest There were no new declarations of interest declared.

3.0 Minutes from the previous meeting The minutes from the previous meeting were agreed. Note

4.0 Finance Budget 2017/18 Tom Travers gave an overview of the new integrated budget paper that provides the commissioning financial position for the three CCGs, which is a QIPP requirement for 2017/18 of £45.1m and a deficit of £10.2m.Tom advised that the full value of the net financial risk totals Note £40.8m, with a mitigated risk value of £21.7m. The full unmitigated risk based on assessment of current plans could result in the CCGs delivering an end of year deficit of up to £31.9m.

Dr Mohi asked how the planned £10.2m deficit is mitigated. Tom advised that this is supported by the STP taking on additional QIPP to support the CCGs and that the expectation by NHS England is that this will be the final position for 2017/18.

It was noted the line for ACO investments should be changed to ACS and that this is the Note budget provision for invest to save initiatives as part of this.

Richard Coleman asked on the progress of reconciling the BHRUT, NELFT and Barts Health Cost Improvement Plans with our QIPP plans. Tom advised that this was in progress.

Dr Aggarwal questioned the activity in Appendix D – Forecast Outturn for 2016/17. Tom confirmed this was the number of referrals made for all providers.

Tom outlined the new national process for systems in financial recovery, the Capped Expenditure Programme, and how the principles for affordability will change going forward. Tom advised that some modelling has already been done internally as to what that may mean for the CCGs and that we are already looking at early opportunities using those principles, such as looking at current contracts that are coming to an end, so that we be in a position to respond when required.

Dr John raised concerns on the implications of the new process on patient care and the viability of the system as a whole.

5.0 System Delivery update James Gregory updated members on the progress and latest position of the System Delivery plan. The key next steps are to work with Barts and NELFT to identify any additional opportunities.

6.0 Items for information 6.1 Collaborative risk log Members were asked to note the risks outlined.

7.0 Date of next meeting Thursday 8 June 2017, 1.30-3.30pm at Becketts House. The next informal JEC will be held on Thursday 4 May at 2pm at Becketts House.

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Redbridge Clinical Commissioning Group Patient Engagement Forum (PEF)

Tuesday, 9 May 2017 Becketts House, Ilford

Minutes of the meeting

Present: Lorraine Silver (LS) PEF Chair, Fairlop Vivien Nathan (VN) PEF Vice Chair, Cranbrook and Loxford Howard Clarke-Melville (HC-M) PEF member, Seven Kings David Lyon (DL) PEF member, Fairlop Dee Datta (DD) PEF member, Cranbrook and Loxford Boba Rangelov (BR) PPE Advisor BHR CCGs Swati Vyas (SV) Health Partnership manager, Redbridge CVS Christine Lewis (CL) PEF member, Wanstead and Woodford Jean Cowie PEF member, Fairlop Harjit Sangha (HS) PEF member, Cranbrook and Loxford Michelle Greene (MG) PEF member, Wanstead and Woodford Tahir Mahmud (TM) PEF member, Seven Kings Kenneth Turner (KT) PEF member, Cranbrook and Loxford Naina Thaker Redbridge Healthwatch Raina Gee (RG) The Redbridge Youth Council Co-ordinator Kishan Sharma The Redbridge Youth Council member Dr Jyoti Sood Redbridge CCG Clinical Director Stuart Bellwood PEF member, Seven Kings Jack Weedon PEF member, Seven Kings David Hall PEF member, Cranbrook and Loxford

Apologies: Jon Abrams (JA) Redbridge Forum representative Filiz Zaman (FZ) PEF member, Fairlop Louise Mitchell (LM) Redbridge CCG Chief Operating Officer Khalil Ali (KA) Lay member Elaine Freedman (EF) PEF member, Seven Kings Vanessa Madu The Redbridge Youth Council rep Chandrakant Patel PEF member, Wanstead and Woodford

Absent: Karen Douglas Uniting Friends, support worker for Mr Elliff John Elliff (JE) Uniting Friends, LD representative Andrea Leathers Uniting Friends, LD representative

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Item Action 1 Welcome and apologies Two new PEF members were welcomed to the meeting, Mr Weedon and Mr Bellwood. LS informed everyone that BR is leaving BHR CCGs. LS congratulated BR on her new job and thanked her for her work and contribution to the PEF. 2 Minutes and matters arising (including PEF log) 2.1 Minutes were approved as a correct record of the meeting. Matters arising: All actions were completed, apart from the letter to BHRUT CEO, Matthew Hopkins, to congratulate the Trust on coming out of the special measures. 4.1: The Healthwatch emailed all care homes in Redbridge regarding re- admission to hospital and they are awaiting their response. ACTION: NT to liaise with the sheltered housing residents for the same NT reason (hospital re-admission) and to report at PEF’s July meeting about the findings. 3.0 Localities in Redbridge-Natalie Keefe, Head of Primary Care Transformation Programme, BHR CCGs 3.1 NK gave a presentation about the latest developments of the localities in Redbridge. 3.2 There are number of transformation programmes in Redbridge and there are three workstreams. Six network leads have been appointed. The network meetings are happening monthly. There are number of new schemes and programmes that are happening at present. Four practices in Redbridge took up the scheme. There is also Leadership programme. 3.3 There is also text messaging pilot project: They are trying to have all practices to have two way texting. It is voluntary for practices to join this pilot and they have to fund the other half. DD asked how PCTP will link up the work of PPGs in localities and what the plans are. Dr JS said that this is very important issue. NK said that she will take this back for a response. ACTION: NK NK 3.4 SW asked how the voluntary sector is going to be involved in PCTP. NK replied that they work with providers and other stakeholders. SW asked if they are looking to use SKYPE or maybe telephone 3.5 conference to communicate with the patients. NK replied that they are looking at different ways to communicate for GPs. CL asked how the Network Leads will be involved with the PPG localities. ACTION: NK to take back and find out what the plans are regarding PPG NK localities. PEF members shared their experiences in their own practices. NK said that practices won’t stop sending letters to patients about their appointments or calling them. 3.6 TM said that booking GP appointments on line can be difficult for some patients. NK replied that patients still can book their appointments by calling the practice. 50% of the appointments are allocated for on line appointments. ACTION: BR to send NHS England email response about DNAs procedure BR in practice to PEF. 4.0 Lay member’s report-Khalil Ali, Lay member 4.1 As KA was absent from the meeting, LS asked everyone to read the report. 4.2 BR reminded everyone that the deadline for the consultation is 18 May and encouraged PEF to complete the questionnaire.

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4.3 Dr JS said that the directions regarding the savings are coming from NHS England. 5.0 Redbridge Healthwatch-Naina Thaker 5.1 RH held a Celebration event recently. Mental Health came up as one of the priorities. They also carried out Mental health survey. ACTION: NT to send Intermediate Care reports to BR for PEF NT 5.2 SW said that the Redbridge CVS organised training about mental health 5.3 and they did a lot of work to raise awareness about dementia and other mental health conditions. Safe hospital discharge: RH is visiting discharge lounges in hospital and 5.4 finding out patient experience during hospital discharge. Accessible Information Standard (AIS): RH staff is visiting GP practices 5.5 together with volunteers who have impairments in order to find out if and how practices comply with the AIS. RH is also working with Redbridge People’s Parliament (LD organisation) regarding AIS. 6.0 The Youth Council - Raina Gee, YC Co-ordinator and Kishan Sharma, RYC member 6.1 RYC have elected a new Youth Parliament. 6.2 The Youth Conference is on 12 July. 6.3 RYC is promoting the App “Citizen’s Aid” among young people. They found it useful as it gives advice and information regarding urgent everyday situations. This App is free and it is for everyone. 6.4 DD mentioned “Life Saver”, also free App, which gives tutorials regarding First Aid etc. ACTION: DD and RG to liaise and exchange information about Apps. DD and RG 7.0 PPG log-BR 7.1 BR went through the log. The issues that have been responded to have been kept on a log for a new PPE Advisor to be aware of. IT issue is now formal complaint and therefore Forest Edge PPG has to wait to receive a formal response from our IT department. The issue regarding waiting for the medication too long at BHRUT during 7.2 hospital discharge has been addressed to BHRUT. ACTION: LS to send an email to the Chair of the Patients’ Council at LS BHRUT and address this issue. 8.0 AOB 8.1 PPG survey: BR thanked everyone for participating in the survey. The response was excellent, 50% of practices responded. District Nurses: This will be the main topic for July’s PEF meeting. STP: H C-M said that STP is very important and should be the main topic in July. Phlebotomy: MG claimed blood tests results are not coming through to GP practices from Whipps Cross. 9.0 Forward Planner 9.1 All the topics requested by the PEF members have been added to the Forward Planner. 10.0 Close and date of the next meeting 10.1 LS closed the meeting and thanked everyone. The next meeting is on Tuesday, 11 July 2017, Becketts House, Ilford, IG1 2QX, 2nd floor, boardroom A.

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Dates of the PEF meetings in 2017: Tuesday, 12 September 2017 Tuesday, 14 November 2017 Tuesday, 9 January 2018 Tuesday, 13 March 2018

All meetings are held 5-7pm in Becketts House, 2nd floor, boardroom A.

Glossary PEF Patient Engagement Forum CCG Clinical Commissioning Group YC Youth Council CVS Council for Voluntary Service PPE Patient and Public Engagement PPG Patient Participation Group BHR CCGs Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups IAPT Improving Access to Psychological Therapies BHRUT Barking Havering and Redbridge NHS Trust CAMHS Children and Young People Mental health services RTT Referral to treatment AIS Accessible Information Standard DNA Did not attend CQC Care Quality Commission ECTC Elective Care Treatment Centre STP Sustainable Transformation Programme LD Learning Disability

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