Agenda Document for Greater Preston CCG Governing Body

Greater Preston CCG Governing Body - Part 1

24 January 2019 at 2.00 pm Preston Grasshoppers RFC, Lightfoot Green Lane, Fulwood, PR4 0AP

Item Agenda Item Objectives/ Presented By Time No Desired Outcomes 1 Welcome and Apologies for Dr S Mukerji 2.00 pm Absence Verbal

2 Patient Story To update the Mrs H Curtis 2.02 pm group Verbal 3 Declarations and Register of To provide Dr S Mukerji 2.32 pm Interest (Pages 3 - 14) assurance Assurance

4 Minutes of Previous Meeting For group approval Dr S Mukerji 2.35 pm (Pages 15 - 32) Approval

5 Matters Arising (Pages 33 - For group approval Dr S Mukerji 2.35 pm 34) Approval

Standing Items 6 Chair's Update To update the Dr S Mukerji 2.25 pm group Verbal Board Assurance 7 Governing Body Assurance To provide Mr M Gaunt 2.55 pm Framework / Corporate Risk assurance Assurance Register (Pages 35 - 72)

Strategy 8 Integrated Care Partnership To update the Mr D Gizzi 3.05 pm Update (Pages 73 - 90) group Mrs S James Discussion 9 Our Health Our Care Acute To update the Mr D Gizzi 3.20 pm Sustainability Update (Pages group Mrs S James 91 - 94) Discussion

Operational Delivery 10 Integrated Board Report To update the Mrs H Curtis 3.40 pm (Pages 95 - 186) group Discussion

11 Financial Performance Report To update the Mr M Gaunt 3.55 pm

Agenda Greater Preston CCG Governing Body - Part 1 Meeting MEETING HELD IN PUBLIC

(Pages 187 - 206) group Assurance

Governance 12 EPRR - EU Exit Letter and To provide Mr M Gaunt 4.10 pm Operational Guidance Update assurance Assurance (Pages 207 - 210)

Quality and Engagement 13 Equality Annual Report (Pages For group approval Mrs H Curtis 4.20 pm 211 - 276) Approval

14 CCG Safeguarding Annual For group approval Mrs H Curtis 2.30 pm Report 2017/18 (Pages 277 - Approval 312)

Committee Updates and Minutes 15 Audit Committee Update and To provide Mr I Cherry 4.35 pm Minutes (Pages 313 - 330) assurance Assurance

16 Joint Quality and Performance To provide Mr P Richardson Committee Update and assurance Assurance Minutes (Pages 331 - 340)

17 Delegated Commissioning To provide Mr P Richardson Committee Minutes (Pages assurance Assurance 341 - 348)

18 Clinical Effectiveness To provide Mrs D Corcoran Committee Update (Pages 349 assurance Assurance - 352)

19 Lancashire Health and For Information Mr D Gizzi Wellbeing Board Minutes Information (Pages 353 - 376)

Questions from the Public 20 Questions from the Public Dr S Mukerji 4.45 pm Verbal Any Other Business 21 Risk Review Dr S Mukerji 4.50 pm Verbal 22 Any Other Business Dr S Mukerji 4.55 pm Verbal Date, Time and Venue of next meeting: Friday, 29 March 2019, 2.00 pm, Preston Grasshoppers RFC, Lightfoot Green Lane, Fulwood, PR4 0AP

Agenda Greater Preston CCG Governing Body - Part 1 Meeting 24 January 2019 Agenda Item 3

Governing Body Meeting

Date of meeting 24 January 2019 Title of paper Declarations and Register of Interests Presented by Dr Sumantra Mukerji, Chair Author Joanne Croasdale - Administrative Assistant Clinical lead N/A Confidential No

Purpose of the paper This register is a standing item on all statutory Committee agendas. The register is for information purposes and allows members to challenge any potential conflicts against agenda items. This item also allows members and attendees to declare any additional interests against agenda items prior to the main body of the meeting.

Executive summary The Clinical Commissioning Group (CCG) has a statutory requirement to keep and maintain a Register of Interests for the organisation with regard to actual or potential interests declared by; Governing Body members, Membership Council members, members of Sub Committees of the Governing Body, and employees of the CCG.

This report presents the flowchart for declaring and managing Conflicts of Interest, as outlined in the Managing Conflicts of Interest Policy.

The Governing Body should note that the annual request for Members to declare their interests was distributed in December 2018; all submissions received have been included within this latest register.

All conflicts or potential conflicts should be declared, and where a conflict of interest has required specific management arrangements during the course of the meeting, this should be recorded in the minutes, along with the action taken by the Governing Body Chair in managing the conflict.

Recommendations The Governing Body is asked to note the register of interest and to make any additional declarations as appropriate against any agenda items.

Declarations and Register of Interests NHS Greater Preston CCG Governing Body Meeting Page 3 24 January 2019 Links to CCG Strategic Objectives SO1 Improve quality through more effective, safer services, which deliver a ☐ better patient experience SO2 Commission care so that it is integrated and ensures an appropriate ☐ balance between in-hospital and out-of-hospital provision SO3 Be an integral part of a financially sustainable health economy ☐

SO4 Ensure patients are at the centre of the planning and management of ☐ their own care, and that their voices are heard SO5 Be a well-run clinical commissioning group and the system leader ☒

Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome

This paper was last reported to 29 November Governing Body Governing Body on 29 2018 November 2018 Were any conflicts of interest identified at previous meetings (mark X in the correct box below) Yes No X If conflicts of interest were identified what were these: N/A

Implications Quality/patient experience Yes ☐ No ☒ N/A ☐ implications? (Potential) conflicts of interest? Yes ☐ No ☒ N/A ☐ Equality Impact Assessment? Yes ☐ No ☒ N/A ☐ Privacy Impact Assessment? Yes ☐ No ☒ N/A ☐ Are there any associated risks? Yes ☐ No ☒ N/A ☐ Are the risks on the CCG’s risk Yes ☐ No ☒ N/A ☐ register? If yes, please include risk description and reference number

Assurance Assurances will continue to be provided to the Governing Body from the CCG’s Audit Committee.

Declarations and Register of Interests NHS Greater Preston CCG Governing Body Meeting Page 4 24 January 2019

NHS Greater Preston CCG Governing Body - Declarations of Interest Declarations of Interest are recorded on the Register when specifically declared by a member of the meeting. This Register was accurate at the time meeting papers were submitted; therefore, any changes received after submission will be included on the Register for the next statutory meeting.

Codes for the types of interests declared are (2018 proforma): DP=Direct Pecuniary, IP=Indirect Pecuniary, NP=Non Pecuniary Personal Interest, CL=Conflict of Loyalty, PR=Professional or Personal Relationship. (2019 proforma): FI=Financial Interest, NFProI=Non Financial Professional Interest, NFPI=Non Financial Personal Interests, II=Indirect Interests. Interests declared in 'bold' are pending confirmation of the type of interest.

Name Role Declaration Date Mitigating Actions Ms Helen Curtis Director of Quality and NFPI - Daughter is Specialty Business 14.12.2018 This will be declared separately in any Performance, NHS Manager for Surgery at Lancashire meetings whereby this presents a conflict Chorley and South Teaching Hospitals NHS Foundation Trust, to my decision making Ribble and NHS Greater December 2018 Preston CCG NFPI - Son is a Social Worker in central Preston, current Ms Patricia Governing Body Nurse, No interests declared 19.12.2018 Not applicable - no interests declared Hamilton NHS Chorley and South Ribble and NHS Greater Preston CCG

Dr Eamonn Secondary Care Doctor, NFProI - Retired consultant Anaesthetist 18.12.2018 Interest noted. Will be reviewed in line McKiernan NHS Chorley and South who worked at Lancashire Teaching with agenda items at committee meetings Ribble and NHS Greater Hospitals NHS Foundation Trust for 31 and procurement involvement. Where a Preston CCG years conflict emerges the individual will be NFPI - Oldest daughter is a social worker excluded from decision making. in Newcastle Upon Tyne, current 5 Page Declarations and Register of Interests

NHS Greater Preston CCG Governing Body meeting 24 January 2019

Name Role Declaration Date Mitigating Actions NFPI - Second daughter is a Psychiatrist researching and practicing in Cambridge, current NFPI - Third daughter is Children's nurse in Stockport, current NFPI - Son in Law training in Cardiology in Cambridge and Norwich, current Mr Paul Vice Chair and Lay NFPI - Son is employed by NHS Blackpool 10.12.2018 Interest to be managed as and when Richardson Member for Governance, Teaching Hospitals Trust conflict arises NHS Greater Preston NFPI - Daughter employed by Public CCG Health England, from 2013 Mr Denis Gizzi Chief Accountable FI - The Den Recording Studio, current 11.12.2018 Interest noted, will be reviewed in line with Officer, Chorley & South FI - Smart Sight Coaching, current agenda items at committee meetings and Ribble & Greater Preston FI - Ndeed Consulting, current procurement involvement. Where a CCG’s NFProI - Dr Alan Nye is a long-time conflict emerges the individual will be acquaintance from my time in Oldham, excluded from decision making current NFPI - My partner is owner and MD for C&I Consulting, current NFPI - Jackie Proctor, who is the CCG's anti-fraud specialist employed by MIAA, is a personal friend of mine, current

Dr Sumantra Clinical Chair - NHS FI - GP partner - Stonebridge Surgery - 18.12.2018 Interest noted, will be reviewed in line with Mukerji Greater Preston CCG Current agenda items at committee meetings and FI - Salaried GP - employed by Lancashire procurement involvement. Where a Care Foundation Trust to manage patients conflict emerges the individual will be clinically in Longridge Community Hospital excluded from decision making - Current

6 Page Declarations and Register of Interests

NHS Greater Preston CCG Governing Body meeting 24 January 2019

Name Role Declaration Date Mitigating Actions FI - Shareholder - Preston Primary Care Centre - Current FI - Stonebridge Surgery - Member of Preston East Network - Current FI - Director - P&S Mukerji Ltd - Current FI - Wife - Shareholder P&S Mukerji - Current Mr Matt Gaunt Chief Finance & No Interest declared 11.12.2018 No risk to decision making as no potential Contracting Officer, conflicts identified Deputy Accountable Officer, Chorley & South Ribble & Greater Preston CCG’s Mr Ian Cherry Lay Member for Finance, II - My daughter, Dr Mary Gemma Cherry, 03.01.2019 Interest noted, will be reviewed in line with Audit & Conflicts of is a lecturer in Clinical Health Psychology agenda items at committee meetings and Interest, Greater Preston at the University of Liverpool and honorary procurement involvement. Where a CCG clinical psychologist with Royal Liverpool conflict emerges the individual will be and Broadgreen Hospitals Trust. - excluded from decision making. 03.01.2019 until further notice II - My son-in-law, Dr Jake Rigby, is a specialist Trainee(ST4) in Psychiatry. His lead employer is St Helens and Knowsley NHS Trust, however, he is currently on placement with Cheshire and Wirral Partnership NHS Trust - 03.01.2019 until further notice NF ProI - Greater Preston CCG Conflicts of Interest Guardian - current

7 Page Declarations and Register of Interests

NHS Greater Preston CCG Governing Body meeting 24 January 2019

Name Role Declaration Date Mitigating Actions Dr Brigid Finlay GP Director, NHS FI - GP Partner, Park View Surgery, 04.01.2019 Interest noted, will be reviewed in line with Greater Preston CCG Preston - Current agenda items at committee meetings and FI - Member of Greater Preston Medical procurement involvement. Where a Group limited company - Current conflict emerges the individual will be FI - Provide Medical Services to registered excluded from decision making population. (PMS, moving to GMS, CCG Quality Contract) FI - Practice provides 8 week checks to neighbouring practices and has contract to provide medical cover to Meadowfield Rehabilitation Unit from 01/07/16 onwards FI - Provides training to F2 and GP ST2 and ST3 doctors: Practice receives training grant from the North West Deanery NFProI - Involvement with Our Health Our Care (OHOC) FI - Potential plans in development for co- location of services with other provider

II - Dr Jerry Hann is a GP Partner at Park View Surgery, part of team considering GP involvement in integrated care partnership Dr Hann is the director of the network (Greater Preston Medical Group limited) company) NFProfI - Dr Yousaf (partner) and Appraiser, also works for the LMC NFProfI - Dr Linda Fan (salaried) provides medical services to patients registered with Park View Surgery

8 Page Declarations and Register of Interests

NHS Greater Preston CCG Governing Body meeting 24 January 2019

Name Role Declaration Date Mitigating Actions NFProfI - Refer patients to professionals for care, and sometimes asked to register patients (unaware if they have/are contracting for NHS services) NFPI - Mr Martin Letheren (husband), Anaesthetist providing anaesthetic services at Lancashire Teaching Hospitals NHS Foundation Trust to both private and NHS patients at Ramsay Healthcare and Gisburne hospitals Mrs Jayne Mellor Head of Planning and Personal 06.04.2018 No risk to decision making as no potential Delivery, NHS Chorley - No interests declared conflicts identified and South Ribble and Associated NHS Greater Preston - No interests declared CCG Dr Sandeep GP Director FI - GP Partner Park Medical Practice - 04.01.2019 Interest noted, will be reviewed in line with Prakash Current agenda items at committee meetings and FI - GP Quality Contract and any other procurement involvement. Where a general practice initiatives commissioned conflict emerges the individual will be by CCG - Current excluded from decision making NFI - GP trainer - Current Sue Stevenson Chief Operating Officer No Interest declared 14.11.2018 No risk to decision making as no potential for Healthwatch conflicts identified Lancashire, Seeking Observer Status on the CCG Vancant post - Public Health Consultant, Public Health NHS Chorley and South Consultant Ribble CCG and NHS

9 Page Declarations and Register of Interests

NHS Greater Preston CCG Governing Body meeting 24 January 2019

Name Role Declaration Date Mitigating Actions Greater Preston CCG Dr Arumugam LMC Representative, Personal 16.03.2018 Interest noted, will be reviewed in line with Umapathy NHS Greater Preston DP - Locum in central Lancashire agenda items at committee meetings and CCG Associated procurement involvement. Where a - No interests declared conflict emerges the individual will be excluded from decision making Mrs Debbie Lay Member - Greater NFProI - From 15th May 2017, employed 11.01.2019 Interest noted, will be reviewed in line with Corcoran Preston CCG as Clerk to the Corporation to Nelson and agenda items at committee meetings and Colne College. The College works directly procurement involvement. Where a with NHS organisations/Trusts to deliver conflict emerges the individual will be training. 2 College Board Members are excluded from decision making also associated with the East Lancashire Hospitals NHS Trust – one is an employee, another is a Non-Executive Director of the Board. NFPI - Husband is an employee in a commercial organisation (Intersystems), which contracts with acute NHS Trusts for the provision of electronic patient record (EPR) systems. Dr Praful GP Director Preston 10.01.2019 Interest noted, will be reviewed in line with Methukunta CCG FI - Senior GP Partner at Briarwood agenda items at committee meetings and Medical Centre - Current procurement involvement. Where a FI - Signed up to the quality contract from conflict emerges the individual will be Preston CCG - Current excluded from decision making FI - Signed up for LES/DES from CCG FI - Prescribing Lead NFProI - Member of LMC FI - PMS contract

10 Page Declarations and Register of Interests NHS Greater Preston CCG Governing Body meeting

24 January 2019

Name Role Declaration Date Mitigating Actions NFProI - Honorary Secretary for Preston Medico Ethical Society (forum of primary care and secondary care consultants) FI - Business partner with Dr.Craven at Lostock Hall Medical Centre, Preston on a new project (moving existing surgery into new premises) FI - As a business partner at Lostock Hall Medical Centre, might be entering into a contract with 3rd party providers for example physio, mental health services to sub let. NFPI - Wife is a business partner (not a clinical partner) NFPI - Wife is a manager at Gujarat Hindu Society - where few of the CCG meetings happen. Dr Hari Nair GP Director Greater FI - Senior GP Partner in Practice - Current 10.01.2019 Interest noted, will be reviewed in line with Preston CCG FI - PMS Contract - Current agenda items at committee meetings and FI -GP Quality Contract - Current procurement involvement. Where a FI -GP Trainer - Current conflict emerges the individual will be FI -GP Recruitment Assessor - Current excluded from decision making FI -Enhanced Services LES/DES - Current FI- Locality based work - Clinical lead for extended access in Greater Preston locality - Current FI -BHR Investments Ltd - Private company owned by Partners involved in new GP premises building - Current FI -Member of Primary Care limited

11 Page Declarations and Register of Interests NHS Greater Preston CCG Governing Body meeting

24 January 2019

Name Role Declaration Date Mitigating Actions company comprising of all practices in Preston and Chorley - Current NFPI -Wife is consultant Histopathologist employed by Lancashire Teaching Hospital, also carries out private reporting work for Ramsey Group - Current Dr Anitha GP Director, Greater No Interest declared 11.01.2019 No risk to decision making as no potential Rangaswamy Preston CCG conflicts identified

12 Page Declarations and Register of Interests NHS Greater Preston CCG Governing Body meeting

24 January 2019

Declarations of Interest Flowchart

6 monthly declarations In Year Changes In a Meeting

Are you aware You should complete a I have a I need to I have just I have an You need to of the potential Declaration of Interest Pro- new change my been interest in an N declare in the conflict before Forma 6 monthly interest declaration appointed agenda item meeting the meeting?

Do you know what to include? You must provide details in Y writing, as soon as you You should become aware and no later complete a Declaration than 28 days after becoming Is this on the You need to update of interest N aware to the Governing Body Y Register of N your declaration of Y Pro-Forma Secretary Interests? Interest Form

Refer to You should declare when requested, and Pro-Forma before the agenda item

Declarations are collated and What type of Interest do you have? the register of Interests Direct Pecuniary updated: Could YOU (or a close relation, partner or friend) financially benefit? • Membership Council Interest • Governing Body Are YOU (or a close relation, partner or friend) a partner / member / Indirect Pecuniary • Statutory Committees and shareholder in an organisation that would financially benefit? Interest Sub Committees Do YOU (or a close relation, partner or friend) hold a non-remunerative or Non-Pecuniary • Employees not for profit interest in an organisation that would benefit? Interest Could YOU (or a close relation, partner or friend) enjoy a qualitative Non-Pecuniary benefit, which cannot be given a monetary value? Personal benefit

Review by Head of Strategy Review by Head of Strategy The Chair of the meeting will determine if there is a conflict of interest and the course of action to & Corporate Services and & Corporate Services and take (YOU should advise of the arrangements already agreed for managing the conflict) Lay Member for Finance, Lay Member for Finance, audit and Conflicts of Interest audit and Conflicts of Interest to determine arrangements to determine arrangements for managing conflicts for managing conflicts Are more than 50% of members affected?

The type and details of the interest and the course The Register will be amended and the change Y N of action taken to be recorded in the minutes Reported to Audit Committee reflected in the next quarterly refresh

Page 13 Page Chair to refer to CCG Constitution Written notification of declarations made and P31 Clause 8.4.9-8.4.12 to course of action taken (using template) to be PUBLISH REGISTERS determine next steps submitted to Governing Body via GBS

This page is intentionally left blank Agenda Item 4

Governing Body Meeting – Minutes

Thursday 29 November 2018 The Guild Lounge, Preston North End, Sir Tom Finney Way, Preston, PR1 6RU

Present Dr Sumantra Mukerji, Chair Mr Ian Cherry, Lay Member for Finance and Audit Mrs Debbie Corcoran, Lay member for Patient and Public Involvement Mrs Helen Curtis, Director of Quality and Performance Dr Brigid Finlay, GP Director Mr Matt Gaunt, Director of Contracting and Finance Mrs Tricia Hamilton, Governing Body Nurse Dr Eamonn McKiernan, Secondary Care Doctor Dr Praphulla Methukunta, GP Director Dr Hari Nair, GP Director Dr Sandeep Prakash, GP Director Mr Paul Richardson, Vice Chair and Lay Member for Governance

In attendance Mrs Sarah James, Programme Director Integrated Care Partnership Ms Hollie Johnson, Governing Body Secretary (Minutes) Mr Glenn Mather, Evidence & Effectiveness Lead Mrs Jayne Mellor, Director of Planning and Delivery Mrs Sue Stevenson, Healthwatch Representative In attendance to present Mrs Jane Fisher, Patient Story

Members of the Five members of the public attended public

GPGB Welcome and Apologies for Absence /181128-1 Dr Mukerji welcomed everyone to the meeting. Introductions were made for the purpose of members of the public. Dr Mukerji welcomed Mrs Sue Stevenson to the meeting.

Apologies were received from Mr Denis Gizzi, Chief Officer and Dr Arumugam Umapathy, Local Medical Committee Representative.

GPGB Patient Story /181128-2 Mrs Curtis introduced Mrs Jane Fisher to the Governing Body. Mrs Fisher attended the Governing Body meeting to present her personal experience with perinatal mental health. She explained how she had previously worked as a community psychiatric nurse, which gave her a unique perspective from both a patient and a health professional

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side.

Mrs Fisher first became unwell after the birth of her youngest child, Bella, in 2015. She detailed her journey with perinatal mental health by way of reading aloud a letter that she had written to Bella.

Mrs Fisher explained in the letter how minds could become unwell, similar to how bodies could. She explained how difficult it had been when Bella had been born; how she had felt confused, tired and that Bella had not been her baby. She had cried a lot, felt sad and overwhelmed. It had been hard to make simple decisions as her thoughts had been jumbled up.

Mr Fisher described in the letter how she had made it through a difficult night when she had felt as though she could not make it through to the morning. It was after this that Mrs Fisher reached out for help, and she explained the steps she went through to with mental health services. She reiterated the importance of the message that she had received; that she was unwell, but that she was going to get better.

Mrs Fisher emphasised throughout the letter to her daughter that it was okay not to be okay, and the importance of asking for help.

Mrs Hamilton questioned whether Mrs Fisher felt that her husband could have received more support. Mrs Fisher alluded to the pressure that her husband had been under at the time whilst caring for her and three young children. She explained that he had not recognised the responsibility that had been placed on him to keep her safe, and she felt that support from a specialist team would have been helpful for him.

Mrs Stevenson questioned what difference Mrs Fisher felt it had made that she had the background of a community psychiatric nurse. Mrs Fisher explained that it had not made a difference. She explained how other mental health practitioners had made dangerous assumptions that she was aware she was unwell and knew what her treatment plan should have been, when that had not been the case.

Mrs Stevenson asked Mrs Fisher what advice she would give to those employed in maternity care, specifically midwives, to help recognise signs sooner. Mrs Fisher felt that midwives would benefit from perinatal mental health training. She emphasised the power of the acknowledgement that she was unwell, but that she would be supported to get better.

Mrs Curtis referred to the mother and baby unit at Chorley Hospital. Mrs Fisher felt that her recovery would have been quicker and enhanced had she had access to specialist perinatal mental health

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services, such as the mother and baby unit.

Dr Mukerji thanked Mrs Fisher for sharing her experience with the Governing Body.

GPGB Declarations and Register of Interests /181128-3 Dr Mukerji reminded Governing Body members of their obligation to declare any interest that they may have on any issues arising during the meeting which might conflict with the business of the Greater Preston CCG.

The register is available either via the Governing Body Secretary or the CCG’s website at the following link:-

www.greaterprestonccg.nhs.uk/archived-governing-body-meeting- papers

No amendments were made to the declarations and register of interests.

GPGB Minutes of Previous Meeting /181128-4 The minutes from the meeting held on 27 September 2018 were presented for approval.

There were no amendments to the minutes of the previous meeting.

Resolved That the Governing Body accepted the minutes of the meeting held on 27 September 2018 as a correct record.

GPGB Matters Arising /181128-5 Governing Body members noted the actions completed on the matters arising sheet provided.

GPGB/180927-11 The terms of reference for the OHOC Joint Committee would be presented to the Governing Body.

Resolved That the Governing Body noted the updates provided.

GPGB Chair’s Update /181128-6 Dr Mukerji welcomed everyone to the Governing Body meeting and provided an update on recent activities.

Healthier Lancashire and South Cumbria Integrated Care System The CCG continued to be a key partner in the work of the wider Integrated Care System across Lancashire and South Cumbria, with membership on the Joint Committee of the eight CCGs and also the

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system board.

Following the recruitment process for the Integrated Care System (ICS), a number of executive leaders were now formally in place. This included Dr Amanda Doyle as Chief Officer, Andrew Bennett as Executive Lead for Commissioning, and Jane Cass as Director for Assurance & Performance, amongst others.

The priorities for Healthier Lancashire and South Cumbria have been to review the progress on the major portfolios of work and ensure each project has an executive ‘sponsor’ working with all commissioner and provider organisations to identify the purpose and objectives of the work, and also the resource needed across the system to deliver it.

GP Direction Election Dr Mukerji was pleased to announce that following successful election and ratification of the election by the GP Membership Council, Dr Anitha Rangaswamy would begin her first tenure as a GP Director in January 2019.

NHS Clinical Commissioners national members’ event The NHS Clinical Commissioners national members’ event took place on 1 November in London, with a focus on ‘integrating the future of health and care’.

Dr Mukerji detailed his involvement with the ongoing work around the involvement of the voluntary and faith sector within the Integrated Care Teams.

Dr Mukerji informed the Governing Body that the CCG had been shortlisted in the staff engagement category recently at the Health Service Journal awards for its work on the operational plan. Unfortunately the CCG did not win, but this same project has previously won and been shortlisted for other numerous awards as well.

The Value Stream Analysis work as a health economy to help improve flows around urgent and emergency care in central Lancashire had also been shortlisted for an award in the North Region A&E Improvement Awards, for which the CCG was a runner up.

Resolved That the Governing Body noted the update provided by the Chair.

GPGB Central Lancashire Integrated Care Partnership Update /181128-7 Mrs James presented the Central Lancashire Integrated Care Partnership (ICP) update, detailing the progress made towards

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Integrated Care arrangements in Central Lancashire during May and October 2018.

The update detailed the work that had been undertaken in the following areas:

• ICP Mobilisation • Development and implementation of the strategic framework • Next Steps – November to April 2019 • Appendix One; Developing an Integrated Care Strategy (ICS) in Central Lancashire

Mrs James drew Governing Body members’ attention to the development and implementation of the strategic framework. The ICP Board agreed a high level of scope for each of following the ‘big seven strategic platforms’:

• Integrated Care Strategy • Integrated Care Partnership • Wellbeing and Health in Integrated Neighbourhoods • Acute Sustainability • Economic and Financial Reform • Clinical Care Reform • System Management Reform

Mrs James confirmed that a list of the ICP Board members would be circulated to the Governing Body for information following the meeting.

Mrs James alluded to the appendix that had been presented at the ICP Board meeting in October; Developing an Integrated Strategy in Central Lancashire. Recommendations had been made by the ICP Board for the consideration to make information less complex. Mrs Corcoran agreed that the information presented was strategic and complex, and welcomed a translation to something more accessible.

In response to a question surrounding employment opportunities for staff, Mrs James confirmed for Mrs Hamilton that it an important challenge for the system to develop new ways of working whilst maintaining the current systems in place.

Resolved That the Governing Body noted the Integrated Care Partnership update provided.

GPGB Our Health Our Care Update /181128-8 Mrs James presented an update on the Our Health Our Care (OHOC) programme. The ambitions and patient focused objectives of the OHOC programme were presented, alongside the outputs from

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recent joint informal Governing Body session.

Mrs James provided an overview of next steps and the timelines associated with the first meeting of the OHOC Joint Committee of the CCGs on 13 December 2018.

Mr Cherry was pleased to note that it was set out that the ambition of all organisations commissioning and providing healthcare for the population of Chorley and South Ribble and Greater Preston was to achieve the best possible outcome for patients.

Resolved That the Governing Body endorsed the need for the OHOC Programme to continue in order to examine potential solutions.

GPGB Winter Plan and Value Stream Analysis Updates /181128-9 Mrs Mellor presented an update on the Central Lancashire A&E Delivery Board arrangements for Winter 2018/19. The plan has been developed to ensure the delivery of safe and high quality services to the population during potential periods of pressure. The Central Lancashire Winter Plan:

• Reflects a whole system approach to the delivery of services over the forthcoming 2018/19 winter period from 1 December 2018 to Easter 2019 • Builds upon lessons learnt within Central Lancashire over recent years and in particular from Winter 2017/18 • Identifies the challenges, risks and mitigating actions required

Mrs Mellor informed the Governing Body that the CCG had been notified at the start of the financial year that additional winter funds previously received would not be allocated for 2018-19. The CCG therefore took the opportunity of more time to implement plans for winter, as only receiving funding 5-6 weeks to initiate successful schemes in the past had proved difficult due to the short space of time.

Mrs Mellor provided an overview of the system wide urgent and emergency value stream analysis event, and detailed the methodology, analysis and pressures identified. She outlined that it was important to note that the difficulties experienced in urgent and emergency care were across all urgent care pathways and included prevention and alternative services.

Mrs Mellor informed the Governing Body that performance against the A&E 4 hour standard had not yet met the 90% trajectory or 95% national target. There was an expectation that performance for patients who did not require admission to hospital would not fall below 98% against the 4 hour standard. Governing Body members

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heard that LTHTR performance for September 2018 had been 76.1%.

A number of programmes of improvement work were identified during the event, and the following work streams were now in place:

• Early Intervention and Prevention • 111 and 999 • Emergency Department • Mental Health Unscheduled Care • Rapid Assessment / Care Coordination • Flow out of Hospital

The improvement work streams identified would deliver capacity that equates to a reduction of 44 beds. The additional bed capacity required would be delivered through the introduction of a short stay medical ward on the Chorley Site.

Mrs Mellor detailed the robust monitoring arrangements and governance in place. The plan was accountable to the A&E Delivery Board supported by the Urgent Care Programme Group system wide accountability. Winter reporting had commenced daily to NHS England which was led by an on-call manager, and system escalation process was in place if necessary.

At the request of Dr Mukerji, Mrs Mellor clarified that CATCH was a single access point initiated to be a central hub where referrals were made. The MDT receiving the referral made an assessment and mobilised the most appropriate service to manage a patient’s needs through to discharge.

Mr Cherry complimented the winter plan. He questioned what monitoring would be in place to ensure the delivery of projects and the flexibility should delivery fail. Mrs Mellor explained how each work stream had a programme lead responsible and accountable to report on a 2 weekly basis. She described how each workstream had a starting point and a standard operating model outlining what it needed to achieve, using the mental health unscheduled care scheme as an example.

Mrs Hamilton questioned how the winter plan would be communicated to staff and members of the public. Mrs Mellor referred to a suggestion made at the Chorley and South Ribble CCG Governing Body meeting the previous day to undertake unannounced quality visits and speak with staff at the hospital directly. Mrs Curtis added that the CCG promoted a series of messages through social media signposting patients in the right direction.

Mrs Mellor confirmed for Dr Methukunta that 111 was a national

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service, and that the pathways implemented were on a national footprint. It had been initiated locally that North West Ambulance Service could access the CATCH service to ensure patient treatment in the most appropriate place if it was found that an admission to A&E was not necessary.

Resolved That the Governing Body received and noted the Winter Plan and Value Stream Analysis Update provided.

GPGB Governing Body Assurance Framework /181128-10 Mr Gaunt presented the Governing Body Assurance Framework that records the significant principle risks that could impact on the CCG achieving its strategic objectives. It should summarise the sources of control and assurance that are in place or are planned to mitigate the risks identified. Changes that had been made to the GBAF were highlighted in red for Governing Body Members’ attention and approval.

Mr Gaunt outlined that the risk rating of GBAF01; Quality, Safe and Effective Services had increased from 12 to 16, and therefore it was reported as a high risk.

Resolved That the Governing Body approved the GBAF for 2018/19.

GPGB Integrated Board Report /181128-11 Mrs Curtis presented the Integrated Board Report (IBR). The IBR provides an overview of CCG business and performance across key national healthcare standards that the CCG is measured against. The IBR described the action taken by the CCG and service providers to tackle any concerns and drive improvements.

Mrs Curtis highlighted the following areas within the IBR to the Governing Body:

• The minor injuries scheme had shown a reduction of breaches by 10 per day. • Contract performance notices remained in place where constitutional standards were not being met. • Figures in October for ambulance handover delays had seen an improvement, with a reduction of breaches across Chorley Hospital and Royal Preston Hospital. • Referral to Treatment (RTT) remained below trajectory, however an elective care board had been established which would monitor the improvement plan that was put in place. • Improvements had been seen in diagnostic testing in October, following the source of additional funding. • Mrs Curtis highlighted that it was pleasing to note that Greater

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Preston met all cancer standards. • LTHTR were commissioning work around cancelled operations and theatre utilisation. The CCG have requested key indicators from this analysis. Mrs Curtis informed the Governing Body of a quality visit undertaken that Dr McKiernan attended at which time it had been made apparent that a delay in the start of scheduled theatre times were often for non-clinical reasons that could be removed. • An event had been arranged to take place in December with LTHTR, NHS England and NHS Improvement to discuss never events in terms of wrong site surgery. Mrs Curtis outlined that this was a positive practice in order to ensure that learning was in place across the organisation. • Mrs Curtis alluded to a conversation at the Chorley and South Ribble CCG Governing Body meeting the previous day at which time a request had been made for more information surrounding the sleeping accommodation in the intensive care unit. Mrs Curtis would update this information at the Quality and Performance Committee meetings.

Mrs Curtis drew Governing Body members’ attention to the mental health update inn the CCG summary Dashboard against the Improvement and Assessment Framework. She confirmed that the CCG would be assessed jointly with Chorley and South Ribble CCG, and thereafter assessed and assured on an ICP footprint with all partners. She highlighted the benefit of providers being involved in board level discussions where targets had not been met.

Mrs Mellor confirmed that the Operational Plan had delivered over £10m in-year savings. A risk in continuing healthcare had been identified, and a mitigating action plan had been established and put in place.

Mrs Curtis clarified for Dr Mukerji that the CCG had been informed by NHS England that the RTT waiting list should be no greater in March 2019 than it was at the start of March 2018.

Mrs Curtis referred to previous Governing Body discussions around stroke performance and the frustrations that arose. Appended to the IBR for Governing Body members’ review was the stroke update that had been presented at the Joint Committee of CCGs in October 2018 in Lancashire and South Cumbria. The report outlined the current position, the work being progressed and key decisions required over the course of the coming months of the programme.

Dr Nair added that work around stroke prevention would be built into the Quality Contract for 2019/20. It would be embedded in all practices in terms of increased detection of risk factors.

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Resolved That the Governing Body noted the update in the IBR.

GPGB Lancashire Teaching Hospitals NHS Foundation Trust Care /181128-12 Quality Commissioning Report Mrs Curtis presented an update following the CQC Well Led Inspection of Lancashire Teaching Hospitals NHS Foundation Trust (LTHTR) that took place in June 2018. The report would be discussed in detail at the December meeting of the Quality and Performance Committee where LTHTR have been asked to attend to present their action plan.

Mrs Curtis outlined that the Improvement Board that had previously been in place would continue to meet to monitor the improvement plan. Mrs Curtis attended the monthly meetings alongside NHS England, NHS Improvement and representatives from LTHTR, including the medical director.

Mr Cherry referred to a meeting held with LTHTR at which time the trust had assured the CCG that it had learnt from lessons and the improvement plan would increase the rating from ‘requires improvement’. He questioned level of assurance the CCG had that the Trust were taking the improvement plan seriously and embedding it throughout the organisation. She detailed that encouraging pieces of improvement work were presented to the board, for which challenge was robust. An example was provided by way of the work ongoing with the care of patients in mental health and learning disabilities in the acute sector.

Mrs Hamilton stated that she would seek assurance from the leadership at LTHTR that they would take ownership and lead on the improvements required as part of the strategic plan.

Mr Mukerji agreed with Dr Nair that it was difficult to view the plan as a positive. He outlined his interest in how clinicians and patients would view the report. Mrs Curtis outlined that the friends and family tests, staff recommendation and staff survey results could be triangulated alongside the action plan.

Resolved That the Governing Body received and noted the update report provided.

GPGB Transformation Care of Learning Disabilities /181128-13 Mr Mather presented an update on the Transforming Care agenda for learning disabilities and autism and the work underway to reduce the number of people in an inpatient setting.

Governing Body members heard how the programme worked on the

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principle that people with learning disabilities and/or autism should not be living in hospitals, unless there was a clear rationale for assessment and treatment required in an acute setting. The CCG worked closely with secondary care and community teams to support discharge back to the community for all individuals who are in hospital and to prevent further admissions.

The programme was coordinated through the Lancashire and South Cumbria Transforming Care Partnership within the Integrated Care System (ICS), and is accountable to the North Transforming Care Programme Board. The current focus of the programme was to develop an infrastructure in relation to community specifications and models of care, development of pooled budgets across health and social care, workforce development and housing strategy.

An overview of the ‘support’ register of patients held by the CCG was provided to the Governing Body. The register tracked the progress towards discharge for patients who were in hospital. A 12 point discharge plan defined an individual’s stage on the discharge pathway. The documented information was reviewed at a monthly meeting with the community learning disability team and the Lancashire County Council. Further, fortnightly accelerated discharge calls commenced across all CCG’s in Lancashire and South Cumbria to further scrutinise discharge plans and address any barriers that may exist.

The Quality and Performance Committee had oversight of patients within Chorley and South Ribble CCG that met Transforming Care criteria. Mr Mather explained the process for the Care (Education) Treatment Reviews (CTR) and the Learning Disability Mortality Review programme (LeDeR) to the Governing Body.

Governing Body members heard that not all patients with a Learning Disability on a GP practice learning disability register had an annual health check. As a result of the work undertaken around this, additions were made to the GP Quality Contract to ensure that a practice would establish and maintain a learning disability ‘health check register’ of patients aged 14 and over with learning disabilities, and invite all patients on the register for an annual health check and produce an action plan.

Mr Mather referred to a recent ‘deep dive’ undertaken by NHS England Oversight for Lancashire and South Cumbria Transforming Care Partnership. The CCG would work with NHS England to progress discharge plans, CTRs and review the current position of annual health checks and the completion of LeDeR reviews.

Dr Nair provided further detail surrounding how care for people with learning disabilities and autism was built into the GP Quality Contract.

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Further work to aid in undertaking annual health checks would be implemented in 2019-20.

Mrs Stevenson alluded to work undertaken by Healthwatch Cumbria surrounding the quality of services and the improvement of care for people with learning difficulties and autism and carers. She detailed the benefits of patient involvement in the work from those who used the services. Mr Mather referred to the engagement group for the transforming care programme and confirmed that the feedback they provided was built into the development of service plans.

Mr Gaunt referred to a recent meeting with Lancashire County Council, at which time it had been confirmed that funding for supported living services provided by Lancashire Care NHS Foundation Trust (LCFT) would be withdrawn. Mr Mather outlined his concerns around the removal and/or reduction of funding of any service, and outlined that the impact of this would need to be understood. This would be addressed through the Transforming Care Partnership.

Resolved That the Governing Body noted the Transforming Care update provided.

GPGB Financial Performance Report /181128-14 Mr Gaunt presented the joint Financial Performance Report. The joint report sets out the combined financial position for NHS Greater Preston and NHS Chorley and South Ribble CCGs as at 31 October 2018. The report detailed the summary financial position, summary I&E, productivity and efficiency (QIPP) and net risks.

The CCGs were forecasting to achieve the planned breakeven position, although there were pressures resulting in a net risk of £0.8m across both CCGs against this forecast. The CCGs full year forecast reflected £4.9m of acute overspend against contract driven largely by non-elective cost pressures at LTHTR. The previously published QIPP shortfall of £2.7m and cost growth across out of hospital services, in particular drugs costs for eye treatments.

The risks that had not been built into the forecast were as follows:

• Any expenditure above plan required to ensure the number of patients waiting for treatment was no higher at the end of March 2019 than it was in March 2018. Mr Gaunt informed the Governing Body that teams at the CCG were working closely together to establish a plan that could be put in place to get to that position.

• The shortfall between the full value of 0.5% risk reserve and

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what was approved as mitigation by NHS England and the ICS. The resultant shortfall is £0.8m. The CCG planned to recover that amount from the ICS investment fund. Mr Gaunt informed the Governing Body that he was working with providers to achieve a financial position with the respective contracts in place.

With regard to referral to treatment (RTT) Mr Gaunt informed the Governing Body that the teams at the CCG were working to quantify the gap to keep waiting lists in line with the position at the start of the financial year as required.

In response to a query from Dr Mukerji, Mr Gaunt confirmed that pharmaceutical companies of CCGs in the North East of England had gone to the Court of Appeal following the loss of a case against use of avastlin. He confirmed that he felt that there could be an appetite within Lancashire and South Cumbria to follow a similar course of action.

Resolved That the Governing Body noted the financial position of the CCGs at the end of October 2018.

GPGB Constitution Review /181128-15 Mr Gaunt presented the Constitution Review, which updated Governing Body members as to the proposed changes to the CCG’s constitution prior to engaging with the Membership Council.

The CCG reviewed its constitution annually to ensure that it remained reflective of national guidance and was fit for purpose in order to govern the practice of the CCG. NHS England had recently issued a new template for all CCGs to use going forward which would be utilised as part of the review for 2018-19.

Mr Gaunt detailed the changes that were being proposed, in particular a change that would require the Membership Council; that being the proposal to remove the section at 2.2.4 iv that in exceptional circumstances, such as no suitable, eligible candidates coming forward to apply for GP Director posts, the Governing Body may extend the advertisement of the post to other practicing primary care clinicians employed by Member Practices.

Mr Gaunt alluded to the discussions by Chorley and South Ribble CCG Governing Body the previous day surrounding the suspension of voting for the membership representatives that had failed to return their annual declarations of interests.

Dr Finaly referred to the number of sessions outlined in the eligibility criteria for GP directors and noted that it could be a reason for the

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lack of expressions of interests submitted when recruiting to GP Director vacancies.

Resolved That the Governing Body noted the Constitution review update provided.

GPGB Workforce Report /181128-16 Mrs Curtis presented the Workforce Report. The Workforce Report provides key updates in relation to the CCG’s workforce using human resources data and information on organisational development activities. Updates were provided in relation to sickness absence, turnover and mandatory training compliance, alongside an overview of the annual staff survey results.

Governing Body members heard that there had been deterioration in the annual staff survey scores. Mrs Curtis referred to discussions earlier in the meeting and outlined how this was reflective of the start of a period of uncertainty. The CCG would be mindful of sickness absence and turnover rates in light of the impact had in light of the changing landscape.

Greater Preston CCG and Chorley and South Ribble CCG were rated as the highest across CCGs for mandatory training compliance.

Mrs Curtis drew Governing Body members’ attention to the staff survey question around workplace bullying and was pleased to report that it had been reported 100% satisfaction that it had been dealt with correctly.

An overview of ‘what’s going well’ and areas highlighted for improvement were outlined within the report. Mrs Curtis noted that aspects of the two were contradictory, and that work would be undertaken across the teams within the CCG to address areas of concern.

Mrs Corcoran referred to the reference within the report that staff felt frustrated around the lack of clarity and questioned whether it was within the CCGs’ gift to ensure that staff were aware of where they fit within the organisation. Mrs Curtis stated that she felt that this related to CCGs generally, and alluded to the staff away day that had had positive outcomes earlier in the year. A further staff away day had been arranged for 2019, at which time staff would be updated around the NHS 10 Year Plan and what it meant for them as individuals. Dr Mukerji added that the updates provided at the monthly staff briefing were open and transparent about the changing landscape.

Resolved

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The Governing Body noted content of the Workforce Report.

GPGB Policies for Approval /181128-17 Mr Cherry presented the following policies for the approval of the Governing Body.

• Hospitality, Sponsorship and Gifts policy • Risk Management Strategy • Emergency Planning, Resilience and Response (EPRR) Policy • Anti-Fraud, Bribery and Corruption Policy and Response Plan

Mr Cherry highlighted the changes made to each policy, and confirmed that they had been reviewed the Audit Committee ahead of requiring approval.

Dr Finlay referred to the declaration Mr Gizzi’s friendship with Mrs Jacqui Proctor, Anti-fraud Specialist for MIAA. Mr Cherry confirmed for her that should it be the case that concerns were raised with regard to Mr Gizzi, an independent review would take place. Mr Gaunt added that a robust process would be followed in that instance, and that that process would thereafter be scrutinised by the Audit Committee.

Resolved That the Governing Body approved the proposed changes to the policies.

GPGB Audit Committee Update and Minutes /181128-18 Mr Cherry presented an update report on the work undertaken by the Audit Committee at the meeting held on 2 November 2018. The minutes from the meetings held on 7 September 2018 were presented for information.

Resolved That the Governing Body noted the committee update report provided.

GPGB Joint Quality and Performance Committee Update and Minutes /181128-19 Mr Richardson presented an update report of the Quality and Performance Committee at its meetings held on 3 October and 7 November 2018.

The committee received presentations on Workforce challenges from LCFT and LTHTR. The trusts had been asked to correlate workforce issues with quality of care and patient safety.

Resolved That the Governing Body noted the update report provided.

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GPGB Delegated Commissioning Committee Update, Minutes and /181128-20 Terms of Reference Mr Richardson presented an update report on the activities of the Delegated Commissioning Committee at its meeting held 3 October 2019, at which time the committee discussed the following:

• Terms of Reference • Quarterly Contractual Changes reports • Out of Hospital Transformation • Edith Rigby specification • Medicom premises relocation

Mr Gaunt drew Governing Body members’ attention to the Terms of Reference presented for the Delegated Commissioning Committee. The committee would be renamed the Primary Care Commissioning Committee.

Mr Gaunt alluded to discussions at the Chorley and South Ribble CCG Governing Body meeting the previous day, at which time it had been raised that the lay member for patient and public involvement should be a voting member of the committee if on the membership. Mrs Corcoran agreed with the changes requested by the Chorley and South Ribble CCG Governing Body. The Terms of Reference would be amended to reflect that change.

Resolved That the Governing Body noted the update report provided and approved the Terms of Reference, subject to the change discussed that would be approved by chairs action.

GPGB Patient Voice Committee Update and Minutes /181128-21 Mrs Corcoran presented an update report on the activities of the Patient Voice Committee at its meeting held on 7 November 2018. The minutes from the meeting held on 5 September 2018 were presented or information.

Resolved That the Governing Body noted the update report provided.

GPGB Joint Committee of CCGs Update /181129-22 Dr Mukerji presented the key messages from the Joint Committee of Clinical Commissioning Groups meeting held on 4 October 2018.

Resolved That the Governing Body noted the update report provided.

GPGB Lancashire Health and Wellbeing Board Minutes /181129-23 The Lancashire Health and Wellbeing Board minutes from 18 September 2018.

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GPGB Risk Review /181129-24 Mr Gaunt questioned whether the Governing Body felt that the risks on the GBAF needed further amendment in light of the discussions taken place throughout the meeting.

The Governing Body were in agreement that the changes made to the GBAF highlighted in red were accurate, and no further amendments were required.

GPGB Questions from the public /181129-25 There were no questions from members of the public.

GPGB Any Other Business /181129-26 There was no further business to discuss.

Date, Time and Venue of next meeting: Thursday 24 January 2019 at 2pm The Wiseman Room, Preston Grasshoppers RFC, Lightfoot Lane, Preston, PR4 0AP

Signed as an accurate record ………………………………. Date ………………......

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This page is intentionally left blank NHS Greater Preston CCG Governing Body - Matters Arising

Code Title Lead Status Due Date Comments GPGB/181129 Central Lancashire ICP Update Programme Director November A list of the ICP Board Members was circulated to A list of the ICP Board Members would be Integrated Care 2018 the Governing Body following the meeting. circulated. Partnership GPGB OHOC Joint Committee TOR Director of Finance and November The terms of reference for the OHOC Joint /180927-11 The terms of reference would be amended as per contracting 218 Committee have been amended and will be the discussions in the meeting and approved by presented to the Governing Body. Chairs Action.

5 Item Agenda

33 Page Matters Arising NHS Greater Preston CCG Governing Body Meeting

24 January 2019

This page is intentionally left blank Agenda Item 7

Governing Body Meeting

Date of meeting 24 January 2019 Title of paper Governing Body Assurance Framework and Corporate Risk Register Presented by Mr Matt Gaunt, Chief Finance Officer Author Mrs Sarah Mattocks, Corporate Affairs and Governance Manager Clinical lead N/A Confidential N/A

Purpose of the paper The purpose of this report is to provide an update to the Governing Body in respect of the Governing Body Assurance Framework (GBAF) and Corporate Risk Register (CRR).

Executive summary The GBAF is a framework that records the significant principle risks that could impact on the CCG achieving its strategic objectives. It should summarise the sources of control and assurance that are in place, or are planned to mitigate against the risks identified.

The GBAF was submitted to the Audit Committee and the Quality and Performance Committee (QPC) this month. The Audit Committee has provided scrutiny on the systems and processes used to manage the GBAF risks, with the committee also receiving a ‘deep dive’ into GBAF 02.

The key changes made to the GBAF for the Governing Body’s approval are as follows and all changes are highlighted in red text on the full GBAF:

GBAF01 - Quality, Safe and Effective Services - Action A7 has been closed. This action stated that Lancashire Teaching Hospitals (LTH) would attend the CCG’s Quality and Performance Committee to present the latest CQC assessment report and corresponding action plan to take the organisation to a rating of ‘good’. This took place at the Committee on 05.12.2018. - Progress has been added against the two remaining open actions. - Action A6 has been extended from a due date of 31.12.2018 to 31.03.2019 to reflect the target to deliver zero 52 week waiters and no more open pathways by end of March 2019 (compared to 2018).

Governing Body Assurance Framework Update and Corporate Risk Register NHS Greater Preston CCG Governing Body Meeting 24 January 2019 Page 35 GBAF02 – Financial Sustainability - Action A2 has been closed. This action stated that the terms of reference (TOR) for the Primary Care Commissioning Committee would be reviewed. This has been completed and the new TOR were ratified by the Governing Body in November 2018. - Action A1 has been extended from a due date of 30.09.2018 to 31.03.2019 as this is ongoing work - Progress has been added against the four remaining open actions

GBAF 03 – Well Led - An update has been added to the gap in control regarding the election process for the vacant GP Director posts on both CCGs; Chorley and South Ribble CCG is running with one GP Director vacancy and the new Greater Preston CCG GP Director is due to start in January 2019. - Progress has been added against the five remaining open actions. - A new gap in control has been added regarding the Our Health Our Care Programme potentially not progressing at pace or with the desired outcomes. This is to ensure that the progress of the OHOC programme is reflected in this risk. Associated actions (A5 and A6) have been added to mitigate this.

GBAF04 – Service Transformation - Progress has been added against the three remaining open actions. - Now that the 10 year plan has been released this will be incorporated into the next risk review.

Corporate Risk Register (CRR):

One new risk has been added to the CRR regarding Referral to Treatment times as follows:

There is a risk that the CCG may not deliver the RTT and 52 week trajectory, or that the delivery of this has a significant finical impact on CCG resources. This may result in an adverse financial impact for the CCG and adverse reputation.

The full risk assessment is included in this paper.

Recommendations The Governing Body is asked to approve the changes made to the GBAF The Governing Body is asked to approve the CRR

Governing Body Assurance Framework Update and Corporate Risk Register NHS Greater Preston CCG Governing Body Meeting 24 January 2019 Page 36 SO4 Ensure patients are at the centre of the planning and management of ☒ their own care, and that their voices are heard SO5 Be a well-run clinical commissioning group and the system leader ☒

Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome

Were any conflicts of interest identified at previous meetings (mark X in the correct box below) Yes No X If conflicts of interest were identified what were these:

Implications Quality/patient experience ☐ ☒ ☐ implications? Yes No N/A (Potential) conflicts of interest? Yes ☐ No ☒ N/A ☐ Equality Impact Assessment? Yes ☐ No ☐ N/A ☒ Privacy Impact Assessment? Yes ☐ No ☐ N/A ☒ Are there any associated risks? Yes ☐ No ☒ N/A ☐ Are the risks on the CCG’s risk ☐ ☐ ☒ register? Yes No N/A If yes, please include risk description and reference number

Assurance The Governing Body have overall ownership of the risks contained within the GBAF and CRR. The Audit Committee are responsible for gaining assurance on the processes used to manage the GBAF.

Governing Body Assurance Framework Update and Corporate Risk Register NHS Greater Preston CCG Governing Body Meeting 24 January 2019 Page 37

GBAF-01 - Quality, Safe and Effective Risk owner Next review date Current status Current trend Services Helen Curtis 31.01.2019

Risk description Failure to deliver safe and effective services resulting in poor outcomes and experiences Risk appetite

High Tolerance Low Confidence = Do not expend High Tolerance High Confidence = Take a balanced significant effort developing mitigations approach to how we expend effort developing mitigations Low Tolerance Low Confidence = Earliest possible Low Tolerance High Confidence = Always take all actions required to prevent risk rising available actions to mitigate risk Page 38 Page

Are there any gaps in this risk that do not have any Is the risk an 'accepted risk': Yes associated mitigating actions: No (despite all mitigating actions being completed the risk would still remain to some degree as specified in the target risk rating)

Original risk Current risk Target risk

Impact Likelihood Rating Impact Likelihood Rating Impact Likelihood Rating

4 3 12 4 4 16 4 2 8

Existing assurance Existing controls Gaps in assurance Gaps in controls

Quality Accounts from Integrated Business Plan in ICP Performance Dashboard LTH CQC report published Providers place which has been to be established 17.10.18 with a continued approved by Governing Body rating of 'requires encompassing schemes which Action to address: A1 improvement' will deliver better patient experience, meet constitutional Action to address: A7 targets and financial trajectories Care Quality Commission Integrated Performance and Efficacy of LTH recovery plan (CQC) inspection reports for all Improvement Group in place to providers and establishment of monitor Integrated Board Action to address: A6 an Improvement Board Report and organise onward following latest inspection of reporting to Quality and Lancashire Teaching Hospitals Performance Committee and (LTH) Governing Body

Page 39 Page

Health economy wide Enhanced PMO function collaborative in relation to following successful harm free care, i.e. falls, React recruitment to Senior to Red, Care Homes Programme Manager role Health economy wide C Development of internal Difficile review panel escalation process to raise awareness of performance issues Patient experience data as Serious Incident Review Group measured by friends and to assess for improvements family test when serious incidents have taken place. Serious incidents are not closed down until the CCG receives confirmation from the Provider that all actions within action plan have been completed. Where themes are identified thematic reviews take place at the Quality and Performance Committee Quality Surveillance Group Safeguarding Toolkit in place assurance for all providers Trend analysis from complaints Quality and Performance provides assurance on quality Committee to monitor to Quality and Performance outcomes and performance Committee measures against the NHS Outcomes Framework and standards to drive improvement, Provider dashboards, CQUINS which Page 40 Page

are also built into contracts for Providers, effectiveness, advancing quality, mortality rates, schemes within the Integrated Business Plan and benchmarking Annual review of compliance Provider recovery plans in against the safeguarding place where constitutional assurance framework - Health targets are not being met Watch local intelligence reports which are publically available Right Care packs give Improvement plans in place benchmarking information with LTH to ensure delivery across the full clinical pathway and work towards meeting from referral to mortality, constitutional targets therefore providing more outcome based information, as opposed to just performance based data (A4) All Acute providers, GP Primary Care Quality Contract practices and Care Homes have been Care Quality Commission (CQC) assessed (A3) LTH quality risk profile A&E Delivery Board Sub completed (A2) Group Contract performance notices allow CCG to hold providers to account (A5)

Page 41 Page

Action plan

Action Due date Assigned to Latest update Status

A1. Through the delivery 31.01.2019 Helen Curtis / Sarah 06.12.2018: In Open of the shadow James Progress; There is Integrated Care now an indication of Partnership (ICP) agree the contents of the arrangements for performance holding account for dashboard from ICS delivery of constitutional colleagues and work targets has commenced towards bringing this to the ICP Board in January. A2. Baseline 30.11.2018 Helen Curtis 17.07.2018: In progress Closed assessment against 30.08.2018: In progress Quality and Safety 07.09.2018: Complete utilising Quality Risk for LCFT, LTH due Profile tool 13.09.2018 17.10.2018: LTH quality risk profile completed and submitted to Quality Improvement Board. A3. Monitor that CQC 30.11.2018 Helen Curtis 30.08.2018: All Acute Closed assessments have providers, GP practices taken place for all acute and Care Homes have providers, care homes now been CQC and GP practices assessed. Page 42 Page

A4. CCG to receive 30.08.2018 Helen Curtis 30.08.2018: CCG Closed Right Care packs which receiving and utilising give benchmarking this Right Care information across the information full clinical pathway from referral to mortality, therefore providing more outcome based information A5. CCG to utilise 30.08.2018 Helen Curtis 30.08.2018: Contract Closed contract performance performance notice notice process to hold process is in place and providers to account utilised to hold providers to account A6. Closely monitor LTH 31.03.2019 Helen Curtis 07.09.2018: Contract Open recovery plan and notice in place and escalate any concerns recovery plan received. with delivery The specialty level trajectory is being reviewed. 17.10.2018: Being monitored at fortnightly Referral To Treatment (RTT) steering group and then submitted to NHS England (NHSE)/NHS Improvement (NHSI) 09.01.2019: NHSE/NHSI System call took place on 11.12.2018 with CCG Page 43 Page

Accountable Officer and Acute Trust Chief Executive. The focus of this call was RTT, 52 week waiters, cancer and AED performance. Action due date extended from 31.12.2018 to 31.03.2019 to reflect the target to deliver zero 52 week waiters and no more open pathways by end of March 2019 compared to 2018. A7. The CQC report 31.12.2018 Helen Curtis 15.11.2018: Closed published Nov 2018 Presentation arranged reported an for QPC meeting in improvement in a December. In addition number of directorates, the Improvement Board however the Accident & will continue to run and Emergency Department the terms of reference and the Medical Division for this are under remain of concern. LTH review. to attend the CCGs 09.01.2019: LTH Quality & Performance attended the QPC Committee (QPC) in 05.12.18. Committee December to present members gained the CQC report and updates both in terms corresponding action of progress and plan plan. to move the Page 44 Page

organisation towards a rating of 'good'. This will be reported to the Governing Body in January. The CCG will continue to receive updates on the progress of this plan until subsequent CQC assessment. Progress

17.07.2018: New GBAF for 2018-19. Risk score 12. Existing assurance and controls established, gaps identified. Mitigations in place to address gaps. 30.08.2018: Risk reviewed and actions updated. A new section has been added to the risk to illustrate that this is an accepted risk, and that each gap has an associated mitigating action. 07.09.2018: Risk reviewed following feedback from Quality and Performance Committee. An additional gap in assurance has been added regarding the recovery plan from LTH and an associated action has been added to mitigate this (A6). Progress updates have been added against actions A1, A2 & A3. 17.10.2018: Risk reviewed and action plan updated. Additional assurance added re LTH risk profiling. 15.11.2018: Risk reviewed following Audit Committee and Quality and Performance Committee - the completed actions have been mapped to the current controls and assurances (A2,A3,A4&A5). The risk rating has been increased from 4x3=12 to 4x4=16 resulting in this becoming 'high' risk. A new gap in assurance has been added regarding the release of a CQC report in Nov 2018 which showed a continued rating of 'requires improvement', this is linked to action A7. A new gap in control has been added regarding the need to establish an ICP performance dashboard which is linked to action A1. 06.12.2018: Risk reviewed and action plan updated. No changes to scoring or gaps. Page 45 Page

GBAF-02 - Financial Sustainability Risk owner Next review date Current status Current trend Matt Gaunt 31.01.2019

Risk description Failure to achieve financial sustainability within statutory financial frameworks Risk appetite

Original risk Current risk Target risk

Impact Likelihoo Ratin Impact Likelihoo Rating Impact Likelihoo Rating d g d d 3 3 9 4 4 16 3 2 6

Existing assurance Existing controls Gaps in assurance Gaps in controls

Grant Thornton have confirmed Clear Governance Lancashire Teaching Hospital A gap of £2.7 million has been through the Value for Money and decision represents the CCGs principle identified in the delivery of the conclusion that the CCG has proper making process, is partner, has a £46m deficit target CCG QIPP target. arrangements to secure economy, in place with clear in 2018/19 and has failed to agree efficiency and effectiveness. financial a control total with its regulator. Action to address: A4 & A5 delegations. The CCG has limited assurance that the financial strategy pursued by the Trust will not adversely impact on the CCG financial position.

Action to address: A1 & A6 NHS England have assured the CCG The CCG has Ability to secure 1/2% reserve as 'green' for financial arrangements agreed a financial monies

through the CCG improvement and budget which Page 47 Page

assessment framework (CCG IAF). delivers a break Action to address: A3 even position in 2018/19 which will meet the NHS England financial delivery target for the CCG. Head of Internal Audit Opinion is that Financial forecasts the Governing Body can take are prepared substantial assurance that there is a quarterly and good system of internal control included within designed to meet the organisations regular reported objectives, and that controls are updates to the CCG generally being applied consistently. Governing Body. In addition a monthly review of financial risks and opportunities supplements the quarterly forecasting review. The financial position is reported bi- The CCG has a well monthly to the Governing Body, and established every month to the Quality and programme Performance Committee. management process to ensure that financial improvement and transformation schemes are properly resourced and managers and Page 48 Page

clinicians involved in their delivery are held to account. This has been strengthened through the recruitment of clinical advisors to supplement GP Director capacity. ICP finance workshop taken place to agree ways to link all providers into the ICP finance plan (A1) The role of the Primary Care Commissioning Committee (previously Delegated Commissioning Committee (DCC)) has been strengthened with updated terms of reference which now clarify the remit of the committee and include a wider Page 49 Page

role in signing off Primary Care investment proposals and strategy. (A2)

Action plan

Action Due date Assigned to Latest update Status

A1. The CCG Chief Finance 31.03.2019 Matt Gaunt 17.07.2018: In progress Open Officer (CFO) to work with LTH 29.08.2018: An ICP Director of Finance (DOF) workshop has been through the Central Lancashire organised for 25th ICP to provide assurance that September and will be the ICP, CCG and Trust attended by the DOF for Leadership is aware of the both LTH and Lancashire financial consequences of LTH Care Foundation Trust financial recovery strategy. (LCFT)to agree ways to link into the ICP. 19.10.2018: ICP finance workshop took place 08.10.2018 to agree ways to link all providers into the ICP finance plan 06.12.2018: Action due date extended from 30.09.18 to 31.03.19 as this is ongoing work. Page 50 Page

The CCG CFO and Trust DOF have agreed the principles and are in the process of agreeing a final contract payment value for this financial year. A2. A revised terms of 03.10.2018 Matt Gaunt 17.07.2018: In progress Closed reference (TOR) will be 29.08.2018: Revised prepared for the DCC and TOR will be submitted to additional financial information DCC in October for will be provided to better inform approval. investment decisions. 19.10.2018: Revised TOR approved by DCC and will be submitted to Governing Body for ratification in November 06.12.2018: TOR ratified by Governing Body A3. Apply to ICS for 0.5% 01.10.2018 Matt Gaunt 06.09.2018: Process for Closed reserve monies this application of funds has started. 19.10.2018: CFO has written to Director of Finance at NHSE Lancashire confirming that 0.5% reserve is required to meet CCG financial targets. This has still left the CCG with a gap - action A6 has Page 51 Page

been added to address this. A4. Review process for 30.11.2018 Matt Gaunt 06.09.2018: This will be Open financial estimates of scheme built into the integrated delivery to ensure no over business plan 2019/20 estimates going forward planning process. 19.10.2018: Status as above, action to remain open until the 2019/20 is approved. 06.12.2018: Status as above, action to remain open until the 2019/20 is approved. This is currently in draft form. A5. Review planning process 30.11.2018 Matt Gaunt 06.09.2018: Quality Open to ensure that cost saving checks will be built into schemes that require a the contract planning contractual mechanism to process to ensure that if support delivery is built into required appropriate planning process. mechanisms are built into contracts. 19.10.2018: Status as above, action to remain open until the 2019/20 is approved. 06.12.2018: Status as above, action to remain open until the 2019/20 is approved. This is currently in draft form. Page 52 Page

A6. CFO to engage system 31.12.2018 Matt Gaunt 14.11.2018: CFO has Open leaders at NHS England and organised to meet NHSE the ICS to present a case for Director of Finance. additional ICS funds to bridge 06.12.2018: Agreement the gap in risk monies on further £250K from the ICS to the CCG to bridge the gap. A resolution for another £500k has been found. Remaining gap will be closed by review of accounts. Net risk position remains £0.8million Progress

17.07.2018: New GBAF risk 2018-19. Risk score 9. Existing assurance and controls established, gaps identified and mitigating actions in place to address the gaps. 29.08.2018: Risk reviewed and actions updated. A new section has been added to the risk to illustrate that this is an accepted risk, and that each gap has an associated mitigating action. 06.09.2018: 07.09.2018: Risk reviewed following feedback from Quality and Performance Committee. Target risk rating impact reduced from 4 to 3 to be in line with original and current risk rating. Gap in control added re QIPP gap. Gap in assurance added re securing mitigation monies. Current risk rating likelihood increased from 3 to 4 due to these gaps identified. Actions added re QIPP gap & securing mitigation monies (A3, A4, A5) 19.10.2018: Risk reviewed and action plan updated. QIPP target amended from £4.5 million to £2.7 million 14.11.2018: Risk reviewed following Audit Committee and Quality & Performance Committee - the completed actions have been mapped to the current controls and assurances (A1). The risk score has increased from 3x4=12 to 4x4=16 resulting in this becoming 'high' risk. This is due to the risk associated to achieving financial balance as a result of the reserve monies received being £1.8 million as opposed to the £2.5 million requested due to some funds being committed to addressing system risks, this is linked to action A6. 06.12.2018: Risk reviewed and action plan updated. No changes to scoring or gaps. Page 53 Page

GBAF-03 – Well Led Risk owner Next review date Current status Current trend

Denis Gizzi 31.01.2019

Risk description Failure to take a lead role in the health system due to unclear objectives, insufficient capacity and capability or misdirected resources Risk appetite

Original risk Current risk Target risk

Impact Likelihoo Ratin Impact Likelihood Rating Impact Likelihoo Rating d g d 4 3 12 4 3 12 4 2 8

Existing assurance Existing controls Gaps in assurance Gaps in controls

NHS England have assured The CCG has initiated The CCG staff are not clear how The Quality and Performance the CCG as 'good' through the the creation of an their role and objectives are aligned Committee (QPC) Terms of CCG improvement and Integrated Care with the ICP agenda, and their Reference (TOR) need further assessment framework (CCG Partnership and the particular skill sets are used to best work to clarify responsibilities IAF), with quality of leadership ICP Board has agreed effect. rated as 'green'. terms of reference , Action to address: A2 governance process Action to address: A1 & A4 and started to agree priorities. The CCG has built strong The CCG leadership Clinical leadership roles remain governance process for a team has well unfilled; Chorley and South jointly lead sustainable defined objectives Ribble CCG running with one secondary care programme and the resources in GP Director vacancy. Greater that is aligned to the place to deliver them. Preston CCG new GP Director

Lancashire and South Cumbria Clinical leadership due to start Jan 2019. Page 55 Page

Integrated Care System acute has been Action to address: A3 reconfiguration programme. strengthened through the recruitment of GP advisors. Conflicts of interest returns Committee terms of The Our Health Our Care have been completed reference have been Programme may not progress quarterly, with one breach reviewed with the at pace or with the desired reported in 2017/18. A detailed exception of Quality outcomes review was undertaken by and Performance KPMG and further actions Committee and Action to address: A5 & A6 were put in place to deal with Delegated breaches. commissioning Committee. Strong staff engagement, with The policy framework 87% feeling they are equipped is in place and to do their job effectively reviewed annually, mandated training is monitored for all staff. A 'deep dive' presentation has Declarations of been made against this risk to interest are the Audit Committee on maintained quarterly, 07.09.2018 it has been agreed that any Governing Body member who has failed to provide an update will be barred from participating in committee meetings. The ICS commissioning framework has been Page 56 Page

agreed and clarifies the interdependency between ICS, Locality and neighbourhood. CCG assessment framework moved from 'requires improvement' to 'good' in several areas Staff engagement via development day and monthly team brief updates (A1) Updated Primary Care Commissioning Committee TOR in place with a new section to clarify the responsibilities the committee is to take with regards to primary care proposals and strategy (A2)

Action plan Page 57 Page

Action Due date Assigned to Latest update Status

A1. The CCG executive 31.08.2018 Jayne Mellor/ Matt Gaunt/ 17.07.2018: In progress Closed team are running a one Helen Curtis 30.08.2018: Staff day development session development session taken with all staff to bring place, further staff together ICS, ICP and engagement work to now CCG business objectives be undertaken. and to align skills to business need. This will inform a reset of individual and team objectives aligned to ICP/ICS deliverables A2. Quality and 30.11.2018 Matt Gaunt/Helen Curtis 17.07.2018: In progress Open Performance Committee 30.08.2018: Reviews of and Delegated TORs in progress - DCC commissioning revised TOR will be Committee Terms Of submitted to the committee Reference (TOR) under in October for approval, and review subsequent ratification by the Governing Body in November. 19.10.2018: DCC TOR have been approved by DCC and will be submitted to Governing Body in November for ratification. Q&P TOR are being drafted for the next meeting and will be submitted to a

Page 58 Page subsequent Governing

Body. 06.12.2018: Revised DCC TOR have been ratified by both Governing Bodies 28th & 29th Nov. QPC will be submitted to the committee and Governing Body for approval at a future date. A3. Election of qualified 31.10.2018 Matt Gaunt 17.07.2018: In progress Open GPs from the membership 30.08.2018: Expressions of to GP director vacancies interest for both roles closes will be completed. 31.08.2018. 07.09.2018: Expressions of interest have now been extended to 21.09.2018 due to insufficient submissions. 19.10.2018: Election closed 18.10.18, membership ratification of the process is taking place until 25.10.18, after which arrangements can be made for terms of office to begin. 15.11.2018: The election has now been ratified, HR work to be completed to issue offer letter and contract. 06.12.2018 Chorley and South Ribble CCG running with one GP Page 59 Page

Director vacancy, the other post holder has commenced their third term of office. Greater Preston CCG new GP Director due to start Jan 2019. A4. Scope staff 30.11.2018 Denis Gizzi 30.08.2018: In progress Open engagement materials 07.09.2018: This work is from local organisations to underway, 'job1/job2' implement a 'job1/job2' approach shared with staff approach at Team Brief in August. 19.10.2018: A further staff development session is being planned to bring together ICS, ICP and CCG business objectives and build on the 'job1/2 approach'. 06.12.2018: Staff away day planned for 13.02.2019 A5. Develop a risk 31.01.2019 Denis Gizzi 06.12.2018: Draft risk Open register to manage the register presented to risks to the OHOC OHOC Executive programme Oversight Group 05.11.2018, further amendments being made to finalise. Risk Register will be presented to the first Programme Oversight Group meeting Page 60 Page

once established

A6. Establish the OHOC 13.12.2018 Denis Gizzi 06.12.2018: TOR for the Open Joint Committee to joint committee have enable the CCGs to been approved by both make decisions to Governing Bodies. First progress the OHOC meeting scheduled for programme 13.12.2018 Progress

17.07.2018: New GBAF risk 2018-19. Risk score 12. Existing assurance and controls established, gaps identified and mitigating actions in place to address the gaps. 30.08.2018: Risk reviewed and actions updated. A new section has been added to the risk to illustrate that this is an accepted risk, and that each gap has an associated mitigating action. 07.09.2018: Risk updated following Audit Committee to include the deep dive presentation made. Progress updates have also been added against all actions. 19.10.2018: Risk reviewed and action plan updated. No change to risk scoring or associated gaps. 15.11.2018: Risk reviewed following Audit Committee - the completed actions have been mapped to the current controls and assurances (A1). 06.12.2018: Risk reviewed and action plan updated. Additional detail has been added to the risk regarding the progress of the OHOC programme. Page 61 Page

GBAF-04 - Service Transformation Risk owner Next review date Current status Current trend Jayne Mellor 31.01.2019

Risk description Unable to deliver system wide transformation as directed and informed by the ICS and ICP and be a system-wide leader Risk appetite

Original risk Current risk Target risk

Impact Likelihood Rating Impact Likelihood Rating Impact Likelihood Rating

4 2 8 4 2 8 4 2 8

Existing assurance Existing controls Gaps in assurance Gaps in controls

Senior membership at Joint Milestones and key processes Lack of defined commissioning Awaiting outcomes of Committee of CCGs have been set for the ICP to responsibilities between ICS engagement events regarding enable us to produce plans and ICP acute sustainability and new which have been supported by models of care all partners (Out of Hospital Action to address: A2 & A3 and Urgent and Emergency Action to address: A1 & A4 Care) Senior membership on the ICP Programme Board in place Awaiting outcome of the 10 Lancashire and South Cumbria to support delivery year plan in order to produce a Programme Board joint strategy with partners which establishes: -Clear deliverable plans

Action to address: A3 Page 63 Page

STP governance structures Joint Committee of CCGs Awaiting outcome of the 10 agreed established year plan in order to produce a joint strategy with partners which establishes: - Clear vision - Partner 'buy in' - Effective leadership

Action to address: A5 Link with the Integrated Board ToR for ICP Board agreed with Report (IBR) is now in place appropriate representation which triangulates from partners including information relating to plan, Primary Care performance and finance to give overall picture Defined local governance PMO in place structure ICP Board in place from Engagement events taking 01.04.2018 and ToR and place regarding acute governance structure agreed sustainability and new models of care Out of Hospital Strategy System wide value stream agreed and in place analysis event and diagnostic from Newton Europe informed redesign A&E Delivery Board with Joint Committee in place with senior membership ToR ratified by the Governing Body Urgent and Emergency Care Governance structure and Improvement Group scheme of delegation established with CCG PMO approved for Lancashire and Page 64 Page

support South Cumbria Change Programme ICP representation on all ICS Integrated Business Plan has Commissioning Development been approved by Governing Work streams Body Performance measures with Work stream leads in place for targets for improvement for all each scheme on all plans schemes on all plans System wide objectives agreed System wide Urgent and that align to CCG strategic Emergency Care Improvement objectives Plan agreed and in place A 'deep dive' presentation has Pentana system used to been made against this risk to provide assurance reporting the Audit Committee on around programme delivery 02.11.2018 Increased collaboration with stakeholders Integrated Business Plan schemes are contractually tied to Providers Contract monitoring of performance Commissioning programme support in place (A2) Head of Primary Care and Head of Urgent Care now linked in to ICS commissioning framework, which will help to alleviate the lack of defined Page 65 Page

commissioning responsibilities between ICS and ICP Scheduled engagement events have now been completed (A1) Primary Care transformation is progressing with all practices now signed up to 7 day access and the establishment of integrated care teams

Action plan

Action Due date Assigned to Latest update Status

A1. Outcome of 30.11.2018 Jayne Mellor 17.07.2018: In progress Closed engagement events 06.09.2018: regarding acute Engagement events sustainability and new scheduled for models of care to be 18/09/2018, 19/09/2018 taken through local and 20/09/2018 governance structure 10.10.2018: Scheduled engagement events have now been completed and feedback is being linked into the OHOC programme. A2. Appoint 30.08.2018 Jayne Mellor 30.08.2018: Post in Closed commissioning place Page 66 Page

programme support from CSU to work and support ICS Director of Commissioning - to define process for agreeing commissioning framework at ICS/ICP level. A3. Await NHS 10 year 31.01.2019 Jayne Mellor 30.08.2018: In progress Open plan which should 06.09.2018: 2019/20 determine place based planning work has commissioning started, 10 year plan is expected to be released in November 2018 when this can be incorporated into the 2019/20 planning. 10.10.2018: 10 year plan is still awaited - however the early indications which have been released have been crossed referenced into local strategy. 06.12.2018: 10 year plan and guidance which was expected early December has been delayed. A meeting is being held 11.12.18 which is a Page 67 Page

clinical decision group of the ICS whereby the commissioning frameworks will be presented for consideration. Action due date extended from 30.11.18 to 31.01.19 to allow for the 10 year plan to be published. A4. Establish out of 30.11.2018 Jayne Mellor 10.10.2018: Groups are Open hospital and Acute in the process of being reconfiguration established - the COG programme groups will be clinically led by which will report to a the Medical Director of Joint Clinical Oversight the OHOC programme Group (COG) to and the GP for primary oversee acute care from each CCG. sustainability and new 06.12.2018: Awaiting models of care confirmation of first meeting date and draft TORs. ICP platform brief which relates to out of hospital strategy (WHIN) is being presented to ICP Shadow Board on 13.12.2018 which will approve the governance arrangements. Page 68 Page

A5. ICP Board to 31.01.2019 Denis Gizzi 02.11.2018: Strategy Open develop an integrated being worked up strategic plan 06.12.2018: Integrated Care Strategy is being reviewed following comments from partners and due to go back to ICP Board in January for approval. Progress

17.07.2018: New GBAF for 2018-19. Risk transferred over from last year and existing assurance and controls and gaps aligned to new risk description. Risk score 8. Actions determined to address gaps. 30.08.2018: Risk reviewed and actions updated. A new section has been added to the risk to illustrate that this is an accepted risk, and that each gap has an associated mitigating action. 06.09.2018: Risk reviewed following feedback from Quality and Performance Committee. The risk description has been amended to be clear of its' remit. The following action has been removed as this is not directly part of this risk: 'JCCCG to review and agree recommendations from commissioning development work streams to establish commissioning responsibilities for ICS and ICP going forward'. Progress updates have been added against actions A1 and A4. 10.10.2018: Risk reviewed, additional controls added regarding CCG links into the ICS and engagement events taking place, and additional action added regarding programme groups being established. This risk will be the topic for the next audit committee GBAF deep dive. 02.11.2018: Risk reviewed following Audit Committee - the completed actions have been mapped to the current controls and assurances. Further detail has been added to the risk description, additional control added regarding the progress of primary care transformation, additional gap in control added regarding receipt and implementation of the 10 year plan. 06.12.2018: Risk reviewed and action plan updated. No changes to scoring or gaps. Once the 10 year plan is received and digested the action plan for this risk can be expanded. Page 69 Page

Corporate Risk Register

Risk Owner Next Review Date Current RAG Status Direction of Travel

Helen Curtis 31-Jan-2019

Risk Description There is a risk that the CCG may not deliver the RTT and 52 week trajectory, or that the delivery of this has a significant financial impact on CCG resources. This may result in an adverse financial impact for the CCG and adverse reputation.

Original Risk Current Risk Target Risk Impact Likelihood Rating Impact Likelihood Rating Impact Likelihood Rating Target Date 4 4 16 4 4 16 4 3 12 31-03-2019

Existing Assurance Existing Controls Gaps in Assurance Gaps in Controls 36+ week file received on Recovery action plan Awaiting outcome Lack of defined a weekly basis from LTH of ‘Four eyes’ measures which provides detailed Contractual framework – contract review into particularly insight into movement on performance notice in place theatre utilisation around waiting lists and an efficiency, for indication of RTT delivery Demand management schemes example theatre utilisation, and Weekly Patient Tracking Deep dive analysis into referrals clinic start times List which provides a view and activity on the number of open Remedial Action pathways Fortnightly steering group Plan needs meetings with LTH review in order Root Cause Analysis that the actions completed for every Monthly operational and contract defined can patient who breaches 52 Board meetings deliver the weeks, to date there has outcome needed been no evidence of harm Integrated Board Report which identified provides oversight of RTT trajectories and mitigating actions

Weekly Management Executive Team report tracking open pathways

RTT position presented weekly to ‘Integrated Business Plan Weekly Update Meeting’

Corporate Risk Register NHS Greater Preston CCG Governing Body Meeting 24 January 2019 Page 70 Action Due Date Assigned To Latest Update Status 14.12.18 Four eyes Receive outcome of work on going and ‘Four eyes’ review into 31/12/18 Sam James report not yet In Progress theatre utilisation complete Sam James 14.12.18 Links to Agree efficiency the above. Agreed measures with LTH in at RTT steering order to instil oversight group that Four 14/01/19 and scrutiny of eyes metrics will be In Progress efficiency of elective used to review services efficiencies once available Sam James 14.12.18 This is a live document. An updated version was circulated last week and there will be further revisions following the RTT

steering group meeting next week. Update suggested that most specialities are on track against Receive updated trajectory. ENT, 30/11/18 Remedial Action Plan Ophthalmology and In Progress Oral Surgery are specialties that are struggling to meet trajectory. Action to close as this has now been received and will continue to be submitted to the CCG. If any future versions prompt any further action this will be added to the risk.

Corporate Risk Register NHS Greater Preston CCG Governing Body Meeting 24 January 2019 Page 71

This page is intentionally left blank Agenda Item 8

Governing Body Meeting

Date of meeting 24 January 2019 Title of paper Integrated Care Partnership (ICP) Update Presented by Mr Denis Gizzi, Chief Officer Author Mrs Sarah James, Programme Director ICP Clinical lead Dr Sumantra Mukerji, Chair Confidential No

Purpose of the paper This report provides members with an update on the progress of the Central Lancashire Integrated Care Partnership over the last month.

Executive summary The report outlines key appointments, team reconfiguration and the development of a strategic framework underpinning the longer term vision.

Recommendations The Governing Body are requested to note the progress made within the Integrated Care Partnership during the previous month.

Links to CCG Strategic Objectives SO1 Improve quality through more efficient, safer services which deliver a ☒ better patient experience SO2 Commission care so that it is integrated and ensures an appropriate ☒ balance between in-hospital and out of hospital provision SO3 Be an integral part of a financially sustainable health economy ☒ SO4 Ensure patients are at the centre of the planning and management of ☒ their own care and their voices are heard SO5 Be seen as a well-run clinical commissioning group and the system ☒ leader

Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome

N/A Were any conflicts of interest identified at previous meetings

Integrated Care Partnership (ICP) Update NHS Greater Preston CCG Governing Body Meeting 24 January 2019 Page 73 (mark X in the correct box below) Yes No X If conflicts of interest were identified what were these: N/A

Implications Quality/patient experience Yes ☐ No ☐ N/A ☐ implications? (Potential) conflicts of interest? Yes ☐ No ☐ N/A ☐ Equality Impact Assessment? Yes ☐ No ☐ N/A ☐ Privacy Impact Assessment? Yes ☐ No ☐ N/A ☐ Are there any associated risks? Yes ☐ No ☐ N/A ☐ Are the risks on the CCG’s risk ☐ ☐ ☐ register? Yes No N/A If yes, please include risk description and reference number

Assurance The Integrated Care Partnership Board is accountable for oversight and delivery of the programme of change.

Integrated Care Partnership (ICP) Update NHS Greater Preston CCG Governing Body Meeting Page 74 24 January 2019

1. INTRODUCTION

This paper provides an update on progress within the Integrated Care Partnership during the period since the last Governing Body update – December 2018 to January 2019, and looks forward to the next period.

The previous Board/Governing Body update provided in November focused on progress made since April 2018 and looked at ICP Mobilisation / Development of a Strategic Framework / What next for the ICP.

2. INTEGRATED CARE PARTNERSHIP UPDATE (December – January 19)

2.1. ICP Board Business – December

In December, during the ICP Board, they concluded the following business;

• Approved the seven values to support effective Board working and agreed ways in which to operationalise them • Approved the formation of a Senior Leadership Team from existing Executive Officers • Approved the platform brief (a planning and initiation document) for the Wellbeing and Health in Integrated Neighbourhoods Platform • Approved a proposal to build capacity with the voluntary, community, faith and social enterprise sector within Central Lancashire • Noted an update paper on acute sustainability including the Case for Change, and terms of reference for the Programme Oversight Group and Joint Committee

2.2. ICP Mobilisation – Board and Leadership Development

The ICP held two Development Sessions in this period, one focused on culture and collective decision making and the other focused on new ways of contracting. The outcome of the culture and collective decision making session was the development of seven values which will underpin the operation of the Board, and some logistical changes to the management of Board business. The second session invited NHS England to talk about new ways of contracting that have been adopted throughout the country, the outcome of which was an agreement to trial new ways of contracting in central Lancashire, starting with urgent and emergency care. The brief for this work will come to the next ICP Board meeting in January (the slides from this NHSE session are available to GB Members from Sarah James).

Also during this period, the ICP have formalised an ICP Senior Leadership Team. A group of Senior Leaders from statutory organisations already meet weekly

Integrated Care Partnership (ICP) Update NHS Greater Preston CCG Governing Body Meeting Page 75 24 January 2019 (Accountable Officers/Chief Executive Officers from CCGs/LTH/LCFT/LCC) and the proposal that has been agreed is that this is now sustained by formal terms of reference and cycle of business. Included in the functions will be to provide executive leadership, drive and oversight of the ICP business, including the Board agenda and report setting process (working with the Chair), as well as review/assurance of issues facing the system or documents for Board. Their inaugural meeting took place on 7 January 2019.

2.3 Movement towards place based regulation and assurance

As we see the merging of NHS England and NHS Improvement at a national level, it is indicated that we will start to see more of a move towards regulation and assurance at an ICS and ICP level rather than organisational.

1. There are two particular updates on this for December, firstly that we have been asked for an ICP Exec Lead for Quality to help develop Quality Assurance and Improvement processes across the ICS. The focus will be on how we as an ICS develop a stream lined and robust quality processes that supports both local and system wide assurance and improvement activity. The Quality Leads have agreed this will be Helen Curtis.

2. The second update is that we (as an ICP) were invited to an ICP/ICS Assurance meeting. Executive Leads from the statutory partners and the Chair, supported by the Programme Director, met with ICS Executives, NHSE and NHSI on 26 November. The focus of the agenda was on ICP Development, Performance, Quality and Finance. We were provided with an ICP Performance dashboard which compared constitutional targets against other ICP areas, the wider ICS and national benchmarks. It is intended that these meetings will now happen quarterly and we can expect a greater scrutiny on Performance, Quality and Finance in future meetings – the next round have been scheduled for February 2019. To support this process, we are bringing forward the work on system wide performance reporting/assurance so that the ICP Board have oversight of performance from the New Year.

2.4 The NHS long term plan and NHS planning guidance19/20

During the last period we have had the release of the NHS planning guidance in December 2018 and the NHS Long Term Plan in January 2019. More detail on the NHS Long Term Plan is contained elsewhere within the Governing Body Agenda. It is worth noting that for NHS organisations there is a requirement for individual operational plans for 19/20, although these should be aligned locally in terms of capacity/demand planning. These plans will form year one of an ICS Five Year Strategic Plan. This five year plan will be developed by planning leads from the ICS and ICPs and an initial discussion was held on 3 December to discuss how to take that forward before submission in summer 2019. It is likely we will need to bring 19/20 plans through the ICP Board for sign off before the end of the financial year as well as organisational Boards. There will also be a great deal of work for us to do

Integrated Care Partnership (ICP) Update NHS Greater Preston CCG Governing Body Meeting Page 76 24 January 2019 over 19/20 to contribute to the ICS plan and develop our own local integrated longer term plans.

2.5 Big Seven Strategic Framework – Platform Specific Updates

The last update included a section on the Big Seven, the interconnected strategic platforms that we need to deliver as a system, to set out the transformational changes needed to ensure a sustainable future; and therefore the business of the ICP Board in the coming months and years. A brief update on progress against some of these is included below;

• Wellbeing and Health in Integrated Neighbourhoods – As the Lancashire and South Cumbria ICS, we have been selected by NHS England to become one of the four accelerator sites for Population Health Management (PHM) and have been offered bespoke support for 20 weeks starting from mid-December, via Optum International. We have put in an application for the Central Lancashire ICP to get some funding as part of this process. • Our Health Our Care Acute Sustainability – The Joint Committee of CCGs met in December to approve the Case for Change, and work is now in progress to develop a whole health economy model of care, from wellbeing and health, and primary care services through to acute services. • Integrated Care Partnership Development – A workshop was held in December with Board Members and wider stakeholders and focused on out what full ICP status looks like, the functions that might sit underneath it, and some of the milestones to get there. The outcome was a draft vision and roadmap to full ICP status which will be worked up in more detail over the next few months. • Integrated Care Strategy – Feedback from partners (including Governing Body) has been received and is being acted upon in the next iteration of the strategy. An ICP Board Development Session in March will finalise this strategy, and triangulate it with the NHS Long Term Plan to see how it can be put into practice. • Clinical Care Reform – Over the past month, we have undertaken a review of the Value Stream Analysis event and the subsequent workstreams that have emerged as part of the Urgent and Emergency Care Improvement Programme. This seeks to look at how well we undertook transformation as a system and what lessons we could learn for the next time we do this. A full report and recommendations is being provided to the A&E Delivery Board.

3. LOOKING AHEAD TO THE NEXT PERIOD (January – February 2019)

In January 2019, the ICP Board meeting will look to;

• Approve the Economic and Financial Reform Brief • Approve a methodology for system wide performance management, risks and opportunities • Discuss the latest position on capital and estates, the Lancashire County Council Budget Proposals and an update on the Mental Health Improvement Plan

Integrated Care Partnership (ICP) Update NHS Greater Preston CCG Governing Body Meeting Page 77 24 January 2019 In addition, during the next two months, the business of the ICP will focus on;

• Understanding and preparing for the implications of the NHS Long Term Plan in relation to partnership working • Developing the draft roadmap to full ICP status and mobilising a system wide working group • Progressing mobilisation work around the enabler platforms (particularly communications and engagement) • Developing an ICP Purpose Document – following feedback from Board and Governing Bodies, it has been decided to produce a stakeholder publication which brings together all of the relevant information about the ICP in terms of its aims, vision, work programme etc. • Preparing for the ICP/ICS second review meeting

Integrated Care Partnership (ICP) Update NHS Greater Preston CCG Governing Body Meeting Page 78 24 January 2019

Our Health Our Care Shadow Integrated Care Partnership Board

Key Messages and Actions

13th December 2018 | 10.30 | Seminar 9, Education Centre 1, Royal Preston Hospital, PR2 9HT

Introduction; This briefing note provides the key messages and actions from the December ICP Board meeting for information. Partnership Board members are encouraged to share this document with their Governing Body/Board/Elected Members.

Agenda Item ICP 097/18: ICP Programme Director Report – 15 November – 10 December

Key Messages:  In response to the question ‘How do we get to the point where issues are collectively owned rather than being others problems to solve, and that commitments made together are upheld within organisations, even if there is challenge?’ the partnership Board developed the following seven principles and recommendations for the way the Partnership operates at their development session in November; i. We need a shared understanding of the issue and agreement on what we are trying to fix (informed by business intelligence, metrics, comparisons and patient views) and the outcome required to enable a solution ii. We need to have clarity of commitment, individually and collectively and to maintain this commitment (through points 3 and 4 below) iii. We need to have a robust accountability framework in which we report at a system level on progress and have checks and balances on a timely basis to ensure we deliver our commitments iv. Leaders have a duty to bring their organisation with them, to discuss any impacts and implications up front and then to publically commit to a shared solution v. We need to have honest, open discussions where we check shared understanding, with respectable challenge and where we add value and are not afraid to ask each other difficult questions, if they are constructive to the overall outcome vi. We need to review our governance and mechanisms to ensure that we have the time and space to understand and resolve our collective issues. vii. There needs to be agreed shared ownership of the problem with clear individual and if necessary collective ownership of actions to address the issue.

 To operationalise these values, the Board agreed to; 1. Cross reference them with the review of the ICP Memorandum of Understanding 2. Develop them into a working checklist to be used for ICP Board decision making / setting policy direction 3. Include a standing ICP Board item on ‘Checking our value and values’ – to review how we have added value and how we have behaved against our values at each ICP Board meeting  The Partnership Board approved the formalisation of Senior Leadership Team weekly meetings, made up of the statutory organisations, to provide Executive oversight of the ICP Board Agenda and Report setting and review process, to begin from January 2019.

Page 79

Our Health Our Care Shadow Integrated Care Partnership Board

13th December 2018 | 10.30 | Seminar 9, Education Centre 1, Royal Preston Hospital, PR2 9HT

 Helen Curtis, Director of Quality and Performance for Greater Preston and Chorley & South Ribble CCGs has been agreed as the ICP Executive Lead for Quality to help develop Quality Assurance and Improvement processes across the ICS  A central Lancashire ICP Purpose Document is in development to articulate the ICP’s purpose and vision of the future, and explain the big seven strategic platforms  Scope documents are being developed for the following enabler workstreams, and it was agreed that organisational leads would be nominated for working groups; o System wide Programme Management Arrangements o System wide Continuous Improvement o System wide Performance Reporting and Assurance o System wide Communications o System wide Public and Patient Engagement and Involvement o System wide Governance Arrangements

Date Action ID Action Lead Owner Due Date 13.12.18 096/18/01 Prepare an update paper reviewing the Gary Hall February current engagement and governance 2019 links with the Housing sector and make any recommendations for change 13.12.18 097/018/01 Prepare an update for Board detailing Jean Wright 14.01.19 the estates analysis that work One Partnership will undertake 13.12.18 097/018/02 ICP Purpose Document to be developed Sarah James 14.01.19 (referencing the values) 13.12.18 097/018/03 ICP Board members to provide All ICP Board 07.01.19 organisational lead contacts for each of members the enabler workstreams 13.12.18 097/018/03 Operationalising the values (three Laura Bell 14.01.19 actions) to be implemented

Agenda Item ICP 098/18: Wellbeing and Health in Integrated Neighbourhoods; Approving the platform brief

Key Messages:  Wellbeing and Health in Integrated Networks (WHINs) Platform Brief is the first of the big seven platforms to be presented to the Partnership Board for approval  The Platform Brief builds upon the principle of care closer to home originating in the objectives of the Our Health Our Care programme at its inception and focuses on a left- shift of activity from acute care to a wellness and prevention based offer to enable a sustainable health and care system for the future. It sets out the vison, aims and objectives as well as high level timescales. It was approved by the Board.  WHINs Platform Board will meet on the 7th February 2019 for the first time to lead and drive the change and will provide a monthly highlight report to the Partnership Board  A discussion noted measuring success, and linking acute clinicians to leadership teams.

Date Action ID Action Lead Owner Due Date 13.12.18 098/18/01 WHINs Platform Resource Paper to be Jayne Mellor February developed for review by the Board 2019 Page 80

Our Health Our Care Shadow Integrated Care Partnership Board

13th December 2018 | 10.30 | Seminar 9, Education Centre 1, Royal Preston Hospital, PR2 9HT

Agenda Item ICP 099/18: Building Capacity within the VCFSE; A proposal from the sector

Key Messages:

 This paper outlines how the VCFS sector propose to build sector capacity to enable them to better influence and engage with the ICP; o Co-produce a prevention offer to be implemented through the eight neighbourhood locations covering Greater Preston, Chorley and South Ribble o Develop a sector profile aligned to the ICP aims and; o Develop agreed methodology for quantifying investment  The proposal was supported by the ICP Board and it was agreed that the next stage would be for the ICP Finance Leads to now consider the source of the investment required.

Date Action ID Action Lead Owner Due Date 13.12.18 099/18/01 Consider source of investment as part of Matt Gaunt February ICP Budget proposal for 2019/20 2019

Agenda Item ICP 100/18: Acute Sustainability Update paper

Key Messages:

 The Acute Sustainability workstream is now in Stage 2 of the NHS England Assurance process. Stage 2 Assurance culminates in the submission of a Pre-Consultation Business Case and a request to authorise formal public consultation should any of the proposed options trigger this by constituting “major service change” as detailed within NHS England guidance.  Partnership Board members were informed that the Acute Sustainability Case for Change had been refreshed as a result of the NHS England Stage 1 Assurance and, post meeting, we can confirm, has been approved by the Our Health Our Care Joint Committee of CCGs  The Board also noted and approved the terms of reference for the Joint Committee of the CCGs and the Programme Oversight Group  It was discussed that the wave 4 capital bids for central Lancashire had not been successful and Board noted their disappointment at this decision. It was agreed that further work was required, firstly to understand the current position statement with regards to capital and then to consider what alternative options are available.

13.12.18 098/18/02 Captial finance paper outlining current Matt Gaunt / 14.01.19 position and options for capital to be Jean Wright prepared

Agenda Item ICP 101/18: LCC Budget Proposal and Agenda Item ICP 102/18: Mental Health Improvement Plan were deferred to the next meeting

Next ICP Board Meeting; 24th January, 2019, Boardroom 1, Chorley House Page 81

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The NHS Long Term Plan – Briefing

The NHS Long Term Plan was published on 7 January 2019 and sets out the ambitions, commitments and priorities for the next ten years – looking to the NHS’s 80th birthday. This briefing paper provides an overview of the Plan, and a short commentary on the content and reception. Full details on all of the commitments are available from the document itself - https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term-plan.pdf.

This briefing note will be supplemented by a more detailed piece of work which will review the commitments made within the plan, and consider them against our current progress within central Lancashire.

Chapter One; A New Service Model for the 21st Century

This is the chapter that sets out how services will fundamentally change over the life of the long term plan (ten years), and become more joined up and coordinated, more proactive and more differentiated in the support they provide to individuals. It focuses on five major changes;

1. Boost out of hospital care and dissolve the boundary between primary and community health services – This includes an investment guarantee on primary medical and community health services – at least £4.5billion higher in five years’ time. Expectation that this will fund expanded community multidisciplinary teams aligned with primary care networks (PCN). It notes potential contract changes to support this ‘Network Contract’ with funds flowing through PCNs. It offers PCNs ‘shared savings’ schemes so that they can benefits from actions to reduce demand. By 2020/21, PCNs will assess their local population by risk of unwarranted health outcomes. It also signals expectations on the improved responsiveness of community health crisis response teams, and a commitment to see the Enhanced Health in Care Homes (EHCH) model rolled out across the whole country by 2023/2024 and changes to the GP Quality and Outcomes Framework. 2. Reduction in pressure on emergency hospital services – Commitments to embed a single multidisciplinary Clinical Assessment Service (CAS) within integrated NHS 111, ambulance dispatch and GP out of hours services from 2019/20, fully implement the Urgent Treatment Centre model by autumn 2020, with the option of appointments booked through a call to NHS 111 and to implement the recommendations from Lord Carter’s recent report on operational productivity and performance in ambulance trusts. Requirements that every acute hospital with a type 1 A&E department will move to a comprehensive model of Same Day Emergency Care, embedded in every hospital, in both medical and surgical specialties during 2019/20. A NHS Clinical Standards Review will be published in the spring. In terms of DTOC, the goal over the next two years is to achieve and maintain an average figure of 4,000 or fewer delays, and over the next five years to reduce them further. 3. People will get more control over their health and more personalised care when they need it – A commitment to roll out the NHS Personalised Care model across the

Page 83 country, to make social prescribing more accessible with trained link workers, an acceleration in the roll out of Personal Health Budgets, a commitment to personalise and improve end of life care, and increased support for people to manage their own health 4. Digitally enabled primary and outpatient care will go mainstream across the NHS - digital-first primary care - every patient will have will have a new right to choose this option usually from their own practice or, if they prefer, from one of the new digital GP providers. A fundamental redesign of outpatients will avoid up to a third of face-to- face outpatient visits over the next five years. 5. Local NHS organisations will increasingly focus on population health and local partnerships through ICS’s everywhere - By April 2021 ICSs will cover the whole country - Every ICS will need streamlined commissioning arrangements to enable a single set of commissioning decisions at system level. This will typically involve a single CCG for each ICS area. CCGs will become leaner, more strategic organisations that support providers to partner with local government and other community organisations on population health, service redesign and Long Term Plan implementation. The chapter notes the requirements for each ICS (most of which are in progress here in LSC). A new ICS accountability and performance framework will consolidate the current amalgam of local accountability arrangements and provide a consistent and comparable set of performance measures, and ICSs will agree system-wide objectives with the relevant NHSE/I Director. NHSI will take a more proactive role in supporting collaborative approaches between trusts, the new Integrated Care Provider (ICP) contract will be made available for use from 2019, the government will set out further proposals for social care and health integration in the forthcoming Green Paper on adult social care and the Better Care Fund will be reviewed in early 2019.

Chapter Two; More NHS Action on Prevention and Health Inequalities

This chapter begins with outlining the five reasons for increasing demand for NHS services, noting that two of them are potentially modifiable by redesigning healthcare so that it is provided in the optimal care setting, or improving upstream prevention. It recognises that a comprehensive approach to preventing ill health requires a multitude of partners, but that the role of the NHS includes secondary prevention and therefore sets out actions to use our contacts with people as positive opportunities to improve their health. This includes actions on the following areas;

• Smoking - NHS-funded tobacco treatment services, a new smoke-free pregnancy pathway and a new universal smoking cessation offer will also be available as part of specialist mental health services • Obesity - a targeted support offer and access to weight management services in primary care, doubling of the NHS Diabetes Prevention Programme, testing of an NHS programme supporting very low calorie diets for obese people with type 2 diabetes, and strengthening the hospital food standards requirements • Alcohol - those hospitals with the highest rate of alcohol dependence-related admissions will be supported to fully establish Alcohol Care Teams • Air pollution - cut business mileages and fleet air pollutant emissions by 20% by 2023/24

Page 84 • Antimicrobial resistance - support implementation and delivery of the government’s new five-year action plan on Antimicrobial Resistance. • Stronger action on health inequalities - NHS England will continue to target a higher share of funding towards geographies with high health inequalities than would have been allocated using solely the core needs formulae. The NHS will set out specific, measurable goals for narrowing inequalities. All local health systems will be expected to set out during 2019 how they will specifically reduce health inequalities by 2023/24 and 2028/29. There are also specific commitments for maternity services for the most vulnerable, people with severe mental health issues, rough sleepers, carers and young carers, and people with serious gambling problems.

This chapter also notes that the Government and the NHS will consider whether there is a stronger role for the NHS in commissioning sexual health services, health visitors, and school nurses, and what best future commissioning arrangements might therefore be.

Chapter Three; Further progress on care quality and outcomes

This section sets out the improvement priorities for the biggest killers and disablers of our communities. It includes further advances on current improvement agendas for some areas (e.g cancer, mental health) whilst taking a more focused look at others (e.g. children’s health). This chapter sets out work programmes in the following areas, some with ten year goals and some to happen within the next two or five years;

• Children and young people; o Maternity and neonatal services - roll out of Saving Babies Lives Care Bundle, care provided by specialist perinatal mental health services will be available from preconception to 24 months after birth, improve access to postnatal physiotherapy, redesign and expand neonatal critical care services, develop our expert neonatal nursing workforce, and enhance the experience of families during the worrying period of neonatal critical care. o Children and Young Peoples Mental Health Services - delivering on our commitments to expand mental health services for children and young people. A new approach to young adult mental health services for people aged 18-25 will support the transition to adulthood o Learning disability and autism - reduce waiting times for specialist services, people with a learning disability, autism or both will be enabled to have a personal health budget (PHBs), and all care commissioned by the NHS will need to meet the Learning Disability Improvement Standard. o Children and young people with cancer - offer all children with cancer whole genome sequencing, CAR-T cancer therapies and proton beam therapy will be available, actively support children and young people to take part in clinical trials and offer boys HPV-related diseases vaccination, and to match-fund CCGs who commit to increase their investment in local children’s palliative and end of life care services including children’s hospices. • Better care for major health conditions o Cancer – milestones will see the introduction of rapid diagnostic centres, a new faster diagnosis standard for cancer will begin to be introduced, HPV primary screening for cervical cancer, lung health check model will be

Page 85 extended, also there will be stratified, follow-up pathways for people who are worried their cancer may have recurred o Cardiovascular disease – improve effectiveness of NHS Health Check and introduce national network of community first responders and defibrillators o Stroke care - ISDNs will support STPs and ICSs to reconfigure stroke services into specialist centres, improve the use of thrombolysis and further roll out mechanical thrombectomy, and dataset SSNAP will be updated o Diabetes – access for type 1 diabetes patients to flash glucose monitors, and all hospitals in future will provide access to multidisciplinary footcare teams and diabetes inpatient specialist nursing teams o Respiratory disease - build on the existing NHS RightCare programme and expanding pulmonary rehabilitation services over 10 years o Adult mental health services – 2.3billion investment by 2023/2024. Expand IAPT. 24/7 community-based mental health crisis response for adults and older adults is available across England by 2020/21. Specific waiting times targets for emergency mental health services will for the first time take effect from 2020. o Short waits for planned care – RTT will be reviewed, and it makes a note that separating urgent from planned services can make it easier for NHS hospitals to run efficient surgical services ‘Planned services are provided from a ’cold‘ site where capacity can be protected to reduce the risk of operations being postponed at the last minute if more urgent cases come in. Managing complex, urgent care on a separate ’hot‘ site allows trusts to provide improved trauma assessment and better access to specialist care, so that patients have better access to the right expertise at the right time. So we will continue to back hospitals that wish to pursue this model. In those locations where a complete site shift to ‘cold’ elective services is not feasible, we will also introduce a new option of ‘A&E locals’.’ o Research and innovation to drive future outcomes and improvement Chapter Four; NHS Staff will get the backing that they need

This chapter notes that workforce growth has not kept up with need and recognises that to make the plan a reality, the NHS will need more staff, working in rewarding jobs and a more supportive culture. It sets out a number of specific workforce actions which can have a positive impact now, and sets out wider reforms for the NHSE workforce which will be finalised by NHS Improvement and the DOHSC when the education and training budget for HEE is set in 2019. This includes actions on the following areas;

• A comprehensive new workforce implementation plan (to be published later in 2019) • Expanding the number of nurses, midwives, AHPs and other staff • Growing the medical workforce • International recruitment • Supporting our current NHS staff • Enabling productive working • Leadership and talent management • Volunteers

Page 86

Chapter Five; Digitally enabled care will go mainstream across the NHS

This chapter sets out the role technology will play in the implementation of the Long Term Plan, and sets out expectations for a ‘digital first’ option for most. There are some practical priorities to drive NHS digital transformation, which references electronic health records, decision support and Artificial Intelligence for clinicians, development of new treatments, capturing data as a by-product of care to empower clinicians etc. The chapter covers five areas;

1. Empowering People – access to digital tools, to NHS information, the plans for the NHS App, plans for digital access to maternity records and creating a range of apps for particular conditions, mobile monitoring devices and connected home technologies and plans for Patients Personal Health Records. 2. Supporting health and care professionals – optimise technology for staff, faster progress for community based staff on mobile access, investing in enhancing the digital leadership of the NHS. 3. Supporting Clinical Care – increasing digital options including access to a GP digitally, all providers to advance to a core level of digitisation by 2024, new wave of Global Digital Exemplars and technology will enable the NHS to redesign clinical pathways 4. Improving Population Health – population health management solutions and use of data to inform research 5. Improving clinical efficiency and safety – both in terms of providing care (e.g. pathology and digital imaging networks), and secure data and systems

Chapter Six; Taxpayers investment will be used to maximum effect

This chapter notes that the new funding settlement promised revenue funding would grow by an average of 3.4%, delivering a real terms increase of £20.5 billion by 2023/24. It notes that putting the NHS back onto a sustainable financial path is a key priority in the plan and essential to allowing the NHS to deliver the commitments. To do so, it sets out five tests that the NHS will need to meet;

Test One – The NHS (including providers) will return to financial balance - The NHS will use the five-year funding settlement to ensure rigorous and disciplined financial management across all NHS organisations. Over the next five years, this means achieving three interrelated objectives:

 continuing to balance the NHS’ books nationally across providers and commissioners;  reducing the aggregate provider deficit each year, with NHS Improvement committing to return the provider sector to balance in 2020/21;  reducing year-on-year the number of trusts and CCGs individually in deficit, so that all NHS organisations are in balance by 2023/24.

o Other commitments include; Reforms to the payment system will move funding away from activity-based payments and ensure a majority of funding is population-based, movement to a blended payment model beginning with urgent and emergency care, with a single set of financial incentives aligned to the commitments in the Long Term Plan, the CQUIN framework will be reformed and NHSI will deploy an accelerated turnaround process in the 30 worst financially performing trusts. It also notes that beyond 2019/20 further financial reforms will support ICSs ‘through a process of

Page 87 earned financial autonomy we will give local health systems greater control over resources on the basis of a track record of strong financial and performance delivery, assessed in part through the new ICS accountability and performance framework’. o Creation of a new Financial Recovery Fund (FRF) to support systems’ and organisations’ efforts to make all NHS services sustainable, we expect that all systems and trusts will implement proven initiatives, including the Model Hospital, Rightcare and GIRFT – this FRF will mean the end of the control total regime and Provider Sustainability Fund for all trusts which deliver against their recovery plans by 2021 at the latest.

Test Two - The NHS will achieve cash-releasing productivity growth of at least 1.1% per year – This notes continued progress with Getting It Right First Time (GIRFT). It also notes that over the next two years we will focus on ten priority areas;

o Improving the availability and deployment of the clinical workforce, further reducing bank and agency costs. o Procurement savings by aggregation of volumes and standardising specifications. o Delivering pathology and imaging networks o Improve efficiency in community health services, mental health and primary care o Delivering value from the £16 billion we spend on medicines. o Making further efficiencies in NHS administrative costs across providers and commissioners. All core transactional services will be automated over the next five years. o The NHS will improve the way it uses its land, buildings and equipment. o Ensure that the least effective interventions are not routinely performed o Improving patient safety through a new ten-year national strategy, to be published in 2019. A new Patient Safety Incident Management System will replace the current NRLS by 2020. o The NHS Counter Fraud Authority will continue Test Three - NHS will reduce the growth in demand for care through better integration and prevention - Chapters One, Two and Three of the Long Term Plan describe how this is being done.

Test Four – The NHS will reduce unjustified variation in performance - Chapters Two, Three and Six of this Long Term Plan describe how this is being done – referencing the Model Hospital work and that reducing unwarranted variation will be a core responsibility of ICSs.

Test Five – The NHS will make better use of capital investment and its existing assets to drive transformation - NHS long-term capital investment will be considered in the 2019 Spending Review, and reforms to the NHS’ capital regime will ensure capital funding is prioritised and allocated efficiently, and a premises review for primary care.

Page 88 Chapter Seven; Next Steps

The final chapter sets out next steps – it notes that to support delivery, a new operating model will be built, based on the principles of co-design and collaboration. Existing commitments in the Five Year Forward View and national strategies for cancer, mental health, learning disability, general practice and maternity will all continue to be implemented. It confirms that 2019/20 will be a transition year, with every NHS trust, foundation trust and CCG expected to agree single year organisational operating plans and contribute to a single year local health system-level plan.

Looking forward, the Government’s Spending Review will set out details of the NHS capital budget and funding for education and training, as well as the local government settlement to cover public health and adult social care services. In spring, the national implementation framework and the Clinical Review of Standards will be published prior to implementation from October 2019.

Local health systems will receive five-year indicative financial allocations for 2019/20 to 2023/24 and be asked to produce local plans for implementing the commitments set out in the Long Term Plan in 2019.

NHS England and NHS Improvement will implement a new shared operating model designed to support delivery of the Long Term Plan, key commitments to deliver this approach are:

 A reorientation away from principally relying on arms-length regulation and performance management to supporting service improvement and transformation across systems  Strong governance and accountability mechanisms in place for systems  a reinforcement of accountability at Board, Governing Body and local system ICS level for adopting standards of best practice and making their contribution to critical national improvement programmes, on a comply or explain basis;  Making better use and improving the quality of the data and information that local systems and providers have access to improve patient services.

As ICSs take hold, we will support organisations to take on greater collaborative responsibility, meaning that neither trusts nor CCGs will pursue actions which, whilst potentially improving their institutional financial position, would result in a worse position for the system overall. This will be supported by a system oversight approach which reviews organisational and system objectives alongside the performance of individual organisations.

There is a provisional list of potential legislative changes for Parliament’s consideration:

o Give CCGs and NHS providers shared new duties to promote the ‘triple aim’, both for their local NHS system and for the wider NHS. o Remove specific impediments to ‘place-based’ NHS commissioning. The 2012 Act / Lifting a number of restrictions on how CCGs can collaborate with NHS England / Section 7A public health functions with its core Mandate functions o Support the more effective running of ICSs by letting trusts and CCGs exercise functions, and make decisions, jointly, allow – and encourage – the creation of a joint commissioner/provider committee in every ICS, which could operate as a transparent and publicly accountable Partnership Board. To manage conflicts of interest, any procurement decisions – including whether to procure – would be reserved to the commissioner only; o Support the creation of NHS integrated care trusts

Page 89 o Remove the counterproductive effect that general competition rules and powers can have on the integration of NHS care. We propose to remove the Competition and Markets Authority’s (CMA) duties, introduced by the 2012 Act, o Cut delays and costs of the NHS automatically having to go through procurement processes. We propose to free up NHS commissioners to decide the circumstances in which they should use procurement, this would mean repealing the specific procurement requirements in the Health and Social Care 2012 Act. We also propose to free the NHS from wholesale inclusion in the Public Contract Regulations o Increase flexibility in the NHS pricing regime. o Make it easier for NHS England and NHS Improvement to work more closely together. Engaging People - We will establish an NHS Assembly in early 2019. The NHS Assembly will bring together a range of organisations and individuals at regular intervals, to advise the boards of NHS England and NHS Improvement as part of the ‘guiding coalition’ to implement this Long Term Plan

Conclusion – A short commentary on the reception of the Plan

Generally, the plan has been well received and praised for its ambition – particularly in relation to focusing on improving care outside of hospital and moving towards more joined up, preventative and personalised care for patients and on prevention. ICS’s are here to stay, with significant commitments and expectations on collaborative working. The level below ICS, (ICPs here in Lancashire and South Cumbria) are not explicitly mentioned and we have some work to do with our ICS to understand the specific expectations on ICPs. Support for the plan is noted from NHS Providers, the Kings Fund, NHS Community Network, Mental Health Network, Local Government Association, SCIE.

Whilst there is strong support, there are also a number of questions that have been raised by the publication of the plan – firstly, it critically relies on tacking workforce challenges, yet the solutions are in a new workforce plan not due to be published till later in the year. There are other notable decisions or policies absent – for example on hospital waiting times, and the detail of the spending review with particular regards to social care, public health and NHS training budgets. The publication of the social care Green Paper has been delayed yet again and overall the plan does not provide a consistent approach across government to the population’s health.

A number of groups indicate that the success lies not in the ambition but in the delivery, and to ensure this happens, the detail above must be filled in, and NHSE/I must now work with local areas to set out a detailed implementation plan to show out exactly what is required, by when, and how these priorities will be matched to availability of money and staff.

Page 90 Agenda Item 9

Governing Body Meeting

Date of meeting 24 January 2018 Title of paper Our Health Our Care Acute Sustainability Update Presented by Mr Denis Gizzi, Chief Officer Author Mr Jason Pawluk, Delivery Director, Transformation Unit Clinical lead Dr Gerry Skailes, Medical Director, LTHTR Confidential No

Purpose of the paper

The purpose of this paper is to provide an update on the progress and priorities of the O Health, Our Care Acute sustainability workstream.

Executive summary On the 13 December 2018 the OHOC Joint Committee approved the Case for Change, at their formal meeting held in public, subject to the decoupling of the issues raised from explicit reference to the urgent and emergency care system. The Governing Body is asked to note the contents of the report as an update further to that meeting.

Recommendations The Governing Body are asked to note the content of this report.

SO4 Ensure patients are at the centre of the planning and management of ☒ their own care, and that their voices are heard SO5 Be a well-run clinical commissioning group and the system leader ☐

Governance and reporting (list committees, groups or other bodies that have discussed this paper)

Our Health Our Care Acute Sustainability Update NHS Greater Preston CCG Governing Body Meeting 24 January 2019 Page 91 Meeting Date Outcome n/a

Were any conflicts of interest identified at previous meetings (mark X in the correct box below) Yes No

If conflicts of interest were identified what were these:

Implications Quality/patient experience Yes ☐ No ☐ N/A ☒ implications? (Potential) conflicts of interest? Yes ☐ No ☐ N/A ☒ Equality Impact Assessment? Yes ☐ No ☐ N/A ☒ Privacy Impact Assessment? Yes ☐ No ☐ N/A ☒ Are there any associated risks? Yes ☐ No ☐ N/A ☒ Are the risks on the CCG’s risk Yes ☐ No ☐ N/A ☒ register? If yes, please include risk description and reference number

Assurance

OHOC Acute Sustainability update Page 92 NHS Greater Preston CCG Governing Body meeting 24th January 2019 Our Health, Our Care: Acute Sustainability update

On the 13th December 2018 the OHOC Joint Committee approved the Case for Change, at their formal meeting held in public, subject to the decoupling of the issues raised from explicit reference to the urgent and emergency care system.

This committee has set a clear expectation that the programme process needs to be followed step-by-step, with the case for change, now needing to be followed by discussions about a future model of care. The model of care should focus on acute services, but also be inclusive of the enabling services provided out of hospital and on preventative measures to reduce patient need; to ensure the effective use of hospital services on a long-term basis.

The programme wasn’t successful in securing Public Dividend Capital in a recent National bid, therefore, there is a clear expectation that the next steps in the programme identify what may be possible to achieve by using the resources that we have at our current disposal differently.

Whilst alternative options for capital will be scoped out through the work of the ICP Shadow Board, we cannot assume at this stage that enabling capital will be available to support the implementation of any option which is developed via the process.

Based on substantial work over December an initial draft Model of Care has been developed, due to be reviewed by the Clinical Oversight Group on the 10th January 2019. These groups will be asked to look at the document specifically from a couple of perspectives namely:

• Is the acute sustainability aspect of the document “correct”; and • What is the correct approach now to developing the enabling work via the WHINs platform and what is possible to expedite this work?

At this stage, the next major milestone of the programme is planned as the presentation of the MOC to the Joint Committee on 14th March 2019 and there will be update sessions on the 17th January 2019 and 27th February 2019.

External assurance of the case for change and the model of care will be provided by the NHS England’s clinical senate. In addition, the programme is also making plans for a Royal College of Emergency Medicine visit before Easter (to pick up an outstanding recommendation from the Stage 1 NHS England clinical senate assurance visit). Colleagues from Lancashire Teaching Hospital will be supporting making sure that the terms of reference are appropriate, particularly with respect to the interdependencies between the emergency care department and adjacencies, including acute medicine pathways. A ‘stage 2’ assurance visit from the NHS England Clinical Senate will then follow.

OHOC Acute Sustainability update Page 93 NHS Greater Preston CCG Governing Body meeting 24th January 2019

This page is intentionally left blank Agenda Item 10

Governing Body Meeting

Date of meeting 24 January 2019 Title of paper Integrated Board Report Presented by Mrs Helen Curtis, Director of Quality and Performance Author Mr Sam James, Head of Performance Clinical lead NA Confidential NA

Purpose of the paper The purpose of this report is to present performance information across key national healthcare standards that the Clinical Commissioning Groups (CCGs) are measured against. It also covers progress against the CCGs Integrated Business Plan and quality metrics that provider organisations are measured against.

Exceptions in performance will be highlighted where the CCGs will be required to provide assurance and progress information as part of the end of year assessments by NHS England when:

1. CCG year-to-date position is below national standards. 2. CCG performance shows a deteriorating position but remains above national standards.

For serious incidents and never events, exceptions will be reported when in-month performance does not meet trajectories.

The report also describes joint action being taken by the CCG and the service providers to tackle any concerns, and drive improvements.

The data periods in this report cover September 2018 and October 2018. However, more recent data has been included where possible.

Executive summary NHS England continues to ask for further assurances against four nationally agreed priority areas. These are finance, achieving cancer waits, mental health and A&E waits standards.

As well as these priority areas there has been an additional focus on the elective programme nationally centred on growth in incomplete pathways for RTT and long waits. Collectively both CCGs have a variance of 7261 pathways from plan in September. This increase in pathways is mainly as a result of the iMSK service being deemed as consultant led by NHSI, a decision being challenged by the CCG.

Integrated Board Report NHS Greater Preston CCG Governing Body meeting 24 January 2019 Page 95 Both Chorley and South Ribble CCG and Greater Preston CCG achieved the 62 day cancer standard for Quarter 1 & Quarter 2 2018 but October position is under standard for both Chorley and South Ribble and Greater Preston CCGs.

A&E performance remains below the STF trajectory and remains under the national standard year-to-date, despite a positive impact of the Winter Plan initiatives which has improved performance in November and December by 3.5% and 7% respectively on an underlying forecast position.

In Mental Health, the proportion of patients completing treatment moving to recovery is being met by both CCGs; however IAPT prevalence is below target for Gtr Preston CCG as is the 2 week psychosis target for Chorley and South Ribble CCG.

There have been no reported never events in October, however there have been three since April 2018. Round table discussions have taken place in December 2018 with NHS England, NHS Improvement and LTHTR and the CCG to discuss incidents and develop an improvement plan.

Recommendations The Governing Body are asked to note the IBR and support improvement actions.

SO4 Ensure patients are at the centre of the planning and management of ☒ their own care, and that their voices are heard SO5 Be a well-run clinical commissioning group and the system leader ☒

Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome

N/A

Were any conflicts of interest identified at previous meetings (mark X in the correct box below) Yes No X

Integrated Board Report Page 96 NHS Greater Preston CCG Governing Body meeting 24 January 2019 If conflicts of interest were identified what were these:

N/A

Implications

Quality/patient experience ☐ ☐ ☒ implications? Yes No N/A (Potential) conflicts of interest? Yes ☐ No ☐ N/A ☒ Equality Impact Assessment? Yes ☐ No ☒ N/A ☐ Privacy Impact Assessment? Yes ☐ No ☒ N/A ☐ Are there any associated risks? Yes ☐ No ☐ N/A ☒ Are the risks on the CCG’s risk ☐ ☐ ☒ register? Yes No N/A If yes, please include risk description and reference number

Assurance Assurance will continue to be delivered to the Governing Body.

Integrated Board Report Page 97 NHS Greater Preston CCG Governing Body meeting 24 January 2019 Chorley and South Ribble CCG Greater Preston CCG Integrated Board Report

December 2018

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 98 Contents Executive Summary ...... 1. Overview...... 1.1 Productivity and Efficiency Savings ...... 1.2 Quality and Performance...... 1.3 Improvement and Assessment Framework...... 1.4 Improvement and Assessment Framework Performance Exceptions ...... 2 Programmes ...... 2.1 Out of Hospital (Community and Primary Care)...... 2.1.1 Out of Hospital Referrals ...... 2.1.2 Out of Hospital Finance and Activity ...... 2.1.3 Out of Hospital Performance Exception ...... 2.1.4 Out of Hospital Integrated Business Plan ...... 2.2 Urgent Care...... 2.2.1 Finance and Activity ...... 2.2.2 Urgent Care Performance Exceptions ...... 2.2.3 Urgent Care Integrated Business Plan ...... 2.3 Elective Care ...... 2.3.1 Elective Care Referrals ...... 2.3.2 Elective Care Finance and Activity ...... 2.3.3 Elective Care Performance Exceptions ...... 2.3.4 Elective Care Integrated Business Plan...... 2.4 Mental Health and Learning Disabilities...... 2.4.1 Mental Health Referrals...... 2.4.2 Mental Health Finance and Activity ...... 2.4.3 Mental Health Performance Exceptions...... 2.4.4 Mental Health Integrated Business Plan ...... 2.5 Medicine Management ...... 2.5.1 Medicine Management Finance and Activity...... 2.6 Provider Quality Performance Exceptions ...... 3. RightCare ...... 4. Leadership ...... 4.1 Workforce ...... 4.2 Complaints ...... 4.3 Freedom of Information (FOI) requests ...... 5. Glossary......

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 99 The purpose of this report is to present performance information across key national healthcare standards that the Clinical Commissioning Groups (CCGs) are measured against. It also covers progress against the CCGs Integrated Business Plan and quality metrics that provider organisations are measured against.

Exceptions in performance will be highlighted where the CCGs will be required to provide assurance and progress information as part of the end of year assessments by NHS England when:

1. CCG year-to-date position is below national standards. 2. CCG performance shows a deteriorating position but remains above national standards.

For serious incidents and never events, exceptions will be reported when in-month performance does not meet trajectories.

The report also describes joint action being taken by the CCG and the service providers to tackle any concerns, and drive improvements.

The data periods in this report cover September 2018 and October 2018. However, more recent data has been included where possible.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 100 Executive Summary

NHS England continues to ask for further assurances against four nationally agreed priority areas. These are finance, achieving cancer waits, mental health and A&E waits standards.

As well as these priority areas there has been an additional focus on the elective programme nationally centred on growth in incomplete pathways for RTT and long waits. Collectively both CCGs have a variance of 7261 pathways from plan in September. This increase in pathways is mainly as a result of the iMSK service being deemed as consultant-led by NHSI, a decision being challenged by the CCG.

Both Chorley and South Ribble CCG and Greater Preston CCG achieved the 62 day cancer standard for Quarter 1 & Quarter 2 2018 but October position is under standard for both Chorley and South Ribble and Greater Preston CCGs.

Contract Notices

There are three main types of formal notice issued to providers in managing their contracts, these are: • Contract Performance Notice (CPN) • Information Breach Notice (IBN) • Activity Query Notice (AQN)

The CCG currently has a number of formal notices with different providers these are outlined below: LTHTR: Page 101 Page Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019

• CPN: 62 day Cancer issued 04/10/2017 – failure to achieve required performance for service users waiting from referral to first definitive treatment. • AQN: Major Trauma issued 27/02/2018 – issues around attribution of commissioner for activity with TARN score >8, possible duplication of payment – this is being worked through in conjunction with Specialised Commissioners. • CPN: Stroke Activity issued 11/06/2018 - non-achievement of stroke performance and five consecutive months of deteriorating performance. • AQN: Ophthalmology issued 20/07/2018 - significant increase in Outpatient Procedure activity relating to Minor / Intermediate retinal procedures and Retinal Tomography, meeting took place 01 August 2018 to discuss in more detail. • CPN: RTT issued 01/08/2018 - concerns that planned trajectories will not be met, delays in receiving RCAs and increasing number of 52 weeks breaches. Recovery Plan received from LTHTR. • CPN: Diagnostics issued 04/12/2018 performance under national standard.

GTD: • IBN: Issued 04/12/2018 Failure to report data into the national SUS (Secondary Uses Services) system.

Ramsay • CPN: Diagnostics issued 16/11/2018 Performance under national standard.

The tables on the following pages summarise the main areas where performance is below national standard year-to-date and highlights mitigating actions and expected recovery dates.

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Strategic Objective: Improving quality through more effective, safer services, which deliver a better patient experience.

Work Expected Issue Action stream Recovery Urgent Percentage of A&E attendances Care admitted, transferred or discharged within 4 hours of arrival at an A&E Department Target 95%

Main issues remain in flow and Flow is being addressed through moving more minor injury activity through to urgent care and March 2019 continued poor performance on discharge work stream following VSA continues to be developed with more patients being identified minor breaches. to follow the home first pathway. Additional actions to improve flow include:

Link to report 1. New pathways from the RAT team to Ambulatory care to prevent admissions and Reporting on the Winter Plan improvements in wait for first assessments. schemes are included in the 2. Additional work for winter including: moving doctor job planning to seven day coverage on detailed exception report. ward rounds, winter ward in place and extended pharmacy cover for the weekends response times. This has improved performance against the underlying forecast.

We are still waiting for published December data to fully measure impact on wider urgent and emergency care outcomes like ambulance handovers and delayed transfers of care. Once available a further assessment of impact can be made.

November data (Published) : 80.84%

Urgent Trolley waits in A&E no longer Care than 12 hours Target: 0

Main issue is insufficient capacity to move patients and accuracy of As above, with a focus on flow, streamlining the discharge processes and developing a minor injury reporting. stream will improve the 12hr breach position.

Link to report November data (Published) : 12

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Urgent Ambulance Handover Delays Care Target: 0

Link to report

Main issues affecting performance Improvement plans have included: are flow through the hospital and processes for rapid handovers. 1. Reducing Corridor Nursing: The Trust is working on new Rapid Assessment and Treatment Unclear protocols for clinical work, with capacity to assess 7 patients –this is now live. coordinator handover. 2. Time to First Assessment and Time to DTA: The Emergency Department (ED) clinicians are working with the acute physicians and specialty clinicians to design the pathways which are being tested currently using a Plan, Do, Study, Act (PDSA) approach. This includes direct streaming from the ambulance crews to ambulatory care and will include direct streaming from triage to ambulatory care over time.

November data (Published): CSR (30-60mins) 7; (60mins+) 2 GP (30-60mins) 75; (60mins+) 16 December data (Published): CSR (30-60mins) 4; (60mins+) 0 GP (30-60mins) 50; (60mins+) 30

Urgent Category 1 - Time critical and Care life threatening events Target: 00:7:00 and 00:15:00

Link to report

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Response time improvement The CCG have now setup bi-monthly meetings to discuss specific performance concerns for Central March 2019 requires operational Lancashire. Following the first meeting NWAS have agreed to set local recovery trajectories that we reconfiguration of vehicle can use to measure improvements against. A number of actions have commenced and profile. Call volume remains high improvements in performance can be expected in January 2019. Actions include:

1. Auto clear, being piloted at RPH so ambulances are turned round more quickly. 2. 5 additional vehicles (3 Preston, 1 Chorley, 1 Leyland). 3. Update of the staffing rotas.

November data (Published) 7 mins: NWAS 00:07:42; CSR 00:08:34; GP 00:07:08 15 mins: CSR 00:15:14

Urgent Category 2 - Potentially serious Care conditions that may require rapid assessment, urgent on- scene clinical intervention/treatment and/or urgent transport Target: 00:18:00 and 00:40:00

Link to report

Please see Category 1. Please see Category 1.

November data (Published) : Target 18 mins: NWAS 00:23:16; CSR 00:24:07; GP 00:21:57 Target 40 mins: NWAS 00:49:50; CSR 00:49:08; GP 00:47:16

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Urgent Category 3 - Urgent problem Care that requires treatment to relieve suffering and transport or assessment and management at scene with referral where needed within a clinically appropriate timeframe Target: 02:00:00

Link to report Please see Category 1. Please see Category 1. November data (Published) : NWAS 02:43:29; CSR 02:25:10; GP 02:10:53

Urgent Category 4/4H/4HCP - Non Care urgent problem that requires assessment and possibly transport within a clinically appropriate timeframe Target: 03:00:00

Link to report Please see Category 1. Please see Category 1. November data (Published) : NWAS 03:09:04; CSR 03:07:13; GP 03:34:44

Urgent Non-Achievement of 4hr Care standard for stroke admission Target: 90%

Link to report

Underperformance was largely due 1. The CCG are continuing to monitor the remedial action plan and progress against March 2019 to capacity issues and the ring improvement trajectory with the acute trust in relation to this indicator. Data analysis has fencing of beds. highlighted that the median time from arrival in ED to assessment by a stroke nurse is around 40 minutes and the median time for admission to the stroke unit from ED is 3 hours and 41

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minutes. 2. Monthly meetings continue with LTHTR and the CCG. 3. The business case developed following the Peer Review will be resubmitted to LTHTR Executives on January 2019. The outcome of this will be shared with the CCG.

November data (Published) : Not available

Elective RTT pathways waiting no more Care than 18 weeks from referral Target: 92%

Link to report

November data (Published) : CSR 88.2% ;GP 89%

Capacity issues regarding Main actions to address poor performance include: March 2019 workforce and beds affecting 1. Deep dive analysis on activity and demand for high volume specialities. performance. 2. Continued use of waiting list initiatives (WLIs) clinics to increase activity. 3. Higher levels of out sourcing activity. 4. Review of the consultant to consultant referral process. 5. RTT Steering Group monitoring of the LTHTR Recovery Plan routinely reported to NHSE.

Elective RTT waits over 52 weeks for December Care incomplete pathways 2018 Target: 0 Revised positon: Link to report March 2019

November data (Published) : CSR 13; GP 12

As above however there are a Please see RTT section above for update. number of patients choosing a date past their breach point.

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Elective No increase of total Acute March 2019 Care pathways from March 2018 figure Target: CSR 11,215; GP 13,470

Link to report

Pathways have increased due to There are a number of actions outlined in the RTT section that will support the reduction in pathways. classification changes for iMSK However this growth in pathways due to the introduction of the iMSK service requires specific where these pathways are now actions: classed as consultant-led so are 1. The decision to classify MSK referrals as consultant-led is being challenged by the CCG with subject to RTT rules. This places NHSE both CCGs significantly above 2. Work with LCFT to support their conversations with NHSI on the classification of this activity target, and even further above planned levels (which vary over the year) – the CCGs combined variance from plan is now 7261 November data (Published) :Not available pathways.

Elective Percentage of Service Users Care waiting 6 weeks or more from referral for a diagnostic test Target: 1.00%

Link to report

November data (Published) : CSR 2.11%; GP 3.12%

The main specialty affecting The CCG has formally raised concerns on diagnostics performance at the LTHTR contract board. January overall diagnostic performance is Contract Performance Notice has now been issued. LTHTR has sourced additional capacity in 2019 Endoscopy endoscopy from a third party provider to bring LTHTR back in line with the standard.

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Elective Referral to Treatment RTT (Non Care Admitted - Allied Health Professionals) Target: 95.00%

Link to report November data (Published) : Not available

Main issues affecting performance 1. All teams have a situation report (SITREP) weekly call with professional leads. February are capacity due to both vacancies 2. The reduced capacity with sickness and vacancies is in part being mitigated by staff working 2019 and sickness/absence. overtime in the short term. 3. Existing staff are being upskilled, where appropriate, using the Occupational Therapy (OT) competency framework, to maximise capacity. 4. The service is reviewing triage to ensure consistency in acceptance of referrals. 5. Recruitment across both services is underway and ongoing.

Percentage of Service Users waiting no more than one month (31 days) from diagnosis to first definitive treatment for all cancers Target: 96%

Link to report November data (Published) : CSR 97.27%; GP 97.17% The performance at GP CCG 1. Performance has been met for both CCGs year-to-date. represents 5 breaches out of 108 2. LTHTR has published their Cancer Performance Action Plan to target 75% of patients being patients on the pathway, There is a seen within one week of referral. mix of reasons for these breaches; 3. LTHTR have identified those tumour groups not meeting the target and have identified actions 1. Elective Capacity to improved performance. Inadequate 4. Further monies from the Cancer Alliance are being used in EMIS to make the referral process 2. Patient delayed for Medical more efficient and in procuring extra endoscopy lists through the independent sector. reasons Page 110 Page Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019

Percentage of Service Users waiting no more than two months (62 days) from urgent GP referral to first definitive treatment for cancer Target: 85%

Link to report November data (Published) : CSR 80.39%; GP 87.93%

The performance at CSR CCG Please see the 31 day exceptions above. relates to 13 breaches out of 53 patients on the pathway. The performance at GP CCG represents 8 breaches out of 47 patients on the pathway.

Percentage of Service Users waiting no more than 62 days from referral from an NHS screening service Target: 90%

Link to report November data (Published) : CSR 100%; GP 84.62%

The performance for CSR CCG Please see the 31 day exception above. represents one breach on the pathway for the Colorectal tumour group, which was due to an inconclusive diagnostic result.

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Elective Non-Achievement of Cancelled- Care ops not rebooked within 28 days Target: 0

Link to report

November data (Published) :15 These occurred across a range of specialties. Two patients do not 1. The CCG 18wk RTT action plan continues to be monitored on fortnightly basis and as a result yet have a date for their surgery. the performance for cancelled electives is expected to improve. The main reason for 2. The CCG have requested an update in relation to the patients who are awaiting their date for underperformance in this area is surgery. due to capacity. 3. The CCG routinely request assurances that the affected patients are not waiting for cancer surgery and that no harms occur as a result of the cancellations. 4. The CCG have requested additional assurances around the actions being taken to reduce the number of cancellations that occur for non-medical reasons.

Elective Increase in Sleeping Care Accommodation Breach Target: 0

Link to report

Sleeping accommodation 1. A thematic review has been completed and presented at LTHTR Safety & Quality committee. breaches continue to be reported 2. The existing Mixed Sex Accommodation Breach policy has been reviewed by NHSE. As a due to more stringent timescales result of the policy review a number of additional measures will be implemented. being applied to the critical care Measures include staff identifying early the discharge requirements of the patient, with the environment. expectation of this being commenced the day before discharge. 3. The patient flow team track the flow requirements of the critical care unit three times a day. 4. A deep dive review is underway and will be shared with the CCG once complete. 5. No complaints have been received as a result of this position. 6. Steps are taken to protect the patient’s privacy and dignity when a breach occurs.

November data (Published) : CSR 38; GP 49 Page 112 Page Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019

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Mental First episode of psychosis Health treated with a NICE approved care package with two weeks of referral Target: 53%

Link to report November data (Published): CSR 100%; GP 33.30%

Reason for breaches is delays in Actions to improve referrals pathways include: November referrals from other mental health 2018 services 1. A SITREP process is in place to ensure that all service user pathways are tracked to monitor timely appointments. 2. Regular dialogue is in place between EIS and AMH teams to review why any service user’s referral was delayed and to consider how to improve the process.

Mental The percentage prevalence of Health people who have depression and/or anxiety disorder who receive psychological therapies (NEW KPI 2018/19)

Target: 1.54% November data (Published): CSR 1.92%; GP 1.97% (November Target 1.56%) Link to report The underperformance is caused 1. Review all job plans to ensure the capacity is available across all teams to meet the demand November by a reduced number of referrals for welcome calls coming into the service on a weekly basis due to recent clinical model 2018 received by the service to achieve change. the prevalence There are also 2. Increased communication and engagement with primary care to increase referrals and some capacity issues within teams engagement with the service.

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Quality Serious Incidents Target: 0

Link to report

Eight serious incidents were 1. The CCG serious incident review panel continue to review all submitted STEIS reports in order reported in October. to ensure that the action plans submitted in the reports reflect the learning that has been One apparent /actual suspected identified from the incident. self -inflicted harm, two diagnostic 2. LTHTR continue to send lead clinicians to discuss their reports at the CCG serious incident delays, two slips trips and falls, one panel. sub-optimal care of the 3. A review of five slips, trips and falls, which resulted in a fractured neck, will be undertaken. The deteriorating patient and one case CCG Chief Nurse will agree the terms of reference for the review in partnership with LTHTR. pending review. No new never events have been November data (Published): 5 reported this month.

Quality Medication Errors (with harm) Target: 2

Link to report 26 medication errors with harm 1. Two improvement actions are currently underway by the medicines safety champions were reported in October (25 were focussing on improving the checking of controlled drugs and reducing delays to essential low harm, 1 caused moderate medications for patients with Parkinson Disease. harm). The moderate harm incident 2. The CCG continue to receive monthly medicine safety reports to ensure that further detail was in relation to an and assurances are received. This includes trends and themes of incidents reported. adverse/allergic reaction. A rapid review is planned. November data (Published): 17

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Quality Incidence of MRSA bacteraemia- BLOODSTREAM INFECTION

Target: 0

Patient with multiple co-morbidities, 1. The care home to revisit their pre-assessment protocols. metastatic cancer and urological 2. The care home to improve the management of a long-term catheter and specifically to complications with recurrent urinary review the obtaining of urine samples. tract infections. 3. LTHTR to further investigate why some blood results were not sent back to the GP for this patient. Diagnosed MRSA post mortem. 4. LTHTR Urology to note that patients in nursing home beds are not under the care of the The conclusion of the multi- district nursing service when communicating follow up instructions. disciplinary team investigation was 5. GP practice to ensure timely response to GP task requests as part of Internal learning that It is not possible to know when following the investigation. or how the patient acquired MRSA 6. LTHTR to improve the scanning of paper records onto evolve. 7. LTHTR Infection control nurse to review ANTT compliance internally. Link to report November data (Published): 1

Quality Pressure Ulcers Grade 3 Target: To be determined

Link to summary

In October 2018, LCFT reported 14 1. All pressure ulcers have been reviewed and scrutinised by the LCFT Safety Senate to grade 3 pressure ulcers. determine whether they were avoidable or unavoidable, and identify any learning to be shared. 2. LCFT have undertaken a thematic review of a cluster of PU’s which have occurred between As a health economy, there is a 25/01/18 and 30/08/18. LCFT presented the thematic review to the CCG SI Group on 07/11/18. targeted focus to reduce the prevalence of pressure ulcers by Fours themes were identified based on the findings, Self-management / education, increasing awareness of pressure Assessment, Clinical record keeping and Staff training. However, the incident remains open as ulcers, to reduce harm by enabling further assurances have been requested. preventative interventions to be implemented at an earlier stage. November data (Published): 7

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Quality Serious Incidents Reported (Community contract only) Target: 0

Link to report In October 2018, LCFT reported 1 1. Following a STEIS reportable incident, LCFT will undertake a Rapid Review (within 72 hours) serious incident. and submit this to the CCG. This has been received and notes immediate actions taken inclusive of duty of candour. The incident related to a 2. A full RCA will be submitted to the CCG within 60 days. The investigative reports will then be confidential information governance breach. duly reviewed by the CCG SI Review group to determine if the incidents have been thoroughly investigated and any lessons learnt cascaded across the health economy. 3. The CCG attends LCFT SI meetings where all SI cases are subject to a high level of scrutiny.

November data (Published): 5

Quality Inpatient FFT (% who would recommend)

Target: 96%

Link to report FFT failed to reach target due to 1. There was a caveat to this month submission as the denominator of patients attending was the denominator of patients higher than usual for this month. attending was higher than usual for 2. During quality visits the CCG have witnessed every effort is made to ask in patients to complete this month. the FFT prior to leaving. 3. Ramsay will continue to send email questionnaires to all patients seen.

November data (Published): Not available

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Quality Ramsay Health Care – Complaints

Target: 0

Link to report 1 complaint at Euxton Hall 1. Delays in clinics can be unavoidable due to unforeseen circumstances, however, the provider involving an out-patient attendance now routinely inform waiting patients in clinic when they are running late. where clinics were running late (1 hour) and a patient felt rushed by 2. Consultant was informed of the complaint and has reflected on his consultation style. the consultant. November data (Published): Not available

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1. Overview 1.1 Productivity and Efficiency Savings

To support the investment plan, the CCG required a productivity and efficiency savings target of £18.5m as reported to the Governing Body in March 2018. Against this target there was £13.7m of identified schemes leaving a gap of £4.8m.

As at the 30 November 2018, the year to date performance shows the plan is underperforming by £2.3m.

YTD Risk Net QIPP QIPP overview Plan YTD Plan Actual (Shortfall) Adjusted (Shortfall) as at 30th November 2018 / Benefit FOT / Benefit

£000 £000 £000 £000 £000 £000

Out of Hospital 316 32 (217) (249) 1,510 1,194 Elective Care 3,810 2,413 1,748 (665) 3,402 (408) Urgent Care 2,156 1,407 1,386 (21) 2,051 (105)

Mental Health and Learning Disabilities 527 351 351 0 527 0 Medicines Management 5,289 4,076 4,215 140 5,807 518 Other Programme 1,597 539 2,230 1,691 2,523 926

Sub total - assigned QIPP schemes 13,695 8,818 9,713 896 15,820 2,125 Unidentified QIPP 4,834 3,152 0 (3,152) 0 (4,835)

Total QIPP 18,529 11,970 9,713 (2,257) 15,820 (2,710)

Across both CCGs there is a risk adjusted forecast outturn of £15.8m leaving a potential gap of £2.7m.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 119 1.2 Quality and Performance 2017/18 2018/19 Reporting Q3 Metric Q3 Q4 Q1 Q2 YTD Level Trend Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct ELECTIVE CARE Referral to Treatment (RTT) and Diagnostics

Target 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00%

E.B.3 Referral to Treatment RTT (Incomplete) CSR CCG Actual 90.2% 90.2% 89.3% 88.5% 87.3% 87.5% 87.7% 87.3% 86.7% 86.2% 85.6% 88.2% 87.1% Percentage of Service Users on incomplete RTT pathw ays (yet to start treatment) w aiting no more than 18 w eeks from ref erral GP CCG Actual 89.4% 88.8% 87.7% 87.3% 86.8% 87.2% 87.7% 87.1% 83.9% 85.8% 85.6% 88.6% 86.7%

Status P P P P P P P P P P P P

Target 0 0 0 0 0 0 0 0 0 0 0 0 0 E.B.S.4 Zero tolerance RTT w aits over 52 w eeks for incomplete pathw ays CSR CCG Actual 0 0 0 1 2 3 5 4 14 11 12 13 62 The number of patients w aiting at period end for incomplete GP CCG Actual 0 0 1 0 1 7 3 8 12 12 22 21 85 pathw ays >52 w eeks Status P P P P P P P P P P P P

Target 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00%

E.B.4 Percentage of Service Users w aiting 6 w eeks or CSR CCG Actual 0.48% 0.66% 0.48% 0.45% 0.48% 0.37% 0.51% 0.94% 1.36% 1.23% 2.07% 2.13% 1.26% more from referral for a diagnostic test GP CCG Actual 0.50% 0.81% 0.81% 0.49% 0.81% 0.40% 0.77% 1.32% 0.72% 1.44% 2.23% 2.23% 1.33%

Status P P P P P P P P P P P P

Target 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% Referral to Treatment RTT (Incomplete - Allied Health Professionals) CSR CCG Actual 99.7% 100.0% 99.6% 99.0% 97.6% 97.5% 97.0% 95.6% 95.6% 95.1% 95.1% 94.7% 95.8% Percentage of service users on Incomplete pathw ays w aiting no GP CCG Actual 99.3% 99.7% 99.2% 98.7% 97.7% 98.7% 98.4% 97.3% 97.9% 99.1% 99.4% 98.9% 98.5% more than 18 w eeks from ref erral (AHP @ LCFT) Status P P P P P P P P P P P P

Target 0 0 0 0 0 0 0 0 0 0 0 0 0 Zero tolerance RTT w aits over 52 w eeks for incomplete pathw ays (Allied Health Professionals) CSR CCG Actual 0 0 0 0 0 0 0 0 0 0 0 0 0 The number of patients w aiting at period end for incomplete GP CCG Actual 0 0 0 0 0 0 0 0 0 0 0 0 0 pathw ays >52 w eeks Status P P P P P P P P P P P P

Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% Referral to Treatment RTT (Non Admitted - Allied Health Professionals) CSR CCG Actual 97.7% 100.0% 99.7% 98.7% 98.2% 95.3% 96.6% 93.9% 92.0% 93.5% 94.6% 94.2% 94.3% Percentage of service users on Non Admitted pathw ays w aiting GP CCG Actual 99.8% 99.3% 99.6% 98.1% 97.9% 97.9% 98.1% 95.1% 93.3% 95.2% 97.5% 98.0% 96.5% no more than 18 w eeks from ref erral (AHP @ LCFT) Status P P P P P P P P P P P P Page 120 Page Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019

2017/18 2018/19 Reporting Q3 Metric Q3 Q4 Q1 Q2 YTD Level Trend Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct ELECTIVE CARE Referral to Treatment (RTT) and Diagnostics

Target 0 0 0 0 0 0 0 0 0 0 0 0 0 Zero tolerance RTT w aits over 52 w eeks for Non Admitted pathw ays (Allied Health Professionals) CSR CCG Actual 0 0 0 0 0 0 0 0 0 0 0 0 0 The number of patients w aiting at period end for Non Admitted GP CCG Actual 0 0 0 0 0 0 0 0 0 0 0 0 0 pathw ays >52 w eeks Status P P P P P P P P P P P P

Target 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00%

CSR CCG Actual 91% 91% 113% 128% 129% 124% E-referral coverage - percentage of total referrals

(NEW KPI 2018/19) GP CCG Actual 98% 96% 120% 139% 133% 133% not Status P P P P P P avail 17/12

Target 11,21 11,21 11,21 11,21 11,21 11,21 11,21 11,21

CSR CCG Actual 11,553 12,390 12,642 12,752 13,383 12,418 14,401 No increase of total CCG pathw ays from March 2018

figure Target 13,470 13,470 13,470 13,470 13,470 13,470 13,470 13,470 (NEW KPI 2018/19) GP CCG Actual 13,129 13,669 13,777 11,937 14,248 13,464 16,680

Status P P P P P P P Cancer Waiting Times

Target 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% E.B.6 Percentage of Service Users referred urgently w ith CSR CCG Actual 98.30% 98.77% 97.49% 98.78% 97.92% 95.56% 97.02% 96.30% 98.02% 96.76% 95.17% 96.75% 96.56% suspected cancer by a GP w aiting no more than tw o GP CCG Actual 99.07% 97.62% 97.46% 98.12% 97.81% 94.70% 97.39% 95.75% 95.99% 96.51% 95.15% 95.98% 95.95% w eeks for first outpatient appointment

Status P P P P P P P P P P P P

Target 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% E.B.7 Percentage of Service Users referred urgently w ith breast sym ptoms (w here cancer w as not initially CSR CCG Actual 98.15% 100.00% 92.31% 100.00% 92.68% 91.94% 96.43% 93.18% 97.73% 96.88% 93.10% 93.75% 94.56% suspected) w aiting no more than tw o w eeks for first GP CCG Actual 97.26% 100.00% 98.48% 95.65% 97.73% 90.63% 97.01% 92.59% 90.91% 97.22% 94.44% 96.77% 94.12% outpatient appointment Status P P P P P P P P P P P P

Target 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% E.B.8 Percentage of Service Users w aiting no more than CSR CCG Actual 97.09% 92.65% 97.03% 97.65% 96.81% 95.83% 99.00% 98.37% 97.92% 97.54% 89.29% 97.32% 96.73% one month (31 days) from diagnosis to first definitive treatm ent for all cancers GP CCG Actual 99.00% 96.84% 97.92% 100.00% 92.71% 94.44% 95.83% 100.00% 96.67% 98.86% 96.63% 95.37% 96.74%

Status P P P P P P P P P P P P

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2017/18 2018/19 Reporting Q3 Metric Q3 Q4 Q1 Q2 YTD Level Trend Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct ELECTIVE CARE Cancer Waiting Times

Target 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% E.B.9 Percentage of Service Users w aiting no more than CSR CCG Actual 100.00% 100.00% 86.96% 95.65% 90.91% 85.71% 95.00% 95.00% 100.00% 90.48% 83.33% 95.83% 92.36% 31 days for subsequent treatment w here that treatment is surgery GP CCG Actual 95.83% 94.12% 96.30% 93.33% 100.00% 88.89% 100.00% 92.00% 100.00% 100.00% 93.33% 96.30% 95.16%

Status P P P P P P P P P P P P

Target 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% E.B.10 Percentage of Service Users w aiting no more than CSR CCG Actual 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 97.30% 100.00% 100.00% 100.00% 100.00% 99.71% 31 days for subsequent treatment w here that treatment is an anti-cancer drug regimen GP CCG Actual 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Status P P P P P P P P P P P P

Target 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% E.B.11 Percentage of Service Users w aiting no more than CSR CCG Actual 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 96.15% 100.00% 96.55% 100.00% 97.44% 98.53% 31 days for subsequent treatment w here the treatment is a GP CCG Actual 100.00% 100.00% 100.00% 96.15% 100.00% 100.00% 95.45% 100.00% 96.43% 100.00% 96.30% 100.00% 98.19% course of radiotherapy

Status P P P P P P P P P P P P

Target 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% E.B.12 Percentage of Service Users w aiting no more than CSR CCG Actual 86.05% 80.00% 84.75% 88.10% 84.62% 87.50% 95.74% 83.93% 90.38% 87.32% 77.55% 79.37% 85.75% tw o months (62 days) from urgent GP referral to first GP CCG Actual 81.82% 88.24% 84.62% 90.24% 93.48% 90.70% 86.21% 87.50% 91.89% 91.30% 88.10% 82.98% 88.18% definitive treatment for cancer Status P P P P P P P P P P P P

Target 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%

CSR CCG Actual 100.00% 80.00% 60.00% 100.00% 100.00% 75.00% 100.00% 100.00% 100.00% 88.89% 100.00% 83.33% 94.92% E.B.13 Percentage of Service Users w aiting no more than 62 days from referral from an NHS screening service GP CCG Actual 87.50% 66.67% 50.00% 100.00% 100.00% 100.00% 0.00% 100.00% - 100.00% 91.67% 91.67% 89.29%

Status P P P P P P P P P P P P

Target ------

Percentage of patients receiving treatment for cancer w CSR CCG Actual 83.33% 95.24% 100.00% 95.00% 86.36% 96.43% 87.50% 92.86% 100.00% 92.00% 90.91% 90.00% 92.61% ithin 62 days upgrade their priority GP CCG Actual 92.86% 92.59% 94.44% 89.47% 92.00% 94.12% 83.33% 90.00% 96.97% 95.65% 100.00% 96.67% 94.51%

Status P P P P P P P P P P P P

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2017/18 2018/19 Reporting Q3 Metric Q3 Q4 Q1 Q2 YTD Level Trend Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct ELECTIVE CARE

Cancelled Operations

LANCASHIRE Target 0 0 0 0 0 0 0 0 0 0 0 0 0 TEACHING E.B.S.6 No urgent operation should be cancelled for a HOSPITALS NHS Actual 0 0 0 0 0 0 0 0 0 0 0 0 0 second time FOUNDATION Status P P P P P P P P P P P P TRUST E.B.S.2 All Service Users w ho have operations cancelled, Target on or after the day of admission (including the day of LANCASHIRE TEACHING Actual 12% 6% 45% 15% 29% surgery), for non-clinical reasons to be offered another HOSPITALS NHS binding date w ithin 28 days, or the Service User's FOUNDATION P P P P treatment to be funded at the time and hospital of the TRUST Status Services User's choice (QUARTERLY) E.B.S.2 All Service Users w ho have operations cancelled, Target 0 0 0 0 0 0 0 0 0 0 0 0 0 on or after the day of admission (including the day of LANCASHIRE TEACHING 4 25 21 7 16 11 31 6 17 21 10 16 112 surgery), for non-clinical reasons to be offered another Actual HOSPITALS NHS

binding date w ithin 28 days, or the Service User's FOUNDATION treatment to be funded at the time and hospital of the TRUST Status P P P P P P P P P P P P Services User's choice (MONTHLY)

EMSA

Target 0 0 0 0 0 0 0 0 0 0 0 0 0

CSR CCG Actual 3 4 1 4 1 5 4 9 18 12 14 7 69 E.B.S.1 Sleeping Accommodation Breach 11 6 6 6 1 2 4 10 15 15 18 20 84 GP CCG Actual

Status P P P P P P P P P P P U URGENT CARE

Accident and Emergency LANCASHIRE Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% E.B.5 Percentage of A&E attendances w here the Service TEACHING User w as admitted, transferred or discharged w ithin 4 HOSPITALS NHS Actual 84.69% 81.20% 79.97% 78.36% 73.31% 80.06% 83.25% 85.51% 86.43% 86.14% 84.77% 83.13% 84.22% FOUNDATION hours of their arrival at an A&E department TRUST Status P P P P P P P P P P P P LANCASHIRE Target 0 0 0 0 0 0 0 0 0 0 0 0 0 E.B.S.5 Trolley w aits in A&E not longer than 12 hours TEACHING Total number of patients w ho have w aited over 12 hours in A&E HOSPITALS NHS Actual 0 1 10 7 7 24 3 0 5 7 8 5 52 FOUNDATION from decision to admit to admission TRUST Status P P P P P P P P P P P P

Page 123 Page Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019

2017/18 2018/19 Reporting Q3 Metric Q3 Q4 Q1 Q2 YTD Level Trend Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct URGENT CARE Integrated Urgent Care Centre

Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% E.B.5 Percentage of A&E attendances w here the Service Actual 99.5% 98.1% 97.2% 96.9% 95.8% 97.1% 96.9% 96.8% 98.6% 98.6% 97.9% 97.8% 97.6% User w as admitted, transferred or discharged w ithin 4 Go To Doc hours of their arrival at an A&E department Status P P P P P P P P P P P P

LQR1 Percentage of UCC attendances w here the Service Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% User w as admitted, transferred or discharged w ithin 2 Go To Doc Actual 84.8% 75.3% 78.7% 72.4% 62.5% 76.5% 74.6% 73.2% 83.5% 87.6% 69.9% 71.5% 76.6% hours of their arrival at an UCC department (except

w here that delay is attributable to diagnostics). Status P P P P P P P P P P P P

Ambulance

Target 00:07:00 00:07:00 00:07:00 00:07:00 00:07:00 00:07:00 00:07:00 00:07:00 NORTH W EST AMBULANCE SERVICE NHS Actual N/A N/A N/A N/A N/A 00:07:51 00:08:10 00:08:18 00:08:01 00:07:53 00:07:56 00:08:01 00:08:02 TRUST Category 1 -Time critical and life threatening events Status P P P P P P P We aim to respond to these calls w ithin an average time Target of 7 minutes. 00:07:00 00:07:00 00:07:00 00:07:00 00:07:00 00:07:00 00:07:00 00:07:00 (NEW KPI 2018/19) CSR CCG Actual N/A N/A N/A N/A N/A 00:08:07 00:08:51 00:07:53 00:08:28 00:09:24 00:09:27 00:09:41 00:08:49

GP CCG Actual N/A N/A N/A N/A N/A 00:08:01 00:07:27 00:08:29 00:08:31 00:08:01 00:08:04 00:07:21 00:08:01

Status P P P P P P P

Target 00:15:00 00:15:00 00:15:00 00:15:00 00:15:00 00:15:00 00:15:00 00:15:00 NORTH W EST AMBULANCE

SERVICE NHS Actual N/A N/A N/A N/A N/A 00:13:24 00:13:51 00:14:11 00:13:28 00:13:19 00:13:17 00:13:19 00:13:33 TRUST Category 1 - Time critical and life threatening events Status P P P P P P P We aim to respond to these calls at least 9 out of 10 Target 00:15:00 00:15:00 00:15:00 00:15:00 00:15:00 00:15:00 00:15:00 00:15:00 tim es w ithin 15 m inutes.

(NEW KPI 2018/19) 00:14:21 00:15:33 00:13:25 00:15:03 00:16:14 00:15:32 00:15:17 00:15:11 CSR CCG Actual N/A N/A N/A N/A N/A

GP CCG Actual N/A N/A N/A N/A N/A 00:13:51 00:12:42 00:13:48 00:14:33 00:14:32 00:13:55 00:12:01 00:13:40

Status P P P P P P P

NORTH W EST Target 00:18:00 00:18:00 00:18:00 00:18:00 00:18:00 00:18:00 00:18:00 00:18:00 AMBULANCE Category 2 - Potentially serious conditions that may SERVICE NHS Actual N/A N/A N/A N/A N/A 00:23:38 00:24:47 00:23:30 00:25:43 00:21:47 00:22:46 00:24:40 00:23:51 TRUST require rapid assessment, urgent on-scene clinical Status P P P P P P P intervention/treatment and/or urgent transport Target 00:18:00 00:18:00 00:18:00 00:18:00 00:18:00 00:18:00 00:18:00 00:18:00 We aim to respond to these calls w ithin an average time

of 18 minutes. CSR CCG Actual 00:27:20 00:28:46 00:25:00 00:27:12 00:23:06 00:25:34 00:24:58 00:25:59 N/A N/A N/A N/A N/A (NEW KPI 2018/19) GP CCG Actual N/A N/A N/A N/A N/A 00:25:52 00:25:03 00:21:15 00:24:17 00:20:29 00:20:53 00:21:33 00:22:47

Status P P P P P P P

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2017/18 2018/19 Reporting Q3 Metric Q3 Q4 Q1 Q2 YTD Level Trend Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct URGENT CARE

NORTH W EST Target 00:40:00 00:40:00 00:40:00 00:40:00 00:40:00 00:40:00 00:40:00 00:40:00 AMBULANCE Category 2 - Potentially serious conditions that may SERVICE NHS Actual N/A N/A N/A N/A N/A 00:51:59 00:54:48 00:51:43 00:57:01 00:46:25 00:48:33 00:52:44 00:51:58 TRUST require rapid assessment, urgent on-scene clinical Status P P P P P P P intervention/treatment and/or urgent transport Target 00:40:00 00:40:00 00:40:00 00:40:00 00:40:00 00:40:00 00:40:00 00:40:00 We aim to respond to these calls w ithin an average time

of 40 minutes. CSR CCG Actual 00:56:34 01:00:39 00:52:34 00:55:52 00:47:29 00:52:38 00:51:37 00:53:37 N/A N/A N/A N/A N/A (NEW KPI 2018/19) GP CCG Actual N/A N/A N/A N/A N/A 00:58:14 00:53:50 00:45:08 00:53:12 00:45:02 00:44:30 00:44:35 00:49:38

Status P P P P P P P

NORTH W EST Target 02:00:00 02:00:00 02:00:00 02:00:00 02:00:00 02:00:00 02:00:00 02:00:00 Category 3 - Urgent problem (not immediate life- AMBULANCE Actual 02:21:51 02:39:10 02:27:43 02:52:59 02:21:37 02:40:23 03:06:34 02:38:58 threatening) that requires treatment to relieve suffering SERVICE NHS N/A N/A N/A N/A N/A TRUST (e.g. pain control) and transport or assessment and Status P P P P P P P management at scene w ith referral w here needed w ithin a Target 02:00:00 02:00:00 02:00:00 02:00:00 02:00:00 02:00:00 02:00:00 02:00:00 clinically appropriate timefram e.

We aim to respond to these calls w ithin 120 minutes (2 CSR CCG Actual N/A N/A N/A N/A N/A 02:40:06 02:41:56 02:27:04 02:32:00 02:17:57 02:21:41 02:36:55 02:32:24 hours) in 9 out of 10 cases. GP CCG Actual N/A N/A N/A N/A N/A 02:38:27 02:43:50 02:12:49 02:33:07 01:50:26 02:15:24 02:27:25 02:23:50 (NEW KPI 2018/19)

Status P P P P P P P

NORTH W EST Target 03:00:00 03:00:00 03:00:00 03:00:00 03:00:00 03:00:00 03:00:00 03:00:00 Category 4/4H/4HCP - Non urgent problem (not life- AMBULANCE SERVICE NHS Actual N/A N/A N/A N/A N/A 02:56:50 03:06:41 03:03:21 03:15:05 02:58:40 03:13:13 03:19:51 03:07:48 threatening) that requires assessment (by face to face or TRUST telephone) and possibly transport w ithin a clinically Status P P P P P P P

appropriate timeframe Target 03:00:00 03:00:00 03:00:00 03:00:00 03:00:00 03:00:00 03:00:00 03:00:00 We aim to respond to these calls w ithin 180 minutes (3 hours) in 9 out of 10 cases. CSR CCG Actual N/A N/A N/A N/A N/A 03:00:14 03:18:31 03:08:29 03:02:37 02:48:04 03:24:52 03:01:48 03:00:21 (NEW KPI 2018/19) GP CCG Actual N/A N/A N/A N/A N/A 03:12:50 03:32:26 03:29:56 03:51:03 03:15:11 03:46:22 03:42:51 03:31:27

Status P P P P P P P

Target 0 0 0 0 0 0 0 0 0 0 0 0 0

ROYAL PRESTON Actual 308 301 257 173 217 259 174 192 153 85 107 48 1018 HOSPITAL

E.B.S.7a Number of NWAS Notification to Handover Status P P P P P P P P P P P P

Breaches (30-60 mins) (**Excluding valid exceptions) Target 0 0 0 0 0 0 0 0 0 0 0 0 0 CHORLEY AND SOUTH RIBBLE Actual 14 38 37 16 46 11 11 12 7 7 14 9 71 HOSPITAL Status P P P P P P P P P P P P

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2017/18 2018/19 Reporting Q3 Metric Q3 Q4 Q1 Q2 YTD Level Trend Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct URGENT CARE

Target 0 0 0 0 0 0 0 0 0 0 0 0 0 ROYAL PRESTON Actual 98 228 117 70 141 149 48 73 75 33 42 25 445 HOSPITAL

E.B.S.7b Number of NWAS Notification to Severe Handover Status P P P P P P P P P P P P

Breaches (60+ mins) (** Excluding valid exceptions) Target 0 0 0 0 0 0 0 0 0 0 0 0 0 CHORLEY AND SOUTH RIBBLE Actual 1 8 3 1 10 0 0 5 0 3 3 1 12 HOSPITAL Status P P P P P P P P P P P P MENTAL HEALTH AND LEARNING DISABILITIES

Proportion of patients on (CPA) discharged from Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% inpatient care w ho are follow ed up w ithin 7 days CSR CCG Actual 95.24% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 94.44% 88.46% 96.30% 100.00% 100.00% 96.35% The proportion of those patients on Care Programme Approach discharged from inpatient care w ho are follow ed up w ithin 7 GP CCG Actual 96.88% 96.55% 100.00% 95.83% 93.10% 96.00% 100.00% 100.00% 93.75% 100.00% 100.00% 95.65% 97.95%

days Status P P P P P P P P P P P P

Target 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00%

E.A.S.2: The proportion of people w ho complete CSR CCG Actual 64.8% 51.7% 50.0% 57.1% 56.9% 55.4% 59.4% 58.9% 54.6% 56.6% 50.0% 53.0% 55.5% treatment w ho are moving tow ard recovery. GP CCG Actual 58.7% 56.3% 52.3% 53.4% 54.8% 50.8% 67.1% 52.4% 47.6% 58.7% 52.7% 60.6% 55.7%

Status P P P P P P P P P P P P

Target 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% E.H.1_B1: The proportion of people that w aited six w eeks or less from referral to entering a course of IAPT CSR CCG Actual 93.64% 93.55% 86.78% 84.85% 88.46% 83.18% 88.07% 87.86% 90.99% 88.89% 86.36% 88.06% 87.68% treatment against the number of those w ho started a GP CCG Actual 94.44% 94.87% 95.56% 94.53% 95.93% 96.27% 95.91% 96.62% 96.63% 95.42% 95.89% 96.86% 96.25% course of treatment w ithin the reporting period Status P P P P P P P P P P P P

Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% E.H.2_B2: The proportion of people that w aited eighteen w eeks or less from referral to entering a course of IAPT CSR CCG Actual 100.00% 100.00% 99.17% 99.24% 96.15% 100.00% 100.00% 99.29% 100.00% 99.15% 99.09% 100.00% 99.64% treatment against the number of those w ho started a GP CCG Actual 99.07% 99.07% 99.26% 100.00% 98.37% 99.25% 99.42% 99.32% 99.44% 99.24% 100.00% 99.37% 99.44% course of treatment w ithin the reporting period Status P P P P P P P P P P P P

Target 50.00% 50.00% 50.00% 50.00% 50.00% 53.00% 53.00% 53.00% 53.00% 53.00% 53.00% 53.00% 53.00% E.H.4 Percentage of People experiencing a first episode of CSR CCG Actual 50.00% 20.00% 33.30% 50.00% 66.70% 0.00% N/A 100.00% 62.50% 33.30% 50.00% 50.00% N/A psychosis treated w ith a NICE approved care package w 60.00% 66.70% 50.00% 42.90% 60.00% 100.00% 75.00% N/A ith tw o w eeks of referral GP CCG Actual 0.00% 25.00% 20.00% 20.00% 33.30%

Status P P P P P P P P P P P P

Target 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% CSR CCG Actual 70.0% 69.8% 69.0% 69.7% 69.7% 69.8% 70.4% 70.5% 70.6% 70.8% 70.3% 70.7% 70.4% E.A.S.1: Dementia Diagnosis Rate GP CCG Actual 66.9% 66.0% 65.5% 66.3% 67.9% 68.0% 68.1% 72.9% 68.7% 68.7% 68.4% 67.8% 68.9%

Status P P P P P P P P P P P P

Page 126 Page Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019

2017/18 2018/19

Metric Reporting Q3 Q4 Q1 Q2 Q3 Level YTD Trend Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct

MENTAL HEALTH AND LEARNING DISABILITIES

Target 1.40% 1.43% 1.46% 1.48% 1.50% 1.52% 1.54% 10.33% The percentage prevalence of people who have depression CSR CCG Actual 1.58% 1.45% 1.25% 1.83% 1.65% 1.57% 1.57% 10.90% and/or anxiety disorder who receive psychological therapies (NEW KPI 2018/19) GP CCG Actual 1.31% 1.23% 1.23% 1.27% 1.41% 1.23% 1.28% 8.96%

Status P P P P P P P

Target 12.1% 19.1% 25.6% 19.1%

Access to CAMHS service for 32% of local estimated prevelance CSR CCG Actual 23.3% 28.2% 28.2% rate (Quarterly) (NEW KPI 2018/19) GP CCG Actual 18.9% 24.6% 24.6%

Status P P

HCAI

Target 0 0 0 0 0 0 0 0 0 0 0 0 0

E.A.S.4 Zero tolerance MRSA CSR CCG Actual 0 0 0 0 0 0 0 0 0 0 0 1 1 Incidence of MRSA bacteraemia GP CCG Actual 0 1 1 1 1 0 0 0 0 0 0 0 0

Status P P P P P P P P P P P P

Target 39 44 49 54 59 5 10 15 20 25 30 34 59

CSR CCG Actual 5 2 4 6 3 6 10 1 3 5 7 6

Cumm 30 32 36 42 45 6 16 17 20 25 32 38 38 E.A.S.5 Minimise rates of Clostridium Difficile Target 33 37 41 45 49 4 8 12 16 20 24 29 49 Incidence of Clostridium Difficile

GP CCG Actual 9 3 2 2 4 4 4 0 2 4 3 2

Cumm 49 52 54 56 60 4 8 8 10 14 17 19 19

Status P P P P P P P P P P P P OTHER

Target 57 82 141 200

CSR CCG Actual 15 0

Personal Health Budgets: Number of personal health budgets Cumm 15 15 15 that have been in place, at any point during the quarter (cumulative target) Target 66 101 170 240

(NEW KPI 2018/19) GP CCG Actual 16 0

Cumm 16 16 16

Status P P

** Status - P = Published / U = Unpublished

Page 127 Page Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019

2017/18 2018/19 Reporting Q3 Metric Q3 Q4 Q1 Q2 YTD Level Trend Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct OTHER

Target 92.0% 92.0%

Children w aiting no more than 18 w eeks for a w heelchair CSR CCG Actual 94.1% 100.00% (Quarterly) (NEW KPI 2018/19) GP CCG Actual 100.0% 92.30%

Status P P

Target

Extended Access (evenings and w eekends) at GP CSR CCG Actual 94.00% 96.00% 96.00% 96.00% 96.00% 96.00%

services GP CCG Actual 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% (NEW KPI 2018/19) not Status P P P P P P avail 17/12

Page 128 Page Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019

2017-18 2018-19 Reporting Metric Q3 Q4 Q1 Q2 Q3 Level YTD Trend Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Lancashire Teaching Hospitals (LTHTR)

Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% Stroke Care - Admission to designated

stroke ward within 4 hours of presentation LTHTR Actual 67.92% 48.33% 45.45% 38.89% 35.59% 59.62% 66.04% 61.11% 62.16% 65.96% 60.53% 62.50% N/A

Target 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% Stroke Care - 90% of stay within designated

stroke ward LTHTR Actual 79.17% 85.42% 86.15% 72.41% 76.46% 88.64% 85.48% 88.37% 91.49% 90.91% 86.84% 84.30% N/A

Target 100 100 100 100 100 100 100 100 100 100 100 100 HSMR (in month) LTHTR Actual 77 90 80 80 80 90 99 98 88 71 79 77 N/A

Target 31 31 31 31 31 31 31 31 31 31 31 31

Falls (with harm) LTHTR Actual 26 31 25 22 24 32 28 30 19 21 19 20 169

5.5 5.5 5.5 5.5 5.5 5.5 5.5 5.5 5.5 5.5 5.5 5.5 Minimise rates of Clostridium Difficile

LTHTR 5 4 2 7 3 4 4 3 6 4 3 4

Clostridium Difficile - Lapses in care LTHTR 3 3 3 3 0 1 1 14

Target 12 12 12 12 12 12 12 12 12 12 12 12 Hospital Acquired Pressure Ulcers Grade 3 Sept Oct data and 4 (Deemed Avoidable) LTHTR Actual 0 0 2 0 2 1 0 0 1 0 data not not yet 2 yet available Target 0 0 0 0 0 0 0 0 0 0 0 0

MRSA LTHTR Actual 0 0 0 0 0 0 0 0 0 0 0 0 1 Target 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% Harm Free Care 99.20% 98.60% 98.00% 98.70% 98.80% 98.70% 98.00% 98.30% 98.90% 98.90% 97.20% 97.50% N/A LTHTR Actual Target 2 2 2 2 2 2 2 2 2 2 2 2

Medication Errors (with harm) LTHTR Actual 21 27 19 20 22 24 25 19 27 21 18 26 160 Target 0 0 0 0 0 0 0 0 0 0 0 0 0

Never Events LTHTR Actual 0 0 0 0 0 1 0 1 1 0 0 0 3 Target 0 0 0 0 0 0 0 0 0 0 0 0 0

Serious Incidents Reported 8 10 2 3 3 6 4 3 6 12 8 8 47 LTHTR Actual Target 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% A&E FFT (% who would recommend) LTHTR Actual 83.36% 82.71% 87.63% 84.71% 76.16% 83.38% 85.31% 84.56% 85.09% 87.45% 88.74% 86.67% N/A

Page 129 Page *Data Source: LTHTR Quality and Performance Dashboard Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019

2017-18 2018-19 Reporting Metric Q3 Q4 Q1 Q2 Q3 Level YTD Trend Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Lancashire Teaching Hospitals (LTHTR)

Target 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% Inpatient FFT (% who would recommend) LTHTR Actual 91.31% 91.97% 93.29% 92.14% 91.50% 91.83% 93.29% 92.38% 93.37% 93.46% 91.85% 92.57% N/A Target 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% Maternity FFT (% who would recommend) LTHTR Actual 93.88% 96.03% 96.33% 95.45% 97.32% 96.38% 94.41% 95.99% 94.55% 94.59% 97.93% 97.96% N/A Target 64.00% 64.00% 64.00% 64.00% 64.00% Staff FFT (work) (% who would recommend) LTHTR Actual 60% (NHS survey) 67.00% 65.00% Data not available N/A

Target 79.00% 79.00% 79.00% 79.00% 79.00% Staff FFT (care) (% who would recommend) LTHTR Actual 66% (NHS survey) 80.00% 81.00% Data not available

Target 0 0 0 0 0 0 0 0 0 0 0 0

Duty of Candour LTHTR Actual 0 0 0 0 0 0 0 0 0 0 0 0 0 Target n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a

Complaints LTHTR Actual 128 148 146 188 334

Target 0.60% 0.60% 0.60% 0.60% 0.60% 0.44% 0.44% 0.44% 0.44% 0.44% 0.44% 0.44% Still Birth Rate 0.50% 0.50% 0.30% 0.30% 0.30% 0.30% 0.80% 0.00% 0.20% 0.60% 0.00% 0.50% N/A LTHTR Actual Target 80.0% 80.0% 80.0% 80.0% 80.0% 90.0% 90.0% 90.0% 90.0% 80.0% 80.0% 80.0% Mandatory Training 86.00% 86.00% 86.00% 87.00% 86.00% 87.00% 88.00% 89.00% 88.00% 88.00% 89.00% 90.30% N/A LTHTR Actual

Page 130 Page Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019

2017-18 2018-19 Reporting Metric Q3 Q4 Q1 Q2 Q3 YTD Level Trend Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Lancashire Care NHS Foundation Trust (LCFT)

Falls (with harm) (Community Contract Only) Target No Target The NHS Saf ety Thermometer Is a point estimate survey

instrument. It is a measure of the proportion of people in a

population w ho have one or more of the four harms at a particular time and date (on a single day, once a month). It is LCFT Actual 0.66% 0.84% 1.40% 0.54% 0.51% 0.33% 0.57% 0.77% N/A a snap shot of the harm in time, a 'temperature check' on the system.

Target 0 0 0 0 0 0 0 0 0 0 0 0 C. Diff LCFT Actual 0 0 0 0 0 0 0 0 0 1 0 0 1

Target nal target 50% reduction from 2016/17 = <49 for Pressure Ulcers Grade 3 (Cumulative YTD) LCFT Actual 70 78 95 102 110 7 13 10 10 12 9 14 N/A

Target Aspirational target 0 Pressure Ulcers Grade 4 (Cumulative YTD) LCFT Actual 13 15 23 23 26 0 1 1 6 3 2 0 N/A

Target 0 0 0 0 0 0 0 0 0 0 0 0 MRSA LCFT Actual 0 0 0 0 0 0 0 0 0 0 0 0 0

Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95^% 95.0% 95.0% 95.0% 95.0% 95.0% Harm Free Care LCFT Actual 97.00% 95.00% 94.00% 97.00% 96.00% 96.00% 95.35% 96.24% 95.90% 96.00% 95.61% 95.06% N/A Target 0 0 0 0 0 0 0 0 0 0 0 0 Never Events LCFT Actual 0 0 0 0 0 0 0 0 0 0 0 0 0 Serious Incidents Reported (Community contract Target 0 0 0 0 0 0 0 0 0 0 0 0 only) LCFT Actual 1 2 2 6 0 2 1 1 2 4 6 1 17 Community FFT (% who would recommend) Target >90% >90% >90% >90% >90% >90% >90% >90% >90% >90% >90% >90% LCFT Actual 96.00% 96.00% 94.40% 96.12% 95.55% 94.76% 96.00% 96.00% 96.00% 96.00% 97.00% 95.00% N/A Target 58.00% >50% >50% >50% 58.00% Staff FFT (work) (% who would recommend) LCFT Actual 52.74% 48.74% 43.84% 45.95%

Target >67% >67% >67% >67% >67% Staff FFT (care) (% who would recommend) LCFT Actual 71.46% 68.43% 65.75% 66.00% Target 0 0 0 0 0 0 0 0 0 0 0 0 Duty of Candour LCFT Actual 0 0 0 0 0 0 0 0 0 0 0 0 0 Target No Target Complaints LCFT Actual 136 102 131 137 102 101 92 94 113 96 108 117 721

Target 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% Mandatory Training (Core staff) LCFT Actual 92.12% 92.07% 92.00% 92.16% 92.36% 91.15% 86.16% 85.86% 86.11% 86.42% 86.78% 86.99% N/A

Page 131 Page Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019

2017-18 2018-19 Reporting Q3 Q4 Q1 Q2 Q3 Metric Level YTD Trend Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct

Ramsay Health Care UK

Target 0 0 0 0 0 0

Falls (with harm) Ramsay Actual 0 0 0 0 0 0 1 0 0 0 0 0 1

Target 0 0 0 0 0 0 C. Diff Ramsay Actual 0 0 0 0 0 0 0 0 0 0 0 0 0

Target 0 0 0 0 0 0

Hospital Acquired Pressure Ulcers Grade 3 Ramsay Actual 0 0 0 0 0 0 0 0 0 0 0 0 0

Target 0 0 0 0 0 0

Hospital Acquired Pressure Ulcers Grade 4 Ramsay Actual 0 0 0 0 0 0 0 0 0 0 0 0 0

Target 0 0 0 0 0 0

MRSA Ramsay Actual 0 0 0 0 0 0 0 0 0 0 0 0 0

Target 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Harm Free Care Ramsay Actual 100.0% 100.0% 100.0% 100.0% 100.0% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 7

Target 0 0 0 0 0 0 0 0

Never Events Ramsay Actual 1 0 1 0 0 0 0 0 0 0 0 0 0

Target 100 0 0 0 0 0 0

Serious Incidents Reported Ramsay Actual 2 0 1 0 1 0 0 0 0 0 0 0 0

Target 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% Inpatient FFT (% who would recommend) Ramsay Actual 100% 100% 100% 100% 100% 68.00% 83.30% 91.00% 96.50% 85.00% 83.50% 69.00% N/A

Target not available not available not available not available not available not available not available not available not available not available not available not available N/A Staff FFT (work) (% who would recommend) Ramsay Actual not available not available not available not available not available not available not available not available not available not available not available not available N/A

Target not available not available not available not available not available not available not available not available not available not available not available not available N/A Staff FFT (care) (% who would recommend) Ramsay Actual not available not available not available not available not available not available not available not available not available not available not available not available N/A

Target 0 0 0 0 0 0 0 0 0 0 0 N/A Duty of Candour Ramsay Actual 0 0 0 0 0 0 0 0 0 0 0 0 0

Target 0 0 0 0 0 0 0 0 0 0 0 0

Complaints Ramsay Actual 6 2 4 3 0 6 5 4 5 6 3 1 30

Target 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% Mandatory Training Ramsay Actual 83.45% 87.65% 87.00% 75.70% 87.15% 87.25% 92.20% 90.80% 86.75% 92.45% N/A

Page 132 Page Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019

1.3 Improvement and Assessment Framework

Page 133 Page Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019

NHS Chorley and South Ribble CCG 2017/18 Year End Rating: Good

Better Health Period CCG Peers England Trend Better Care Period CCG Peers England Trend 2014-15 to 102a % 10-11 classified overweigh 32.4%  6/11 75/195  2016-17 R 121a High quality care - acute 18-19 Q1 54 9/11 178/195

103a Diabetes patients who achiev 2016-17 43.1%  3/11 24/195 R 121b High quality care - primary c 18-19 Q1 67  2/11 53/195 2016-17 (2015 103b Attendance of structured edu 12.2%  1/11 45/195  cohort) R 121c High quality care - adult soci 18-19 Q1 63 1/11 43/195 104a Injuries from falls in people 17-18 Q3 1,542  1/11 34/195 122a Cancers diagnosed at early s 2016 53.3%  6/11 83/195 R 105b Personal health budgets 18-19 Q1 8.18  7/11 149/195 R 122b Cancer 62 days of referral to 18-19 Q1 88.7%  5/11 22/195

106a Inequality Chronic - ACS & UC17-18 Q3 2,463  8/11 135/195 122c One-year survival from all ca 2015 72.6%  6/11 67/195 R 107a AMR: appropriate prescribin 2018 07 1.016  3/11 90/195 R 122d Cancer patient experience 2017 8.8  5/11 76/195 R 107b AMR: Broad spectrum prescri 2018 07 8.7%  9/11 103/195 R 123a IAPT recovery rate 18-19 Q1 57.1%  5/11 32/195 R 108a Quality of life of carers 2018 0.58  8/11 113/195 R 123b IAPT Access 18-19 Q1 4.1%  7/11 110/195 R 123c EIP 2 week referral 2018 09 42.5%  11/11 188/195 Sustainability Period CCG Peers England Trend 123d CYP mental health (not available) R 141b In-year financial performanc 18-19 Q1 Amber  123f MH - OAP (not available) R 144a Utilisation of the NHS e-referr 2018 07 128.4%  1/11 3/195 123e MH - Crisis care and liaison (not availab R 145a Expenditure in areas with ide 18-19 Q1 Red  123g MH - health checks (not available) 123h MH - cardio metabolic assessments (not

Leadership Period CCG Peers England Trend R 123i MH - investment standard Compliant  R 162a Probity and corporate govern 18-19 Q1 Fully compliant  123j MH - DQMI (not available) 163a Staff engagement index 2017 3.74  10/11 128/195 R 124a LD - reliance on specialist IP 18-19 Q1 76  8/11 178/195 163b Progress against WRES 2017 0.11  6/11 83/195 124b LD - annual health check 2016-17 51.9%  5/11 74/195 164a Working relationship effectiv 2017-18 62.61  8/11 137/195 124c Completeness of the GP learn 2016-17 0.57%  3/11 39/195 166a CCG compliance with standar 2017 Amber  R 125d Maternal smoking at delivery 18-19 Q1 10.2%  4/11 88/195 R 165a Quality of CCG leadership 18-19 Q1 Green  125a Neonatal mortality and stillb 2016 2.0  1/11 5/195 125b Experience of maternity servi 2017 78.5  10/11 183/195 Key 125c Choices in maternity services 2017 64.8  3/11 37/195 Worst quartile in England R 126a Dementia diagnosis rate 2018 08 70.8%  2/11 67/195

Best quartile in England 126b Dementia post diagnostic sup2016-17 82.6%  1/11 12/195 Interquartile range 127b Emergency admissions for UC 17-18 Q3 2,278  6/11 95/195 R 127c A&E admission, transfer, dis 2018 10 83.2%  9/11 163/195 R 127e Delayed transfers of care per 2018 09 11.3  5/11 115/195 127f Hospital bed use following e 17-18 Q3 561.5  7/11 160/195

105c % of deaths with 3+ emergenc 2017 4.69%  1/11 44/195 R 128b Patient experience of GP serv 2018 87.2%  1/11 39/195

R 128c Primary care access 2018 08 96.0%  128d Primary care workforce 2018 03 0.83  11/11 174/195 R R 128e Primary care transformation 18-19 Q1 Green  1/11 1/195

R 129a 18 week RTT 2018 09 85.6%  9/11 124/195

130a 7 DS - achievement of standa 2016-17 2 

R 131a % NHS CHC assesments takin 18-19 Q1 20.4%  10/11 150/195

132a Sepsis awareness 2017 Green  R 133a 6 week diagnostics 2018 09 2.1%  6/11 131/195

Page 134 Page Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019

NHS Greater Preston CCG 2017/18 Year End Rating: Good

Better Health Period CCG Peers England Trend Better Care Period CCG Peers England Trend 2014-15 to 102a % 10-11 classified overweigh 31.4%  2/11 58/195  2016-17 R 121a High quality care - acute 18-19 Q1 54 9/11 178/195

103a Diabetes patients who achiev 2016-17 42.0%  2/11 47/195 R 121b High quality care - primary c 18-19 Q1 67  2/11 53/195 2016-17 (2015 103b Attendance of structured edu 14.3%  1/11 37/195  cohort) R 121c High quality care - adult soci 18-19 Q1 59 9/11 165/195

104a Injuries from falls in people 17-18 Q3 1,478  2/11 23/195 122a Cancers diagnosed at early s 2016 55.6%  3/11 38/195 R 105b Personal health budgets 18-19 Q1 7.64  7/11 153/195 R 122b Cancer 62 days of referral to 18-19 Q1 87.9%  2/11 33/195

106a Inequality Chronic - ACS & UC17-18 Q3 2,012  5/11 87/195 122c One-year survival from all ca 2015 72.1%  2/11 86/195 R 107a AMR: appropriate prescribin 2018 07 1.127  8/11 150/195 R 122d Cancer patient experience 2017 8.7  9/11 132/195 R 107b AMR: Broad spectrum prescri 2018 07 8.8%  6/11 106/195 R 123a IAPT recovery rate 18-19 Q1 53.4%  7/11 75/195 R 108a Quality of life of carers 2018 0.60  2/11 78/195 R 123b IAPT Access 18-19 Q1 4.7%  6/11 42/195 R 123c EIP 2 week referral 2018 09 39.2%  11/11 190/195

Sustainability Period CCG Peers England Trend 123d CYP mental health (not available) R 141b In-year financial performanc 18-19 Q1 Amber  123f MH - OAP (not available) R 144a Utilisation of the NHS e-referr 2018 07 138.5%  1/11 2/195 123e MH - Crisis care and liaison (not availab R 145a Expenditure in areas with ide 18-19 Q1 Red  123g MH - health checks (not available) 123h MH - cardio metabolic assessments (not

Leadership Period CCG Peers England Trend R 123i MH - investment standard Compliant  R 162a Probity and corporate govern 18-19 Q1 Fully compliant  123j MH - DQMI (not available) 163a Staff engagement index 2017 3.73  8/11 134/195 R 124a LD - reliance on specialist IP 18-19 Q1 76  10/11 178/195 163b Progress against WRES 2017 0.11  4/11 79/195 124b LD - annual health check 2016-17 38.2%  8/11 165/195 164a Working relationship effectiv 2017-18 67.45  6/11 102/195 124c Completeness of the GP learn 2016-17 0.41%  9/11 136/195 166a CCG compliance with standar 2017 Green  R 125d Maternal smoking at delivery 18-19 Q1 15.1%  9/11 153/195 R 165a Quality of CCG leadership 18-19 Q1 Green  125a Neonatal mortality and stillb 2016 5.2  6/11 132/195 125b Experience of maternity servi 2017 85.5  2/11 48/195 Key 125c Choices in maternity services 2017 63.3  3/11 53/195

Worst quartile in England R 126a Dementia diagnosis rate 2018 08 68.7%  4/11 91/195

Best quartile in England 126b Dementia post diagnostic sup2016-17 80.5%  2/11 46/195

Interquartile range 127b Emergency admissions for UC 17-18 Q3 2,370  4/11 104/195 R 127c A&E admission, transfer, dis 2018 10 83.1%  10/11 165/195 R 127e Delayed transfers of care per 2018 09 11.1  8/11 112/195

127f Hospital bed use following e 17-18 Q3 573.0  10/11 165/195 105c % of deaths with 3+ emergenc 2017 4.93%  3/11 57/195

R 128b Patient experience of GP serv 2018 82.8%  7/11 121/195 R 128c Primary care access 2018 08 100.0%  R 128d Primary care workforce 2018 03 0.91  4/11 129/195 R 128e Primary care transformation 18-19 Q1 Green  1/11 1/195 R 129a 18 week RTT 2018 09 85.6%  8/11 126/195 130a 7 DS - achievement of standa 2016-17 2  R 131a % NHS CHC assesments takin 18-19 Q1 15.0%  9/11 135/195

132a Sepsis awareness 2017 Green  R 133a 6 week diagnostics 2018 09 2.2%  9/11 138/195 Page 135 Page Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019

1.4 Improvement and Assessment Framework Performance Exceptions

Improvement Assessment Framework (Better Health) IAF 105b – Personal Health Budgets (Number of Personal Health Budgets in place per 100,000 CCG population) Target: 240 GPR/ 200 CSR Current Performance (Q2 CSR CCG 15 GP CCG 16 PHBs by year end 18/19) Current Issues: A table top review of the use and potential of personal health budgets across Greater Preston, Chorley and South Ribble was completed in March 2018, the finding of which was accepted by the management executive team and work commenced in April 2018. It was clear from the review that it would not be possible to meet our NHSE trajectories through the use of personal health budgets within Continuing Health Care alone, and it would be necessary to explore other options. Personal wheelchair budgets were identified as an opportunity that would offer increased choice and control to citizens whilst enabling trajectories to be met, as the lead commissioner for Lancashire Teaching Hospitals, who are the main provider of wheelchairs in Lancashire and South Cumbria, we brought together CCG leads from across the ICS and providers to a workshop and co-produced a set of principles and high level plan that Greater Preston, Chorley and South Ribble CCG’s led on mobilisation of in partnership with Lancashire Teaching Hospitals and Southport and Ormskirk Hospital Trust (the provider in Chorley, South Ribble and West Lancashire). The CCG has been mentored in this approach by Hull CCG, who has had oversight of our action plans throughout. We have worked with people who have used the wheelchair service to develop the care and support plan and the processes and pathways have been trialed in both Trusts, the learning from which has been brought back to the implementation group and used to inform further improvements. The service went live on 01/10/2018 and this will be the standard offer for everyone referred into the service, using one of the three nationally agreed pathways: • Notional budget • Notional budget including third party top up • Third party

Numbers of personal wheelchair budgets for October are 64 for Chorley & South Ribble CCG and 55 Greater Preston, which will enable us to meet the trajectory for this year Improvement Plans: There is a requirement for PHBs to be the default option for people in receipt of CHC living in their own home from April 2019. We are working with the CHC regarding how this will be achieved in Central Lancashire. Improvement Assessment Framework (Better Health) 107a AMR: Appropriate Prescribing Target: Current Performance CSR CCG GP CCG 1.127 (07/18) 1.016 Current Issues: The NHSE antibiotic volume target has been reduced from 1.161 per STAR PU (Specific Therapeutic group Age-sex Related Prescribing Units) to 0.965 per STAR PU. Prescribing volume across both CCGs continues to reduce but does not meet the required targeted by NHSE. https://www.england.nhs.uk/ccg-out-tool/anti-dash/https://www.england.nhs.uk/ccg-out- tool/anti-dash/ Improvement Plans: An annual antibiotic prescribing audit was completed in all practices in Sept/Oct. Individual feedback to practices ongoing. All practices written to with new targets and current position against targets. Antibiotic formulary reviewed and made available on net formulary. Antibiotic target is included in the quality contract.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 136 Better Care Improvement Assessment Framework (Better Care) 121a High Quality Care Acute Target: Current Performance (18- CSR CCG 54 GP CCG 54 19 Q1) Current Issues: Lancashire Teaching Hospitals have received an overall rating of ‘requires improvement’ in their latest CQC inspection.

The main reasons for this are:

1. Insufficient improvements since last inspection in Urgent Care and Emergency and Medical Care - evidence of change but not embedded. 2. Despite improvements in appraisals, mandatory, life support and safeguarding training, still below target. 3. Lack of MCA and DOLS knowledge in front line staff. 4. Despite improvements in staffing, some areas did not have enough staff. 5. Some escalation areas unsuitable, such as MH facilities in ED. 6. Triage in ED not always timely. 7. Concern re Children’s pathway in ED at CDH - risks not fully mitigated. 8. Gaps in safe management of medicines. 9. Gaps in documentation. 10. Access and flow standards not met. 11. Medical services did not have a clear strategy and not all staff aware of wider Trust vision and strategy. 12. Lack of Trust-wide strategic plan or document, although recognised progress with long term strategy aligned to system. 13. Challenge with financial pressures.

Improvement Plans: LTHTR have taken the following actions:

1. Enhanced leadership capacity and capability. 2. Embedded good governance; corporately and locally, ensuring standardisation of governance to the level of higher performing Divisions. 3. Introduced Executive CQC ‘check and challenge sessions’ for Urgent and Emergency Care and Medicine Division. 4. Continued with staffing investment and recruitment. 5. Have improved their approach to patient safety by ensuring multi-disciplinary collaborations. 6. Improved management and mitigation of risk with associated KPI’s. 7. Developed a continuous improvement approach and function. 8. Developed a ‘Big Plan’ approach to connect strategy with front line. 9. Undertaken a cultural review with key actions as a result of this.

The CCG continue to monitor and work with LTHTR in the following ways:

1. Monthly contractual meetings, ensuring remedial action plans are in place where performance is below the expected target. 2. Key participants in the Central Lancashire Quality Improvement Board, which was implemented to ensure progress is made against the CQC inspection ‘should and must do’s’.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 137 3. Continuous programme of CCG Quality Visits in order to understand any challenges that staff and patients are facing, but also to highlight any improvements that have been made. Recommendations from these reports are shared with the Trust.

The CCG instigated a round table event in relation to Never Events that have occurred in 2018-19. This was in partnership with LTHTR, NHS England, NHS Improvement and the CQC. Actions from this meeting included ensuring that a systems learning approach is taken in relation the learning from nasogastric tube incidents. This is being taken forward by NHS England. 121c High Quality Care Adult Social Care Target: Current Performance (18- CSR CCG 63 GP CCG 59 19 Q1) Current Issues: This indicator is based on an overall score indicative of the quality of care in a CCG area as determined by CQC inspection ratings, and then rated against an England average. This overall score is based on the ratings given at each site inspected in a CCG area against the five key questions i.e. “Is it safe?”, “Is it effective?”, and “Is it well-led?”, “is it caring?”, and “is it responsive?” The ratings for each question are scored as follows: outstanding = 3, good = 2, requires improvement = 1, inadequate = 0. This is then added up into a total score for each CCG, and compared against the total maximum score available for each CCG to give a rating score out of 100.

1. Themes across the regulated care sector identify areas of concern around medicines management, record keeping, and inconsistencies with leadership style across the care home sector and the need to focus on an appreciative leadership style. This is coupled with challenges due to retention of registered managers and the impact of inconsistency in practice amongst staff teams. Areas for development also include the need to strengthen risk assessment and management across the sector. The CCG safeguarding team continue to provide safeguarding leadership to those homes identified on RADAR and the QPIP process. 2. Four nursing homes are being managed by the QIPP process; three of the homes are on a monitored staggered admission process. Action plans are in place and support is provided by health and social professionals to enable the homes to make the required improvements.

3. Nine homes remain on Radar and all have action plans in place and support visits planned. One home has been removed from the RADAR

4. Two domiciliary providers placed on Radar, with an agreement that no further placements are placed with 1 provider. The CCG is not able to implement a suspension or contract warning notice due to lack of contractual arrangements in place with domiciliary care providers.

Improvement Plans: One home remains suspended to new admissions with a notice of decision to restrict admissions via CQC. The provider is proactively engaging with the support offered via the safeguarding partnership and is making progress with the improvement plan. The CQC have recently inspected and the report is due to be published following factual accuracies. Quality monitoring and support visits provided by the CCG continue both announced and unannounced.

Service Delivery: 1. The safeguarding champion model continues to be a successful initiative with good

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 138 engagement from care home providers. The last workshop focused on consolidation of skills and knowledge, the requirements of the Adult Intercollegiate document which sets out learning requirements for safeguarding training requirements and an awareness session of the Persons in a Position of Trust (PIPOT) policy. 2. The domiciliary safeguarding champion continues to be well attended and the last workshop focused on staff understanding the requirements of the Mental Capacity Act (MCA) and implications for practice. 3. A self-neglect framework will be launched via the Lancashire Safeguarding Adults Board (LSAB) in March 2019 to support a multiagency response for services working with individuals who self-neglect where there is a risk of harm to individuals or others. 4. The LSAB MCA sub group will be working on a task group to support agencies to understand the requirements of the MCA Amendment Bill 2019 along with the introduction of the Liberty Protection Safeguards which will be replacing the Deprivation of Liberty Safeguards (DoLS).

Improvement Assessment Framework (Better Care) IAF 123f – Mental Health Out of Area Placement Target: N/A Current Performance GP CCG CSR CCG 02/2018 258.3 136.7 Current Issues: This indicator measures the number / rate of bed days for inappropriate Out of Area Placements (OAPs) per 100,000 GP registered population aged 18+ in mental health services for adults in non-specialist acute inpatient care. Greater Preston is in the worst quartile in England at position 181 / 207 CCGs and Chorley South Ribble is in the interquartile range at position 147 / 207 CCGs.

Local data shows OAP Occupied bed days (OBDs) at Provider level have increased again in Month 7, and are above the NHSI trajectory. This has been driven by a significant increase in demand for acute care from June to August, particularly in relation to A&E demand, which continues to increase. A lack of non-acute beds has resulted in non-acute patients being treated in acute beds. The Trust state there would be enough acute treatment beds if the other resources were in place. There are also shortfalls in capacity for substance misuse beds.

Improvement Plans: An improvement plan has been initiated, supported by £5m for schemes to increase local capacity, reduce demand and implement prevention work, e.g. crisis services have now increased to 24/7. The plan includes specific actions for the Emergency Care Intensive Support Team to 1. Review assessment ward functioning. 2. Hold MADE events. 3. Implement board rounds.

IAF 124a – Reliance on specialist inpatient care for Learning Disability/Autism (The number of inpatients for each CCG in the Transforming Care Partnership per million GP registered adult population in the Partnership). Target: N/A Current Performance (Q1 CSR CCG 76 GP CCG 76 18-19) Current Issues: The overarching aim for the CCGs is to support a discharge back to the community for all those individuals who are in hospital and prevent further admissions. The re-settlement programme monitored by NHS England should result in discharges taking place in line with each individuals own plan, with specific effort to discharge the pre 2014 cohort by 2019.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 139 As at 28 December 2018 there were 12 patients in the Greater Preston CCG who met the Winterbourne criteria and 6 patients within the Chorley and South Ribble CCG. Although the number of patients in hospital has increased, the table below summarises the number of admissions and discharges from 1 April 2016. The 2 admissions highlighted in brackets are patients who have stepped down from Secure services into CCG services. The 1 discharge highlighted in brackets is an individual who has been stepped up to Secure service.

28 December 1 April 2016 CCG Admissions Discharges 2018 Position Position Chorley & South Ribble 6 10 (1) 11 6 Greater Preston 6 18 (1) 12 (1) 12 Improvement Plans: 1. New community specification approved, and implementation to be worked through with localities on receipt of each provider gap analysis. 2. Learning Disability and Autism Support risk register reviewed monthly. 3. Workforce developments – group continues to review the current actions. 4. Regular service user engagement using pathways via targeted meetings. 5. Consultation on in-patient provision underway by NHS England. 6. Operational Delivery Network developed inpatient bed model. 7. Learning process from Care and Treatment Reviews and the review of admissions meetings continue. 8. Specialist Support Team fully mobilised and engaging with community teams for full collaborative approach. 9. Greater focus in 2018/19 on children and transition, parity of esteem, increasing annual health checks and screening uptake, quality assurance, prevention of admissions by the Specialist Support Team and the crisis elements.

Improvement Assessment Framework (Better Care) IAF 124b – Learning Disability receiving an annual health check (The proportion of people on the GP Learning Disability Register that have received an annual health check during the year). Target: N/A Current Performance CSR CCG GP CCG (2016-17) 51.9% 38.2% Current Issues: Not all patients with a Learning Disability (LD) on a GP Practice LD register have an Annual Health Check. Performance is based on behavior within general practice in identifying and recording these patients – Greater Preston CCG was in the worst quartile nationally for this indicator last year. Performance at previous reporting period was CSR CCG 46.6%; GP CCG 30.3%, so a significant improvement has been seen. Improvement Plans: The following two elements were included within the GP Quality Contract with effect from 2019/19:

1. Learning Disabilities – the practice will establish and maintain a Learning Disabilities ‘health check register’ of patients aged 14 and over with Learning Disabilities. This should be based on the practices Quality Outcome Framework (QOF) Learning Disabilities register and any patients identified who are known to social services that are not already on the QOF LD register.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 140 2. The practice will invite all patients on the register for an annual health check and produce a health action plan.

These indicators are included within the annual Practice Variation review, looking at the number of patients on the register and those who have an annual health check. Work with the Public Health engagement lead at the Local Authority is underway to extend awareness of annual health checks. Improvement Assessment Framework (Better Care) IAF 125b – Women’s experience of maternity services Target: N/A Current Performance GP CCG CSR CCG 78.5 (2017) 85.5 Current Issues: This indicator uses the CQC National Maternity Survey results to specifically look at the user experience of maternity services across the care pathway; and with regards to choice, information, confidence in staff and clinical care. Chorley and South Ribble are in the worst quartile nationally.

In the 2017 survey LTHTR scored significantly better than the last survey on the following three questions: 1. Labour & Birth – not always able to get help by a member of staff within a reasonable time. 2. Labour & Birth – did not have confidence and trust in staff. 3. Feeding – did not receive support and encouragement regarding feeding. They were only significantly worse on one question: - Postnatal care – saw a midwife too often / too seldom.

Please note Maternity services demonstrated an improved position overall when compared to the previous year’s survey and to other Trusts participating in the survey. The next survey is due to be published in January 2019. Notably, the monthly Friends and Family Test data remains largely positive. Improvement Plans: 1. The Maternity Voices Partnership (MVP) is thriving. Chaired by service users, the partnership has representation from the CCG and the Acute Trust. Service user representation continues to grow. Real-time service user experiences on specific topics are discussed at each meeting and are fed back directly to maternity service staff. Service users are also invited to walk round the maternity wards and give feedback based on their observations. Service users also have the opportunity to comment and input into the development of public facing service information leaflets and posters.

2. The CCG and the Acute Trust together with the MVP chairs are working across the Local Maternity System as part of the delivery of Better Births to improve Choice and Personalisation across the ICS.

3. Work will be undertaken to engage with minority groups to contribute to the MVP.

4. Investment has resulted in an increased staffing establishment, which has been recruited to.

5. A new bereavement suite is being developed. Consideration is being given to what the bereavement suite and bereavement team could be called, as there is recognition that this service may support families prior to suffering a loss e.g. babies born with a life limiting condition, therefore, the word bereavement may not be appropriate.

The improvement plans detailed below continue:

Maternity and Neonatal Health Safety Collaborative. This is an NHSI initiative in Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 141 which LTHTR are participating in the first wave. The maternity service has chosen antenatal care as a focus for their improvement projects. Better Births Better Training – In collaboration with Blackpool Teaching Hospital and East Lancashire Hospital Trust, funding was obtained to improve training in maternity services. As a result of this, a programme has been developed that includes human factors training and the standardisation of emergency obstetric drill. This training has been implemented during 2018. Enhanced elective caesarean section pathway. Two midwives have led on an enhanced pathway for women in order to improve experience for women undergoing this procedure. An information brochure and video have also been introduced. Continuity of carer is also given for this cohort of women. Hearing Impaired project. A community midwife has worked in partnership with the Deaf Society to design information video pods (available on the website) related to pregnancy, birth and parenting.

At LTHTR a group of midwives has come together to focus on home births and increase the home birth rates locally. Up to now, this work has included: 1. A Home Birth Peer Group being set up. 2. A Facebook group, which is used for mums to contribute their ideas. 3. Production of a home birth video, which will be edited and put to together as a series of podcasts. 4. Developing home birth boxes.

Designing ‘ask me about home birth’ badges for all midwives to wear (this is currently awaiting approval from infection control). Improvement Assessment Framework (Better Care) IAF 125d – Maternal Smoking at Delivery Target: N/A Current Performance (18- GP CCG CSR CCG 19 Q1) 15.10% 10.25% Current Issues: The CCG would like to see a further improvement in smoking rates at delivery. Notably, the overall position at the local acute Trust was 8.7% in September and 11.2% in October 2018. Improvement Plans: 1. The Head of Midwifery was instrumental in ensuring the Trust became a smoke-free zone. 2. LTHTR employ a public health midwife and a public health co-ordinator (for the Trust), who are both involved in the smoke-free policy and implementation of this scheme. 3. The Public Health Midwife will be working with the Service Development Midwife on a service improvement project around smoking in pregnancy in 2019. 4. The midwifery department have just had Nicotine Replacement Therapy (NRT) Patient Group Directives authorised this week so that staff can offer dual NRT for pregnant/postnatal women on the ward; training will begin for staff in 2019. 5. The Public Health Midwife has just completed an audit against the Trust smoking in pregnancy policy. 6. An action plan will be devised once the data has been analysed. This will be shared with the CCG. 7. The CCG continue to monitor the monthly performance data around this indicator and work closely with midwifery colleagues at the acute Trust in order to ensure we are sighted on all improvement projects.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 142 Improvement Assessment Framework (Better Care) IAF 128d – Primary Care Workforce Target: N/A Current Performance GP CCG CSR CCG 0.83 (March 2018) 0.91 Current Issues: This indicator is based on the number of full time equivalent GPs and Practice nurses per 1000 population. Chorley & South Ribble CCG is in the lowest quartile.

Improvement Plans:

1. The CCG worked closely with NHS England to submit a bid in November 2017 to recruit additional GPs from abroad. All practices were contacted to scope interest around this scheme and a number of practices wish to be involved. This work is ongoing, with close involvement with NHSE and other CCGs in Lancashire & South Cumbria. Unfortunately, due to the current uncertainty around Brexit, no ongoing applications have been received to date.

2. Funds have been accessed through Health Education North West (HENW) to deliver an extensive training programme for both nurses and non-medical primary care staff. For nurses this training includes care planning, risk assessment & documentation and general overview of long term conditions, recognising the importance of upskilling our primary care workforce to support the provision of care closer to home. Additional training has also been funded to enable nurses to become non-medical prescribers thus supporting skill mix within the practice.

3. Training for non-clinical primary care staff through HENW funding includes chaperone training, coding and investigating serious incidents.

4. A GP Retention Scheme has been relaunched as part of the Five Year Forward View. This scheme enables GPs who would otherwise leave general practice to remain in the workforce. It involves the GP working fewer sessions (up to a maximum of four per week) whilst maintaining their educational support, as the scheme is jointly run by Health Education England and NHS England. Greater Preston CCG & Chorley & South Ribble CCG has received six applications, all of which have been approved by the CCGs. These GPs are experienced practitioners who have retired from general practice and meet the required criteria for the scheme.

5. The CCG have continued to liaise closely with NHS England Local Area Team to identify practices that might benefit under the Resilience Scheme. Practices have been encouraged to access support from their peers both in terms of clinical advice and sharing of best practice along with management and back office support.

6. Practices have formed themselves into collaborative and are working on delivering services such as diabetes and seven day access in their localities. More services will be delivered on these footprints going forward. Interoperability of clinical computer systems has been rolled out to enable practices to share records electronically and book appointments on a collaborative basis, and therefore assisting practices to offer services on behalf of other practices.

7. The CCG have developed an out of hospital strategy which describes the implementation of Integrated Care Teams (ICTs) based on population need. This will enable a wider skill mix, give clinicians the ability to work to their maximum ability, reduce the duplication between organisations and free up GP time to concentrate on the more complex patients.

8. The CCG have commissioned care co-ordination training in line with the GP Five Year Forward View requirements. This training will upskill the receptionists to be the first point Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 143 of contact to ensure patients are directed to the right service/person for their need. This training has been completed in 64% of practices in Greater Preston and 70% of practices in Chorley South Ribble.

9. We have offered all collaborative practices the opportunity to access funding for clinical correspondence training to enable non-clinical staff to process clinical correspondence in an appropriate way, whether that is by booking the patient an appointment or passing to an appropriate clinician. This has been completed in all of the Greater Preston practices and 53% of Chorley and South Ribble practices. The remainder of the practices will be completing in 2018/19.

Improvement Assessment Framework (Better Care) IAF 131a – Percentage of NHS Continuing Healthcare full assessments taking place in an acute hospital setting. Target: 15% or below Current Performance (Q1 GP CCG CSR CCG 18-19) 15.0% 20.4% Current Issues: Number of NHS CHC full assessments in an acute hospital setting in the quarter as a percentage of total NHS CHC full assessments carried out.

The latest local data from November 2018 shows CHC assessments taking place in an acute hospital setting at Greater Preston is 17% and Chorley & South Ribble is 14%. The NHSE data from quarter 1 18/19 shows Greater Preston in the interquartile nationally and Chorley South Ribble in the worst quartile range. Improvement Plans: A CHC post is being recruited to across both CCGs to lead the CHC improvements identified during the review undertaken last year. Improvement action plans are now in place with a trajectory for the reduction in backlog of assessments.

IAF 127f – Population use of hospital beds following emergency admission (total length of all Non elective Finished Consultant Episodes per 1000 population) Target: N/A Current Performance (Q3 CSR CCG GP CCG 17/18) 561.5 573.0 Current Issues: Both CCGs are in the lowest quartile for this indicator. The indicator is based on total length of Finished Consultant Episodes following a Non-Elective admission, per 1000 population. Current length of stay is not at an optimal level. Improvement Plans: 1. Following on from the VSA event a programme of work was agreed and KPI’s for each work stream established, which report to the A and E delivery board, where leads attend and held accountable for their work stream. 2. There are six work streams in this area: • Early intervention and prevention • 111 and 999 • Emergency Department • Rapid assessment and care coordination • Mental Health – unscheduled care • Paediatrics • Integrated therapies • Discharge 3. There is a detailed programme plan underpinning this work 4. Newton Europe has undertaken delayed transfers of care diagnostic and this is being aligned to the flow out of hospital VSA work stream plan. 5. The plan includes introducing ward based discharge co-ordinators; additional board

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 144 rounds in the evening; standardised use of estimated discharge dates; one discharge planner document for each patient that also acts as a referral for any onward care; and a set of standards for discharge that will be delivered by each ward.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 145 2 Programmes 2.1 Out of Hospital (Community and Primary Care)

2.1.1 Out of Hospital Referrals

The cumulative position across both CCGs compared to the same period last year demonstrates an overall increase of 3.3% in GP referrals.

The graph shows a reduction in GP referrals in October due to decommissioning the Rheumatology service within the main LCFT Community block contract. Rheumatology has been commissioned under the new Moving Well Service which went live on the 1 October 2018.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 146 GP Referrals - Tier 2 | Community as at 31st October 2018

2017/18 Market 2018/19 Market Provider Variance Variance % Referrals Share Referrals Share

About Health 1,459 9% 553 3% -906 -62.1% Beacon Medical 1,399 8% 1,876 11% 477 34.1% Chorley Medics 2,507 15% 1,371 8% -1,136 -45.3% TICCS 1,592 9% 1,429 9% -163 -10.2% Community Health and Eyecare 644 4% 538 3% -106 -16.5% LCFT (GP Referrals) 9,339 55% 9,405 56% 66 0.7% Moving Well 0 0% 1,528 9% 1,528 -- Chorley and South Ribble

Total 16,940 100.0% 16,700 100.0% -240 -1.4% About Health 2,574 12% 740 3% -1,834 -71.3%

Beacon Medical 1,779 8% 2,134 10% 355 20.0% Chorley Medics 3,063 14% 1,675 8% -1,388 -45.3% TICCS 1,946 9% 1,746 8% -200 -10.3% Community Health and Eyecare 786 4% 658 3% -128 -16.3% LCFT (GP Referrals) 12,018 54% 12,665 59% 647 5.4% GreaterPreston Moving Well 0 0% 1,867 9% 1,867 --

Total 22,166 100.0% 21,485 100.0% -681 -3.1%

Beacon Medical has seen an increase of 832 referrals compared to 2017/18. The service mobilised in April 2017 and referrals into the service in the early months were slow. As the year progresses the variance is expected to reduce.

The reduction in Tier 2 referrals can be attributed to several services ending in July and August due to the commencement of the new Central Lancashire Moving Well Service. The services which ended were the two Physiotherapy providers: Chorley Medics and TICCs (Ascenti) and the previous MSK service provider, Virgin Care Services. Also, there is no data available on referral numbers for the Community Dermatology service which is due to lack of training on the new Electronic Referral Service (e-RS).

The significant dip in referrals during July – September can be attributed to the gap in activity reporting, during the mobilisation period of MSK and Physiotherapy provision through the Central Lancashire Moving Well service. Activity reporting for the full integrated Moving Well service has commenced from 1 October 2018.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 147 2.1.2 Out of Hospital Finance and Activity

Joint position both CCGs M8 YTD Budget Actual Variance Provider £000 £000 £000 Block / Grants Lancashire Care Foundation Trust 21,753 21,749 (4) Lancashire Care Foundation Trust - Central Lancashire Moving Well Service 2,332 2,195 (137) Hospices (grant agreements) 942 928 (14) Total 25,027 24,872 (155)

Block Contract

Lancashire Care Foundation Trust (LCFT) For year to date to Month 7 of the contract, overall activity is 5% under agreed baselines, within the +/- 10% tolerance level for the contract.

For the CCGs within Central Lancashire, Chorley South Ribble and Greater Preston are overall over the tolerance level at 12% below contracted activity.

For the Chorley South Ribble and Greater Preston CCGs, we are working with Lancashire Care on the following areas:

Care Home Effective Support Service (CHESS) / Community Matrons / Frailty Service The baseline has been agreed for the Integrated Frailty Service with Lancashire Care Foundation Trust to accurately reflect the services being delivered. Lancashire Care will report on the revised baselines for the Central Lancashire locality from Month 8 of the contract. Initial analysis of the activity against the revised baselines shows that the services will be within the tolerance levels agreed.

Children’s Therapy Services The CCG has issued a revised baseline paper to Lancashire Care Foundation Trust which reflects the need to reduce Did Not Attend rates in certain elements of the service. The service continues to work on plans to recruit to vacancies and reduce sickness absence to increase activity. The CCG recognises that some of the baselines may have been overstated due to the absence of assured data, historic manual reporting and the allocation of reference costs. The Performance Lead is meeting with the Deputy Network Director on the 14 December to agree the final baselines before issuing to the Associates for agreement.

District Nursing Services Lancashire Care has completed the deep dive for the District Nursing Service. The activity recorded was split between day care work, out-of-hours activity, discharging patients and Non Contracted Activity (NCA). The whole District Nursing Service is now on ECR which had raised some data quality issues. The service lead has also raised that reduced funding has had an impact on the activity levels and that NCA had increased. On this basis, Lancashire Care has asked for the baseline to be reviewed. A meeting will be held with Lancashire Care to discuss a change control process when services are moved onto the new reporting system (RIO) and data quality issues arising from these system changes.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 148 Paediatric Liaison The number of contacts reported for the Paediatric Liaison services for the Chorley South Ribble and Greater Preston CCGs was recorded as zero for month 7. There have been issues with the flow of the information through the information systems within Lancashire Teaching Hospital to the service as referrals. This has now been resolved. However, it resulted in a late submission of the data in time for contract reporting. This will be rectified for month 8 reporting, to include retrospective reporting for month 7.

Central Lancashire Moving Well The service is showing an underspend against budget of - £137,000 due to the phased implementation of the Moving Well Service.

During the first three months of the service going live, 1 July 2018 – 31 September, LCFT provided Rheumatology, MSK & Physiotherapy with Pain and Chronic Fatigue going live from the 1 October 2018.

From the 1 October 2018 LCFT provides a fully integrated Moving Well Service incorporating Rheumatology, MSK, Physiotherapy, Pain & Chronic Fatigue provision. The service also offers self-referral into the Physiotherapy element of the service. During September and October the service received 465 self-referrals into the Physiotherapy service.

Joint position both CCGs M8 YTD Budget Actual Variance Provider £000 £000 £000 Cost per LCFT Waiting list initiative from Virgin Case Care 270 203 (67) Blackpool Teaching Hospitals NHS FT 12 30 18 Virgin Care Services 769 769 0 TCES contract 1,064 1,345 281 Chorley Medics 450 450 0 The Integrated Care Clinics 188 188 0 Specsavers Hearcare Ltd 382 461 79 LCFT re Children’s Consumables 110 110 0 Marie Curie 71 75 4 Care UK Clinical Services Ltd 478 907 429 Spamedica Ltd 119 166 47 Scrivens Ltd 0 106 106 Spiral Health 950 933 (17) Community Health and Eyecare 582 601 19 Beacon Medical (ENT) 643 619 (24) About Health 586 506 (80) PDS Medical 102 85 (17) Other minor contracts <£50k 231 193 (38) Total 7,007 7,747 740

Cost per Case

Beacon Medical (Community ENT) is a block contract with a 10% cap / collar agreement in place. Current cumulative performance is below the collar threshold by

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 149 -136 (-5.2%). Activity at month 5 is 12% below planned levels. Invoices will be paid at the collar value of the contract until performance is at planned levels.

The TCES contract is over budget as planned VAT savings following Lancashire County Council taking over the management of the contract have not materialised due to delays within LCC in signing the Section 75 agreement.

The Community Macular service (Care UK Clinical Services) is currently over budget as Wet Acute Macular Degeneration (AMD) patients who commenced treatment throughout 2017/18 collectively continue a regime of intraocular injections following the agreed clinical pathway. There has also been an increase in the number of non- Wet AMD macular referrals being made to the service by Optometrists, which previously would have been referred to secondary care.

Chorley Medics, The Integrated Care Clinics and Virgin Care Services were decommissioned from 30 June 2018 therefore no activity will be reported against budget for the remaining months of this financial year. MSK and Physiotherapy were commissioned separately from the 1 July 2018 through the Central Lancashire Moving Well service provided by LCFT.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 150 2.1.3 Out of Hospital Performance Exception

There are no performance exceptions to raise for this reporting period.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 151 2.1.4 Out of Hospital Integrated Business Plan

There are no areas to raise within the Integrated Business Plan for this reporting period. The projects on the plan are on track for delivery against the financial targets and KPIs.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 152 2.2 Urgent Care

2.2.1 Finance and Activity

Activity Cost £'000 Hospital Based Urgent Care as at 31st Cost Var October 2018 Plan Actual Variance Plan Actual Variance Act Var % % Accident and Emergency 53,432 56,367 2,935 £6,633 £6,876 £243 5% 4% Accident & Emergency MIU 75 76 1 £5 £5 £0 2% 2% Non-Elective 14,786 15,389 603 £35,238 £37,022 £1,784 4% 5% Non Elective Short Stay 6,509 6,751 242 £6,196 £6,454 £258 4% 4% Non-Elective Non Emergency 2,861 2,788 -73 £7,599 £7,171 -£428 -3% -6% Non-Elective Same Day Emergency Care 1,846 2,192 346 £1,522 £1,802 £280 19% 18% NEL Threshold Adj 0 0 0 -£1,591 -£1,607 -£17 -- 1% Grand Total 79,509 83,563 4,054 £55,603 £57,723 £2,120 5% 4%

The main cost pressure is related to A&E and Non-Elective, these are described in more detail in the following sections.

Go to Doc – Urgent Care/Walk-in Centre/Minor Injuries Unit

A&E Activity

A&E + Urgent Care Centre

Whilst local data flows are in place, appropriate contractual measures have been taken to support the flow of Urgent Care Centre data to the Secondary Uses Service (SUS+) dataset by way of an Information Breach Notice with the CCG withholding 0.5% of the provider’s income on a monthly basis as permitted by the contract until this is resolved.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 153 Further steps are now being taken with both LTHTR and their system suppliers to determine how GTD can satisfy the new national Emergency Care Dataset (ECDS) for urgent and emergency care, including a move to record Urgent Care Activity on the Trust’s clinical system ‘Quadramed’ this commenced for the Preston site in November and is now flowing, there are further system changes required in order to separate activity between GtD and LTH which requires further development by the system supplier – however local data flows establish volumes of patients seen in both Urgent Care and Emergency Departments.

Non Elective Activity

Non-elective activity levels are above plan by 603 and costs are above plan by £1.8m.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 154 2.2.2 Urgent Care Performance Exceptions Accident and Emergency IAF E.B.5 Percentage of A&E attendances where the Service User was admitted, transferred or discharged within 4 hours of their arrival at an A&E department (Trust) Target: 95% Current Performance 83.13% Current Issues: Following a sustained period of improvement against the 4hr standard October has seen a slight decline. The daily sitrep has shown a further deterioration through September and for the first weeks of October. Issues with flow and a high number of minor breaches are affecting overall performance.

Improvement Plans:

Implementation of the VSA work streams has started with regular updates being taken to A&E Delivery Board. A major component of the work is around the discharge process to improve flow with a focus on applying home first principles. This has resulted in an improved DToC position and a reduction in number of patients with lengths of stay over 7 and 21 days.

Further improvements include: 1. New pathways from RAT to Ambulatory care to prevent admissions and improvements in wait for first assessments. 2. Establishing daily board rounds and all elements of SAFER, including weekly 7 day reviews. 3. New discharge process, tested and being embedded. 4. Long LoS reviews in place weekly (just moved from 21day reviews to 14 day reviews) following success of using the ECIST guidance.

Additional work for winter including having a winter ward in place and extended pharmacy cover for the weekend’s to improve response times have been implemented. These initiatives have had a positive impact overall, however, as a system we have not realised all opportunities identified. The forecast underlying performance position is worse than the actual position for both November and December. The position for November was 3.52% better than if the system had put no measures in place, this rose to 7.05% for December. The chart below describes the initiatives and performance. December data for a number of outcomes metrics is yet to be published. Once available a further assessment of performance can be made.

Winter Plan

90% 90%

80% 80%

70% 70%

60% 60% Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Underlying Forecast Performance Decrease Ambulance Conveyancing Ambulatory Emergency Care Discharge to Assess Outlier Team Impact of reduced planned activity Discharge Planning Work Minors scheme Zero tolerances of Non Admit breaches Actual / Fcst Performance

Link to summary

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 155 E.B.S.5 Trolley waits in A&E no longer than 12 hours. Total number of patients who have waited over 12 hours in A&E from decision to admit to admission. (Trust) Target: 0 Current Performance 5 Current Issues: Please see above. Improvement Plans: Please see above.

Link to summary Ambulance Category 1 -Time critical and life threatening events (We aim to respond to these calls within an average time of 7 minutes.) Target: 00:7:00 Current Performance NWAS CSR CCG GP CCG 00:08:01 00:09:41 00:07:21 Current Issues: Response time improvement requires operational reconfiguration of vehicle profile. Call volume remains high. Improvement Plans:

The CCG have now setup bi-monthly meetings to discuss specific performance concerns for central Lancashire. Following the first meeting NWAS have agreed to set local recovery trajectories that we can use to measure improvements against. A number of actions have commenced and improvements in performance can be expected in January. Actions include: 1. Auto clear, being piloted at RPH so ambulances are turned round more quickly. 2. Five additional vehicles (3 Preston, 1 Chorley, 1 Leyland). 3. Update of the staffing rotas.

The variation in response times between CCGs will be discussed at the next performance meeting with NWAS where trajectories for improvement will be agreed.

Link to summary Category 1 - Time critical and life threatening events We aim to respond to these calls at least 9 out of 10 times within 15 minutes.

Target: 00:18:00 Current Performance NWAS CSR CCG GP CCG 00:13:19 00:15:17 00:12:01 Current Issues: Please see Category 1 above.

Improvement Plans: Please see Category 1 above.

Link to summary

Category 2 - Potentially serious conditions that may require rapid assessment, urgent on-scene clinical intervention/treatment and/or urgent transport (Respond to these calls within an average time of 18 minutes.) Target: 00:18:00 Current Performance NWAS CSR CCG GP CCG 00:24:40 00:24:58 00:21:33 Current Issues: Please see Category 1 above.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 156 Improvement Plans: Please see Category 1 above.

Link to summary Category 2 - Potentially serious conditions that may require rapid assessment, urgent on-scene clinical intervention/treatment and/or urgent transport (Respond to these calls within an average time of 40 minutes.) Target: 00:40:00 Current Performance NWAS CSR CCG GP CCG 00:52:44 00:51:37 00:44:35 Current Issues: Please see Category 1 above.

Improvement Plans: Please see Category 1 above.

Category 3 - Urgent problem (not immediate life-threatening) that requires treatment to relieve suffering (e.g. pain control) and transport or assessment and management at scene with referral where needed within a clinically appropriate timeframe.

Target: 02:00:00 Current Performance NWAS CSR CCG GP CCG 03:06:34 02:36:55 02:27:25 Current Issues: Please see Category 1 above.

Improvement Plans: Please see Category 1 above.

Link to summary Category 4/4H/4HCP - Non urgent problem (not life-threatening) that requires assessment (by face to face or telephone) and possibly transport within a clinically appropriate timeframe We aim to respond to these calls within 180 minutes (3 hours) in 9 out of 10 cases. Target: 03:00:00 Current Performance NWAS CSR CCG GP CCG 03:19:51 03:01:48 03:42:51 Current Issues: Please see Category 1 above. Improvement Plans: Please see Category 1 above.

Link to summary E.B.S.7a All handovers between ambulance and A&E must take place within 15 minutes with none waiting more than 30 minutes (Royal Preston / Chorley District) Target: 0 Current Performance RPH 48 CDH 9 Current Issues: The number of over 30 minute breaches has continued to improve at both Royal Preston Hospital (RPH) and at Chorley District Hospital (CDH). Improvement Plans:

1. Reducing Corridor Nursing: LTHTR working on new Rapid Assessment and Treatment work, with capacity to assess seven patients. 2. Time to First Assessment and Time to DTA: The ED clinicians are working with the acute physicians and specialty clinicians to design the pathways which are being tested

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 157 currently using a PDSA approach. This includes direct streaming from the ambulance crews to ambulatory care and will include direct streaming from triage to ambulatory care over time. 3. Maximised Use of Ambulatory Care: With the support of EY LTHTR has undertaken a comprehensive analysis of our ED attendance and calculated the ambulatory care potential to maximise patients being streamed to ambulatory care (note the national definition is patients who would have been expected to be admitted). The top ten pathways are now being designed to be implemented when the ambulatory care area reopens following the location back. The next focus is to extend the opening hours.

Back to summary

E.B.S.7b All handovers between ambulance and A&E must take place within 15 minutes with none waiting more than 60 minutes (Royal Preston / Chorley District) Target: 0 Current Performance RPH 25 CDH 1 Current Issues: The number of over 60 minute breaches has continued to improve at both Royal Preston Hospital (RPH) and at Chorley District Hospital (CDH). Improvement Plans: Please see Ambulance handover time No. >30 mins (Royal Preston).

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 158 2.2.3 Urgent Care Integrated Business Plan

There are risks identified for two projects in this portfolio – Continuing Health Care (CHC) Improvement project and Category A Bed Procurement project.

The risk around delivery of the Continuing Health Care (CHC) Improvement project has significantly reduced since the last report. The risk continues to be mitigated by NHS England undertaking face to face reviews in order to achieve the savings identified through the desktop review. An update on progress will be reported in the IBR next month.

There are concerns relating to the continuity, quality or outcomes of the service standards relating to the Category A Bed Procurement project. The CCG has developed an action plan in partnership with the Provider, progress against which will be monitored at weekly provider meetings. An update on progress will be reported in the IBR next month.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 159 2.3 Elective Care

2.3.1 Elective Care Referrals

2017-18 2018-19

Referral Market Share of Providers up to 31st October 2018 Market Market Referral Referrals Referrals Variance Share Share Variance % LANCASHIRE TEACHING HOSPITALS NHS FOUNDATION TRUST 67,002 77.16% 66,520 77.16% -482 -0.72% RAMSAY HEALTHCARE UK OPERATIONS LIMITED 11,269 12.98% 12,167 14.11% 898 7.97% BLACKPOOL TEACHING HOSPITALS NHS FOUNDATION TRUST 3,239 3.73% 2,116 2.45% -1,123 -34.67% WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST 2,567 2.96% 2,650 3.07% 83 3.23% EAST LANCASHIRE HOSPITALS NHS TRUST 928 1.07% 838 0.97% -90 -9.70% SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST 642 0.74% 838 0.97% 196 30.53% UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST 558 0.64% 478 0.55% -80 -14.34% BOLTON NHS FOUNDATION TRUST 263 0.30% 338 0.39% 75 28.52% BMI HEALTHCARE 136 0.16% 150 0.17% 14 10.29% SPIRE HEALTHCARE 197 0.23% 76 0.09% -121 -61.42% Grand Total 86,801 99.97% 86,171 99.96% -630 -0.73%

Overall referrals (GP, Hospital and Other) have reduced by 0.73% YTD. The Other referrals category has seen the biggest reduction including these specialties, Orthodontics, Transient Ischaemic Attack, Pain Management and Paediatrics. All referrals by source have reduced in October compared to the previous year as illustrated in the chart below.

2.3.2 Elective Care Finance and Activity

Activity Cost £'000 Elective Care as at 31st October 2018 Cost Var Plan Actual Variance Plan Actual Variance Act Var % % Inpatient Daycase 27,822 28,373 551 £20,839 £21,096 £257 2% 1% Inpatient Elective 4,795 4,548 -247 £14,696 £13,760 -£936 -5% -6% Outpatient First Attends 68,736 70,939 2,203 £10,027 £10,365 £338 3% 3% Outpatient Follow-up Attends 164,499 160,786 -3,713 £10,623 £10,360 -£263 -2% -2% Outpatient Procedure 36,034 36,651 617 £4,703 £4,973 £270 2% 6% Grand Total 301,887 301,297 -590 £60,889 £60,555 -£334 0% -1%

The table above shows that overall planned activity is at expected levels, there are some shifts between points of delivery, which are further explained in the following sections.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 160 Inpatient Day case activity is over performing by 2%. This over performance is driven by specialties, Ophthalmology, Colorectal Surgery and Urology.

The most frequent Ophthalmology procedure undertaken is Phacoemulsification Cataract Extraction and Lens Implant, with CC Score 0-1. For Colorectal Surgery it is ‘Diagnostic Colonoscopy, 19 years and over. For Urology it is ‘Introduction of Therapeutic Substance into Bladder’.

Outpatient First Attends

Both activity and cost are above plan by 3% as at month 7. The main areas of over performance are Dermatology, Urology and Paediatric Trauma and Orthopaedics.

Outpatient Follow up Attends

Follow-up activity and cost are both below planned levels by 2% at month 7. The main areas of underperformance are Trauma and Orthopaedics and Clinical Haematology.

Outpatient Procedures

Overall outpatient procedures are 2% above plan for activity whilst costs are 6% above plan at month 7. The specialties that are affected are Ophthalmology, Gastroenterology and General Surgery.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 161 An Activity Query Notice was issued to LTHTR in respect of the observed increase in Ophthalmology outpatient procedures and a subsequent meeting to discuss findings was held on 1 August 2018. Unfortunately at the meeting it became apparent that LTHTR had not undertaken the required analysis. A further letter was then issued outlining the details required to clarify the Trust position. There has been some change to the recording of procedures which may require a neutrality adjustment. Further CCG analysis has identified that Minor Vitreous Retinal Procedures was the cause of the variance noted.

Elective Activity

Overall elective inpatient and day case activity is under plan by 5% and cost is under plan by 6%. Specialties over performing are Ophthalmology, General Surgery and Interventional Radiology.

Specialties underperforming against plan for activity and cost are Trauma and Orthopaedics, Plastic Surgery and Gastroenterology.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 162 2.3.3 Elective Care Performance Exceptions Referral to Treatment IAF E.B.3 Referral to Treatment RTT (Incomplete) Percentage of Service Users on incomplete RTT pathways (yet to start treatment) waiting no more than 18 weeks from referral. Target: 92% Current Performance 88.2% CSR 88.6% GP CCG CCG Current Issues: Both CCGs are under the 92% threshold again; however both have improved by approximately 3%. LTHTR position has also improved and is now at 80.7%. This is as a result of a number of different factors, with the recovery process having an impact on improved waiting list management at LTHTR.

At LTHTR Neurosurgery continues to be a problem with regards long waits, with (as at 2 December) 32 over 52 week breaches and 123 patients waiting over 40 weeks. There are currently 65 patients now waiting over 52 weeks in total, this position is deteriorating. Other specialties with breaches include ENT (19) Colorectal (6), Orthopaedics (3), Plastics (2), and one each in Ophthalmology, Max Fax and Clinical Immunology. The longest wait is 72 weeks (Colorectal).

The pressures resulting in this level of performance are manifold – there are capacity issues across a number of specialties, a backlog of validation work, and increased growth in GP referrals in a small number of specialties (including Urology, ENT and Oral Surgery), and growth in consultant initiated referrals in a number of other specialties. Improvement Plans: 1. Following the issue of a contract performance notice, the CCG has received and signed off a Recovery Action Plan (RAP) from LTHTR giving trajectories around reducing both waiting list numbers and 52 week breaches. A new fortnightly RTT steering group has been set up with key members from the CCGs and LTHTR - this group is supporting timely action planning around long waits and RTT, as well as monitoring whether the RAP actions and trajectories are on track on a regular and frequent basis.

2. Transformational work is under way across a range of specialties including MSK and Ophthalmology. Ophthalmology transformation should see LTHTR develop significantly more capacity for acute conditions and procedures.

3. Actions in the RAP to address specialty specific issues are usually themed around 3 areas: a) addressing capacity through recruitment, adding extra sessions (including Waiting List Initiatives) and outsourcing, b) validation and working through the validation backlog, and c) reducing demand in GP and Other referrals.

4. The CCG is supporting the demand management work through a targeted programme of deep dives into those specialties which have significant growth in GP referrals. Business Intelligence have developed a comprehensive deep dive tool that enables the CCG to review and analyse a range of data, which includes all specialties and can look at Trust, CCG and practice level. Specific review meetings have been completed for ENT, Ophthalmology and Urology, with the next ones planned for Colorectal and Plastics. A presentation of Deep Dive data was given to LTH colleagues at the last steering group meeting, and it was agreed that the tool would be used to complete regular joint reviews of referral activity.

5. A process has been agreed to manage consultant initiated referrals within LTHTR using a centralised process, which should help reduce growth in this area.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 163

6. The CCG are working with SPEC COMM to facilitate a Lancashire wide Neurosurgery summit to focus on demand management. The CCG is waiting for SPEC COMM to identify a date and agree content. Furthermore there has been agreement to carry out a peer review of the Neurosurgery pathway within LTHTR carried out by the SPEC COMM quality surveillance team – this is planned for January 2019.

7. The CCG is taking part in the North 100 Day challenge, focusing on Urology and Respiratory. As Urology has been highlighted as a growth area with regards GP referrals this work should reduce demand, improve flow, and therefore improve the position around breaches and total pathways.

8. There is no plan to achieve RTT within this financial year with the focus remaining on reducing pathways and 52 week breaches.

Link to summary

Referral to Treatment E.B.S.4 Zero tolerance RTT waits over 52 weeks for incomplete pathways Target: 0 Current Performance 13 CSR CCG 21 GP CCG Current Issues: The numbers of breaches at CCG level have stayed fairly static this month, with an increase of 1 at CSR and a decrease of 1 at GP. However, the latest in month LTH figure shows a slight increase, up to 65 breaches in total (breakdown of these breaches is above in RTT section) - there is no exact correlation as the Neurosurgery breaches are badged against NHS England rather than CCGs, and the position outlined above for LTHTR is an in month figure in December (a ‘live’ position), whereas the figure here is the validated month end figure at end October – breaches only count towards the final end of month figure if they are still breaching at month end, i.e. they haven’t been treated at that point.

At Chorley & South Ribble there are 6 breaches in General Surgery, 3 each in ENT and Cardiology, and 1 in Plastics. 8 of the breaches are at LTHTR, with the 3 Cardiology breaches taking place at Blackpool Teaching Hospitals NHS Trust, and 2 of the General Surgery breaches at North Midlands. The breaches at Greater Preston are in ENT (11), General Surgery (6), Cardiology (2), and one each in Trauma and Orthopaedics and ‘Other’. All breaches were at LTHTR except the 2 Cardiology at Blackpool, 1 General Surgery at North Midlands and 1 in ‘Other’ at Leeds Teaching Hospitals.

Improvement Plans: As described in the RTT section, the levels of 52 week breaches are increasing at LTHTR, and are now up to 65. The CCG are managing LTHTR on a recovery plan specifically for long waits, total pathways and 52 week breaches, which includes choice alternatives for patients, local targets, and escalation procedures. Please see RTT section above for further actions.

Link to summary

E.B.4 Percentage of Service Users waiting 6 weeks or more from referral for a diagnostic test Target: 1.00% Current Performance 2.13% CSR 2.23% GP CCG CCG Current Issues:

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 164 The 6 week diagnostic target has failed at both CCGs, the fourth month in a row at Chorley & South Ribble and the third in a row at Greater Preston. The position has generally deteriorated in that time however the positon is fairly static from the last month. There were a total of 59 patients waiting over 6 weeks in October at Chorley & South Ribble, 44 of which were at LTHTR (with other breaches at Ramsay (10), Manchester University Hospitals NHS Trust, Southport & Ormskirk and Wrightington, Wigan and Leigh). Greater Preston underperformance relates to 82 breaches, 76 of which were at LTHTR (with other breaches at Ramsay, Liverpool heart and chest, Blackpool, Southport & Ormskirk and Lancashire Care Foundation Trust). This is reflected in underperformance at LTHTR at 2.13%, the third month in a row that the Trust has failed this target.

Improvement Plans: 1. Underperformance at CCG level is directly related to LTHTR underperformance in this instance. The main issue is around Endoscopy. The waiting list for Colonoscopies has nearly doubled since April, and whilst this has started to come down a little in the last couple of months, this is still putting pressure on current capacity levels. The Trust cites summer holidays as having an effect here re staff leave. However, there has been growth in Colorectal GP referrals of 17.3% so demand will be playing a part. 2. LTHTR have prioritised cancer referrals and are using their endoscopy capacity to ensure these patients are seen as soon as possible. 3. As LTHTR has now failed this target 3 months in a row the CCG has escalated this through the formal contract process, with an escalation meeting held and a formal request made for a Recovery Action Plan. In the meantime, LTHTR already have an insourcing provider putting on extra sessions in the evenings and weekends, and negotiations are under way to extend this arrangement to provide even more capacity. The long term plan remains to build long term capacity by training staff to become nurse endoscopists; however this is a time consuming process. 4. LTHTR state they will be back in compliance in January 2019. 5. A contract performance noticed was issued to Ramsay Healthcare in November for non- compliance against the diagnostic target for Euxton Hall Hospital.

Link to summary

Referral to Treatment RTT - Percentage of service users on Non Admitted pathways waiting no more than 18 weeks from referral (AHP @ LCFT) Target: 95.00% Current Performance CSR CCG GP CCG 94.2% 98.0% Current Issues: The slight deterioration in performance from the previous month position is due to the number of breaches in Children’s Occupational Therapy and Children’s Speech and Language Therapy. The breaches are due to reduced team capacity in both services.

Improvement Plans:

1. All teams have a situation report (SITREP) weekly call with professional leads. 2. The reduced capacity with sickness and vacancies is in part being mitigated by staff working overtime in the short term. 3. Existing staff are being upskilled, where appropriate, using the Occupational Therapy (OT) competency framework, to maximise capacity. 4. The service is reviewing triage to ensure consistency in acceptance of referrals. 5. The Occupational Therapists are reviewing the clinical benefit of the amount of reporting writing they complete to increase efficiency and give families the information they need.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 165 6. The service is assessing the ration of clinical to non-clinical time. 7. Recruitment across both services is underway and ongoing.

Link to summary

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 166 Cancer Waiting Times E.B.8 Percentage of Service Users waiting no more than one month (31 days) from diagnosis to first definitive treatment for all cancers Target: 96% Current Performance 97.32% CSR 95.37% GP CCG CCG Current Issues: The performance at GP CCG represents 5 breaches out of 108 patients on the pathway, There is a mix of reasons for these breaches; 1. Elective Capacity Inadequate. 2. Patient delayed for Medical reasons.

Improvement Plans: Both CCG have met the 62 day cancer target YTD (to October). There is however a deteriorating position for October and challenges going into November.

LTHTR have published a Cancer Performance Action plan by tumour site to meet a 75% target of first appointment within 7 days. There is a particular emphasis on those tumour sites with challenged performance. All are undergoing demand and capacity exercises were the target is presently not being met. The Cancer Alliance has given LTHTR monies to assist with this demand / capacity exercise.

LTHTR have identified actions against those tumour groups which are performing less well against the target these include; 1. Breast – increased capacity by moving Friday AM clinic to Weds PM. 2. Gynaecology – 3rd consultant starting in January 19, with approval for 4th consultant. 3. Head and Neck – New consultant Radiographer appointed to support radiotherapy pathway. 4. Skin – Continue with WLI clinics to meet demand, new consultant plastic surgeon started in November. 5. Upper GI – Push to resource extra theatre and outpatient slots. Issue with consultant retiring end November. 6. Urology – Introducing up front mpMRI, Procuring Template Biopsy equipment to reduce biopsy waiting times, meeting with BMI (Cheadle) to outsource surgical kidney capacity. 7. Oncology – Working on recruitment of clinical oncologist to cover increased referrals from UHMB. 8. Colorectal – Increasing theatre capacity approved for December

The Cancer Alliance has given LTHTR £50k in Q1 and 2 for extra endoscopy lists, plan being tracked through Integrated Care System. There is another £202K of 62 day recovery monies. LTHTR are using £67k to develop the 2 week monitoring form through EMIS and £63K to procure further endoscopy capacity from the Independent Sector.

Link to summary

E.B.12 Percentage of Service Users waiting no more than two months (62 days) from urgent GP referral to first definitive treatment for cancer Target: 85% Current Performance 79.37% CSR 82.98% GP CCG CCG Current Issues: The performance at CSR CCG relates to 13 breaches out of 53 patients on the pathway. The performance at GP CCG represents 8 breaches out of 47 patients on the pathway.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 167 The breaches reasons show five for complex diagnostic pathway (three in CSR and two in GP), seven for Elective Capacity issues (five in CSR and two in GP) and two as a result of Health Care Provider initiated delay to diagnostic test both due template biopsy both in GPCCG. The other reasons for breaches were; 1. Patient DNA’d treatment. 2. Patient initiated delay. 3. Diagnostic delayed for medical reasons. 4. Treatment delayed for medical reasons.

The breaches by specialty shows three in Haematology (all in CSR CCG), two in Head and Neck (both in CSR CCG), three in Colorectal (all in GPCCG) and six in Urology (three in CSRCCG and three in GPCCG).

Improvement Plans:

Please see E.B.8 above.

E.B.13 Percentage of Service Users waiting no more than 62 days from referral from an NHS screening service Target: 90% Current Performance 83.33% CSR 91.67% GP CCG CCG Current Issues: The performance for CSR CCG represents one breach on the pathway for the Colorectal tumour group, which was due to an inconclusive diagnostic result.

Improvement Plans:

Please see E.B.8 above.

Cancelled Operations E.B.S.2 All Service Users who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the Service User's treatment to be funded at the time and hospital of the Services User's choice (Trust)

Target: 0 Current Performance LTHTR 16 Current Issues: These occurred across a range of specialties. Two patients do not yet have a date for their surgery. The main reason for underperformance in this area is due to capacity.

Improvement Plans: 1. The CCG 18wk RTT action plan continues to be monitored on fortnightly basis and as a result the performance for cancelled electives is expected to improve. 2. The CCG have requested an update in relation to the patients who are awaiting their date for surgery. 3. The CCG routinely request assurances that the affected patients are not waiting for cancer surgery and that no harms occur as a result of the cancellations. 4. The CCG have requested additional assurances around the actions being taken to reduce the number of cancellations that occur for non-medical reasons.

Link to summary EMSA E.B.S.1 Sleeping Accommodation Breach Target: 0 Current Performance 7 CSR CCG 20 GP CCG Current Issues: Sleeping accommodation breaches continue to be reported due to more stringent timescales

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 168 being applied to the critical care environment.

Improvement Plans: 1. A thematic review has been completed and presented at the Trusts Safety & Quality committee. 2. The existing Mixed Sex Accommodation Breach policy has been reviewed by NHSE As a result of the policy review a number of additional measures will be implemented. Measures include staff identifying early the discharge requirements of the patient, with the expectation of this being commenced the day before discharge. 3. The patient flow team track the flow requirements of the critical care unit three times a day. 4. A deep dive review is underway and will be shared with the CCG once complete. 5. No complaints have been received as a result of this position. 6. Steps are taken to protect the patient’s privacy and dignity when a breach occurs.

Link to summary

No increase of total Acute pathways from March 2018 figure

Target: 11215 (CSR) Current Performance CSR CCG GP CCG 13470 (GP) 14,401 16,680 Current issues: There is a new target for CCGs and Trusts for 2018/19 is to ensure that there is no growth in acute pathways (i.e. those on an incomplete RTT pathway) from the March 2018 position. The target levels above are the final March waiting list numbers at CCG level. As documented above in the RTT and 52 week sections, a Recovery Action Plan has been agreed with LTHTR, which includes trajectories to reduce 52 week breaches and total pathways back to target levels. The Trust is still significantly above this trajectory, with 33062 pathways (October position) against a 30610 target. However the October position does show an improvement against August figures where there were 34900 pathways open.

The CCG position has significantly increased this month due to commencement of the new Tier 2 iMSK service provided by Lancashire Care Foundation Trust. NHS England advised that this activity should be considered consultant-led, and therefore count towards the RTT target, despite both the provider and the CCG challenging this position, due to the consultant-led element being approximately 10% of the total activity. As a result of this ruling 4,600 patients have therefore been added to the waiting list this month, which equates to 88% of the total increase. This places both CCGs significantly above target, and even further above planned levels (which vary over the year) – the CCGs combined variance from plan is now 7261 pathways.

Improvement Plans: Please see above RTT section for RAP and other actions to address this target.

The decision to classify MSK referrals as consultant-led is being challenged by the CCG.

Link to summary

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 169 2.3.4 Elective Care Integrated Business Plan

There are no areas to raise within the Integrated Business Plan for this reporting period. The projects on the plan are on track for delivery against the financial targets and KPIs.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 170 2.4 Mental Health and Learning Disabilities

2.4.1 Mental Health Referrals

The mental health referrals, which are a combination of Adult and Children’s Services at LCFT, appear to be relatively static over the previous 18 months.

2.4.2 Mental Health Finance and Activity

Lancashire Care Foundation Trust (LCFT) – Activity by service

Data to 31st October 2018 Service Plan Actual Variance Var % ADHD Contacts 371 265 -106 -28.6% CMHT Adult Teams Contacts 13,377 13,125 -252 -1.9% CMHT Older Adult Contacts 4,137 4,276 139 3.4% CRHT Face to Face Contacts - 18 to 65 7,847 6,712 -1,135 -14.5% CRHT Face to Face Contacts - Below 18 273 281 8 2.9% CRHT Face to Face Contacts - Over 65 112 38 -74 -66.1% CRHT Telephone Contacts - 18 to 65 3,864 4,154 290 7.5% CRHT Telephone Contacts - Below 18 35 186 151 431.4% CRHT Telephone Contacts - Over 65 42 60 18 42.9% Criminal Justice Liaison - Contacts 679 1,092 413 60.8% Eating Disorder Service - Contacts 2,303 694 -1,609 -69.9% Hospital Liaison Contacts 560 523 -37 -6.6% MAS Teams - Contacts 4,858 5,513 655 13.5% RITT Contacts 3,339 3,472 133 4.0% Adult Ward Occupied Bed Days 6,611 8,556 1,945 29.4% Older Adult (Dementia) Ward Occupied Bed Days 1,756 2,107 351 20.0% Older Adult (Functional) Ward Occupied Bed Days 1,607 1,932 325 20.2% PICU Ward Occupied Bed Days 1,750 1,553 -197 -11.3% Year to Date 53,521 54,539 1,018 1.9%

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 171 The CCGs are associate Commissioners to the LCFT Mental Health contract, which is hosted by Blackburn with Darwen CCG.

The table above now includes the baselines. However, there may be further amendments to these, due to Morecambe Bay, Fylde and Wyre and Greater Preston CCGs being involved in GP Practice transfers.

2.4.3 Mental Health Performance Exceptions

Mental Health and Learning Disabilities Percentage of People experiencing a first episode of psychosis treated with a NICE approved care package with two weeks of referral Target: 53% Current Performance CSR CCG GP CCG 50.00 % 75.00% Current issues: Chorley & South Ribble has failed the 53% target as only 4 out of 8 patients were seen within the target timescale. The overall LCFT position has achieved at 53.3%, and has now achieved for the second month in a row.

Most delays in the service at the moment are due to delays in the referral process, as the clock for these patients starts when they have first contact with any LCFT service, even if psychosis is not initially suspected. Increased demand across most mental health services has had some impact on this service, as increased pressure will reduce the capacity for other Mental health services to identify these patients in line with the target timescale.

Improvement Plans: 1. Chorley & South Ribble CCG have now failed this target three months in a row. The service, in conjunction with commissioners, have looked for trends at CCG level, but with the numbers so low the overall conclusion is that there are no prominent trends at this level. 2. The service focused on reducing the number of open pathways to ensure better management of the waiting list. 3. Support is being sought from commissioners to share guidance for GP’s around symptom identification to support timely referrals, with a GP referral form being developed to support this process. 4. A SITREP process is in place to ensure that all service user pathways are tracked to monitor timely appointments. 5. Regular dialogue is in place between EIS and AMH teams to review why any service user’s referral was delayed and to consider how we can improve the process.

Link to summary

Mental Health and Learning Disabilities The percentage prevalence of people who have depression and/or anxiety disorder who receive psychological therapies (NEW KPI 2018/19) Target: 1.54% Current Performance CSR CCG GP CCG 1.57 % 1.28% Current issues:

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 172 The national IAPT prevalence target is 19% by quarter 4. Although the trajectory is staggered to increase every quarter (the target level above reflects this trajectory), at present this is an internal target as contractually LCFT are only mandated to deliver 19% in quarter 4 and 16.8% in quarters 1-3. Greater Preston has underperformed against both the trajectory and the contractual target. 4 out of 7 Lancashire CCGs are failing this target in October.

The underperformance is caused by a reduced number of referrals received by the service to achieve the prevalence target (although this has improved in October, the service is still in deficit for the year). There are also some capacity issues within teams to complete the assessments due to a recent transition to individual welcome calls from group sessions. The majority of these referrals need to come from primary care.

Improvement Plans: • Review all job plans to ensure the capacity is available across all teams to meet the demand for welcome calls coming into the service on a weekly basis due to recent clinical model change • Increased communication and engagement with primary care to increase referrals and engagement with the service.

Link to summary

2.4.4 Mental Health Integrated Business Plan

There are no areas to raise within the Integrated Business Plan for this reporting period. The projects on the plan are on track for delivery against the financial targets and KPIs.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 173 2.5 Medicine Management

2.5.1 Medicine Management Finance and Activity

Primary Care Prescribing Savings Schemes Over / (under) achievement to Annual Savings within Budget date CSR GPR Total CSR GPR Total £000 £000 £000 £000 £000 £000

Planned Work Programme M.O.T. workplan 222 276 498 (48) 34 (14) Meds Opt in Care Homes (MOCH) 37 45 82 0 0 0 Medicines coordinators 908 873 1,781 (59) (104) (163) Scriptswitch 281 302 583 37 58 95 Woundcare products 15 19 34 0 0 0 PQSS Incentive Scheme 135 179 314 (1) (6) (6) 3rd party repeat prescribing waste 518 883 1,400 (54) (39) (93) Sub Total: Planned Work Programme 2,116 2,576 4,692 (125) (57) (181)

Fortuitous QIPP Pregabablin 313 417 730 68 78 146 Pharmaceutical Rebates 45 45 90 4 4 9 Patent Expiries 95 105 199 89 78 167 Sub Total : Fortuitous QIPP 452 567 1,019 161 160 321

Total PC Prescribing 2,568 3,143 5,711 36 103 140

Medicines Optimisation Team (MOT) work plan, Medicines coordinators and Scriptswitch.

The above values are based on November data. CSR MOT savings have improved since last month but are still behind plan. MOT work has predominately focused on key quality areas in the first part of the year, and savings are expected to increase as the focus moves to financial savings areas over the year to go.

CSR Medicines Coordinators savings position has also improved this month. There have been a number of recent staffing changes with medicines coordinators this year. There is a focus on engagement with training sessions increased to accommodate new starters. The 2018/19 GP Quality Contract KPIs have been updated to include medicines coordinator engagement and an increased scriptswitch acceptance rate.

Medicines Optimisation in Care Homes. Recruitment is currently in progress for the two posts.

Woundcare products. This central ordering initiative delivers reductions in item waste and an increase in the proportion of formulary compliance.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 174 PQSS Incentive Scheme. The current gainshare scheme’s twelve month term ended on 30th June 2018. The above savings are based on June data.

Waste reduction - Third Party Repeat Prescribing: The above savings are based on data for Apr to September. Savings are measured for the first 12 months live in each practice and cumulatively the scheme has saved £1.4million over the two financial years. The first practices went live in April 2017 and there are now 49 of 56 practices live as at September 2018, with one more due to go live later this year.

Pregabalin and Patent Expiries are based on September data and reflect savings from tariff reductions.

Pharmaceutical Rebates reflects rebates received on Seretide and Sitagliptin.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 175 2.6 Provider Quality Performance Exceptions

Quality and Experience – Lancashire Teaching Hospitals NHS Foundation Trust Lancashire Teaching Hospitals - Admission to designated stroke ward within 4 hours of presentation Target: 90% Current Performance 62.50% Current Issues: Performance was 62.50% in October (which was an improvement from September). This is not in line with the improvement trajectory that has been agreed with the CCG (October target 70%). Underperformance remains largely due to capacity issues.

Improvement Plans: 1. The CCG are continuing to monitor the remedial action plan and progress against improvement trajectory with the acute trust in relation to this indicator. Data analysis has highlighted that the median time from arrival in ED to assessment by a stroke nurse is around 40 minutes and the median time for admission to the stroke unit from ED is 3 hours and 41 minutes. 2. Monthly meetings continue with LTHTR and the CCG. 3. The business case developed following the Peer Review will be resubmitted to LTHTR Executives on January 2019. The outcome of this will be shared with the CCG.

Link to summary

Lancashire Teaching Hospitals - Serious incidents Target: 0 Current Performance 8 Current Issues: Eight serious incidents were reported in October. One apparent /actual suspected self -inflicted harm, two diagnostic delays, two slips trips and falls, one sub-optimal care of the deteriorating patient and one case pending review. No new never events have been reported this month.

Improvement Plans: 1. The CCG serious incident review panel continue to review all submitted STEIS reports in order to ensure that the action plans submitted in the reports reflect the learning that has been identified from the incident. 2. LTHTR continue to send lead clinicians to discuss their reports at the CCG serious incident panel. 3. A review of the 5 slips, trips and falls, which resulted in a fractured neck, will be undertaken. The CCG Chief Nurse will agree the terms of reference for the review in partnership with LTHTR. 4. In relation to Never Events, a round table event has been completed with NHSE, NHSI, CQC, LTHTR and the CCG. Key actions from the event will be progressed by the Director of Nursing and Care Professionals (NHSE and Lancashire & South Cumbria ICS); to ensure that system learning is enabled.

Link to Serious Incidents summary

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 176 Lancashire Teaching Hospitals – Medication error with harm Target: 2 Current Performance 26 Current Issues: Twenty six medication errors with harm were reported in October (25 were low harm, 1 caused moderate harm). The moderate harm incident was in relation to an adverse/allergic reaction. A rapid review is planned.

Improvement Plans: 1. Two improvement actions are currently underway by the medicines safety champions focussing on improving the checking of controlled drugs and reducing delays to essential medications for patients with Parkinson Disease. 2. The CCG continue to receive monthly medicine safety reports to ensure that further detail and assurances are received. This includes trends and themes of incidents reported.

Link to summary

Incidence of MRSA bacteraemia- BLOODSTREAM INFECTION Target: 0 Current Performance CSR CCG 1 GP CCG 0 Current issues: Patient with multiple co-morbidities, metastatic cancer and urological complications with recurrent urinary tract infections.

Diagnosed MRSA post mortem. The conclusion of the multi-disciplinary team investigation was that It is not possible to know when or how the patient acquired MRSA.

Improvement Plans: 1. The care home to revisit their pre-assessment protocols 2. The care home to improve the management of a long-term catheter and specifically to review the obtaining of urine samples. 3. LTHTR to further investigate why some blood results were not sent back to the GP for this patient. 4. LTHTR Urology to note that patients in nursing home beds are not under the care of the district nursing service when communicating follow up instructions. 5. GP practice to ensure timely response to GP task requests as part of Internal learning following the investigation. 6. LTHTR to improve the scanning of paper records onto evolve. 7. LTHTR Infection control nurse to review ANTT compliance internally.

Link to summary

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 177 Quality and Experience – Lancashire Care NHS Foundation Trust Lancashire Care NHS Foundation Trust (LCFT) - Pressure Ulcers Grade 3 Target: Current Performance: YTD 75 To be determined G3 – 14 Current Issues:

In October 2018, LCFT reported 14 grade 3 pressure ulcers.

As a health economy, there is a targeted focus to reduce the prevalence of pressure ulcers by increasing awareness of pressure ulcers, to reduce harm by enabling preventative interventions to be implemented at an earlier stage.

Improvement Plans:

1. All pressure ulcers have been reviewed and scrutinised by the LCFT Safety Senate to determine whether they were avoidable or unavoidable, and identify any learning to be shared. 2. LCFT have undertaken a thematic review of a cluster of PU’s which have occurred between 25/01/18 and 30/08/18. LCFT presented the thematic review to the CCG SI Group on 07/11/18. Four themes were identified based on the findings, Self- management / education, Assessment, Clinical record keeping and Staff training. However - The incident remains open as further assurances have been requested. 3. A Health Economy Pressure Ulcer Prevention Group will be re-established to facilitate collaborative learning. LCFT have shared a revised draft of the pressure ulcer guidance for LCFT for comments from the CCG. 4. Annual update training sessions for the React to Red Champions will continue throughout 2018 and beyond in order for the champions to maintain and build on their skills and knowledge to ensure good practice continues through dissemination of learning to additional staff.

Link to summary

Quality and Experience – Lancashire Care NHS Foundation Trust Lancashire Care NHS Foundation Trust (LCFT) – Serious Incidents (SI) Target: Current Performance: YTD 17 0 1

Current Issues:

In October 2018, LCFT reported one serious incident. The incident related to a confidential information governance breach.

Improvement Plans: 1. Following a STEIS reportable incident LCFT will undertake a Rapid Review (within 72 hours) and submit this to the CCG. This has been received and notes immediate actions taken inclusive of duty of candour. 2. A full RCA will be submitted to the CCG within 60 days. The investigative reports will then be duly reviewed by the CCG SI Review group to determine if the incidents have been thoroughly investigated and any lessons learnt cascaded across the health economy. 3. The CCG attends LCFT SI meetings where all SI cases are subject to a high level of scrutiny.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 178 Link to summary

Quality and Experience – Ramsay Health Care Ramsay Health Care – in patient FFT Target: 96% Current Performance 69% Current Issues:

FFT failed to reach target due to the denominator of patients attending was higher than usual for this month.

Improvement Plans:

1. There was a caveat to this month submission as the denominator of patients attending was higher than usual for this month. 2. During quality visits the CCG have witnessed every effort is made to ask in patients to complete the FFT prior to leaving.

Link to summary

Ramsay Health Care – Complaints Target: 0 Current Performance 1 Current Issues:

One complaint at Euxton Hall involving an out-patient attendance where clinics were running late (one hour) and a patient felt rushed by the consultant.

Improvement Plans:

1. Delays in clinics can be unavoidable due to unforeseen circumstances, however the provider now routinely inform waiting patients in clinic when they are running late. 2. Consultant was informed of the complaint and has reflected on his consultation style.

Link to summary

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 179 3. RightCare

Update will be available at the end Quarter 3.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 180 4. Leadership

4.1 Workforce

CSRCCG Integrated Board Report – HR – 30/11/2018 Expected Rate Actual Rate Sickness 3% 3.38% Mandatory Training 100% 96.05% compliance Staff Turnover 0.92% 0.00%

Sickness The expected rate for monthly sickness absence is 3%, based on a widely used target throughout the NHS. Data for November 2018 showed that the monthly sickness rate was 3.38%. Sickness absence has decreased since last reported for October 2018 (4.09%), but is above the expected rate. The rolling sickness absence rate for the last 12 months is 3.10% (and 3.42% for the 2018/19 financial year). The CCGs’ in-house HR team continues to undertake random spot checks to ensure that managers are complying with the absence management policy by conducting return to work interviews within two working days of employees returning from sickness. Work continues in order to identify and understand any trends in sickness absences.

Turnover The CCGs are currently reporting a monthly turnover rate of 0.00% for November 2018. Turnover has decreased since last reported for October 2018 (0.65%), and is below the expected monthly rate of 0.92%. The national NHS average turnover is 11% over a twelve month period, and the CCG’s current rolling 12 month turnover rate is 10.49% (and 4.85% for the 2018/19 financial year). The CCGs monitor reasons for people leaving the organisation, with the main reasons over the past 12 months being due to promotions and the end of fixed term contracts.

Mandatory training The CCGs were below the 100% compliance rate for mandatory training in November 2018 with a rate of 96.05% completion. The figure is a combined compliance rate across Chorley and South Ribble CCG and Greater Preston CCG, inclusive of office holders. Compliance has increased since last reported in October 2018, when a combined compliance rate for both CCGs was 93.8%. The in-house HR team monitors compliance on a monthly basis and follows up with further requests to complete all outstanding mandatory training, or to provide the evidence to support where, for example, training has been completed in other organisations.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 181 4.2 Complaints

In November 2018, a total number of 16 complaints were received across both CCGs. This was four less than the previous month as illustrated in table 1.

Table 1: Total number of complaints by CCG

November CCG October 2018 2018 CSR 7 9 GP 13 7 Total 20 16

Graph 1 illustrates the number of complaints received for the period November 2017 to November 2018, broken down by CCG, to provide a full year view.

Graph 1 Complaints received by CCG (November 2017 to November 2018)

Of the complaints received in November 2018, four were transferred to other organisations as highlighted in table 2. Themes of the complaints being dealt with by the CCGs were mixed, and related to issues as varied as referral pathways, delays in communication and clinical care.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 182 Table 2: Complaints transferred to other organisations

October 2018 November Provider 2018 Lancashire Teaching Hospitals 0 0

Lancashire Care NHS Foundation Trust 0 1 Lancashire Care NHS Foundation Trust 2 0 – moving well service Ramsay 1 0

Out of area 0 1

Lancashire County Council 0 0

NHS England 0 1 North West Ambulance Service 0 0

GTD Healthcare 0 0

Other provider(s) 1 1

NHS 111 0 0

4.3 Freedom of Information (FOI) requests

A total number of 28 FOI requests were received in November 2018. This was two more than received in October 2018*. Five requests remained open at the end of November. All of these are still within the statutory timeframe.

Across both CCGs there were no breaches and all responses were made within the statutory 20 working days timeframe. No response extensions were requested or applied in November 2018.

• A breach occurs when a response to a request for information under the FOI Act 2000 exceeds 20 working days.

• If a FOI request is complex, the CCGs can ask the requester for an extension in addition to the original 20 working days. A breach would not occur as long as the response was provided within the agreed extension period.

Across both CCGs, no exemptions were applied in November 2018. There are a number of exemptions that direct the CCGs to withhold information from a requester. This could be due to the harm that would arise or would be likely to arise from disclosure. For example, if disclosure would be likely to prejudice a criminal investigation or prejudice someone’s commercial interests. An entire request can also be refused under the following circumstances:

• It would cost too much or take too much staff time to deal with the request. • The request is vexatious.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 183 • The request repeats a previous request from the same person.

Topics for information requested this month included expenditure on interpreter services, neurological rehabilitation, and audiology services. In addition, requests were made for contract information in relation to eating disorder services, out of hour’s services, and primary care services.

*The number of FOI requests was under–reported in October 2018 due to a technical error that has now been resolved. The actual number received was 26.

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 184 5. Glossary

A&E Accident & Emergency AHP's Allied Health Professionals ASD Autism Spectrum Disorder BP PC Better Payment Practice Code CCG Clinical Commissioning Group CHC Continuing Health Care CI Consultant Initiated CITNS Children's Integrated Therapy Nursing Services CL Cash Limit CPA Care Programme Approach CQUIN Commissioning for Quality and Innovation CSR Chorley South Ribble CYP Children and Young People DC Day Case DPH Director of Public Health DToC Delayed transfer of care EHH Euxton Hall Hospital EL Elective EMSA Eliminate Mixed Sex Accommodation ENT Ear Nose Throat EPACCS Electronic Palliative Care Coordination System FFT Friends and Family Test FOI Freedom of Information GP Greater Preston HCAI - Health Care Associated Infections - Clostridium CDIFF Difficile HFC Harm Free Care HSMR Hospital Standardised Mortality rate IAPT Improving Access to Psychological Therapies IUCS Integrated Urgent Care Service IV Intravenous LCC Lancashire County Council LCFT Lancashire Care Foundation Trust LCSU Lancashire Commissioning Support Unit LTHTR Lancashire Teaching Hospital Trust MAP Main Access Point MAS Memory Assessment Service MH Mental Health MoD Ministry of Defence MRSA Methicillin-resistant Staphylococcus aureus MRC Medical Research Council MSA Mixed Sex Accommodation MSK Musculoskeletal NEC Not Elsewhere Classified NELSD Non-elective same day

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 185 NELST Non-elective short stay NHSI National Health Service Improvement The National Institute for Health and Care NICE Excellence NWAS North West Ambulance Service OHOC Our Health Our Care OPFA Outpatient First Attendances OPFUP Outpatient Follow Up OPPROC Outpatients Procedures PDSA Plan Do Study Act POD Group Point of Delivery POLCV Procedures of Limited Clinical Value QI Quality Improvement QIPP Quality for Innovation, Productivity and Prevention RAT Rapid Assessment and Treatment RCAs Root Cause Analysis RHC Ramsay Health Care RRL Revenue Resource Limit RTT Referral to Treatment SALT Speech and Language Therapy SoFP Summary Statement of Financial Position STEIS Strategic Executive Information System STF Sustainability and Transformation Fund TCI To Come In TICCS The Integrated Care Clinics VSA Value Stream Analysis YTD Year to date

Integrated Board Report NHS Greater Preston CCG Governing Body 24 January 2019 Page 186 Agenda Item 11

Governing Body Meeting

Date of meeting 24 January 2019 Title of paper Financial Performance Report Presented by Mr Matt Gaunt, Chief Finance and Contracting Officer Author Mrs Katherine Disley, Deputy Chief Finance Officer Clinical lead N/A Confidential No

Purpose of the paper The Joint Financial Performance Report sets out the combined financial position for NHS Chorley and South Ribble and NHS Greater Preston Clinical Commissioning Groups (CCGs) as at 31 December 2018. This report includes the summary financial position, summary I&E, productivity and efficiency (QIPP) and net risks.

Executive summary The CCGs are forecasting to achieve the planned breakeven position, although there are pressures resulting in a net risk of £0.3m across both CCGs against this forecast. The CCGs full year forecast reflects £5.8m of acute overspend against contract driven largely by non-elective cost pressures at LTH, the previously published QIPP shortfall of £2.7m and cost growth across tier 2 (out of hospital) services in particular drugs costs for eye treatments.

Risks that have not been built into this forecast are : 1) Any expenditure above plan that is required to ensure the number of patients waiting for treatment is no higher at the end of March 2019 than it was at the same point in 2018. The impact to the CCG's has been estimated at £0.5m. 2) The CCG's formally requested to retain the 0.5% non-recurrent system risk reserve and received approval for £1.8m of the £2.5m. In November 2018, a further £0.2m was approved as mitigation by NHS England and the ICS resulting in a shortfall of £0.6m. This shortfall has been partially mitigated by an additional £0.5m benefit for 2017/18 quality premium award and the expectation of the 2018/19 achievement. 3) There is an emerging pressure in relation to CHC costs due to an increase in retrospective packages of care. This is being scrutinised in detail in order to understand the increase in packages and the likely full year forecast outturn position.

Recommendations The Governing Body is asked to note the financial position of the CCGs at the end of December 2018.

Financial Performance Report NHS Greater Preston CCG Governing Body Meeting Page 187 24 January 2019 Links to CCG Strategic Objectives SO1 Improve quality through more efficient, safer services which deliver a ☒ better patient experience SO2 Commission care so that it is integrated and ensures an appropriate ☒ balance between in-hospital and out of hospital provision SO3 Be an integral part of a financially sustainable health economy ☒

SO4 Ensure patients are at the centre of the planning and management of ☒ their own care, and that their voices are heard SO5 Be a well-run clinical commissioning group and the system leader ☒

Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome

N/A

Were any conflicts of interest identified at previous meetings (mark X in the correct box below) Yes No X If conflicts of interest were identified what were these:

Implications Quality/patient experience Yes ☒ No ☐ N/A ☐ implications? (Potential) conflicts of interest? Yes ☐ No ☐ N/A ☒ Equality Impact Assessment? Yes ☐ No ☐ N/A ☒ Privacy Impact Assessment? Yes ☐ No ☐ N/A ☒ Are there any associated risks? Yes ☐ No ☐ N/A ☒ Are the risks on the CCG’s risk Yes ☒ No ☐ N/A ☐ register? If yes, please include risk description and reference number

Assurance

Financial Performance Report NHS Greater Preston CCG Governing Body Meeting Page 188 24 January 2019

Joint Financial Performance Report 2018/19 As at 31 December 2018 Forecast Outturn to 31 March 2019

189 Page

Chorley and South Ribble CCG Greater Preston CCG

CCG Narrative - Joint position

The CCGs' statutory duty is to deliver a balanced financial position and separately support the Integrated Care System (ICS) proposed planning requirements which includes maintaining a 0.5% non-recurrent system risk reserve. This is consistent with the CCGs' strategic objective: “To be an integral part of a financially sustainable health economy.”

As at 31 December 2018 the CCGs are forecasting to achieve the planned breakeven position, although there are pressures resulting in a net risk of £0.3m across both CCGs against this forecast. The CCGs full year forecast reflects £5.8m of acute overspend against contract driven largely by non-elective cost pressures at LTH, the previously published QIPP shortfall of £2.7m and cost growth across tier 2 (out of hospital) services in particular drugs costs for eye treatments.

Risks that have not been built into this forecast are : 1) Any expenditure above plan that is required to ensure the number of patients waiting for treatment is no higher at the end of March 2019 than it was at the same point in 2018. The impact to the CCG's has been estimated at £0.5m. 2) The CCG's formally requested to retain the 0.5% non-recurrent system risk reserve and received approval for £1.8m of the £2.5m. In November 2018, a further £0.2m was approved as mitigation by NHS England and the ICS resulting in a shortfall of £0.6m. This shortfall has been partially mitigated by an additional £0.5m benefit for 17/18 quality premium award and the expectation of the 18/19 achievement. 3) There is an emerging pressure in relation to CHC costs due to an increase in retrospective packages of care. This is being scrutinised in detail in order to understand the increase in packages and the likely full year forecast outturn position.

The CCG is continuing to work with its NHS partners to agree full year outturn values that will provide a balanced financial position across both CCGs, and which creates an equitable balance of risk across all partners. Agreement in principle has been reached with Lancashire Teaching Hospitals which equates to an over performance of £5.7m against 2018/19 contract values.

Page 190 Page

CCG Summary Financial position - Joint position

Financial Duties Q1 Q2 Q3 Q4 YTD FORECAST OUTTURN Key

Revenue Resource Limit On plan

Cash Limit Actions in place to achieve plan

Better Payment Practice Code NHS Miss to plan

Non NHS Information not available

Business Rules and Financial Performance Q1 Q2 Q3 Q4 YTD FORECAST OUTTURN Key Messages

0% Revenue Surplus/(Deficit)

- The forecast is to achieve an in year break-even £0.0m. This is a 0.5% Non-Recurrent system risk reserve £0.0m variance to plan. - Efficiency and Productivity is performing £2.0m under plan. Efficiency and Productivity performance - 0.5% Non-recurrent system risk reserve is utilised as agreed by the Governing Body in September 2018. Running costs - Running costs are within budget. - Non-recurrent investments are in accordance with plan. Main Provider Performance - LTH - The CCGs are currently reporting a net risk position of £0.3m.

Page 191 Page

Summary I&E - Joint

Annual Annual Annual Budget to Expenditure Variance to Annual Budget Forecast 2017/18 Outturn Date to Date Date Forecast Variance Outturn Variance

£000 £000 £000 £000 £000 £000 £000 £000 Favourable / Favourable / Favourable / (Adverse) (Adverse) (Adverse)

In-year Revenue Resource Limit 427,567 427,567 0 572,455 572,455 0 557,236 15,219

Total Revenue Resource Limit 427,567 427,567 0 572,455 572,455 0 557,236 15,219

Acute services Lancashire Teaching Hospitals NHSFT 157,592 161,416 (3,825) 210,567 216,041 (5,474) 203,051 (12,989) NW Ambulance service NHST 9,079 9,039 40 12,105 12,079 26 11,473 (606) Wrightington Wigan & Leigh NHSFT 5,735 5,542 193 7,601 7,443 157 7,427 (16) Blackpool Teaching Hospitals NHSFT 3,795 3,979 (183) 5,060 5,431 (371) 5,080 (351) East Lancashire Hospitals NHST 2,423 2,484 (61) 3,237 3,295 (58) 3,131 (164) Ramsay 17,118 17,232 (114) 22,928 22,939 (11) 23,402 463 Other Acute service providers 15,469 15,100 369 19,470 19,528 (58) 24,430 4,901 Acute services 211,210 214,791 (3,581) 280,967 286,756 (5,789) 277,993 (8,763) Mental Health Services Lancashire Care NHSFT 29,805 29,875 (70) 39,532 39,626 (94) 38,837 (789) Other Mental Health providers 15,735 15,642 93 21,329 21,329 0 17,844 (3,485) Mental Health services 45,540 45,518 22 60,862 60,956 (94) 56,681 (4,274) Community Health Services Lancashire Care NHSFT 27,267 27,413 (146) 37,171 37,369 (198) 33,438 (3,931) Other Community providers 8,463 9,428 (966) 10,810 11,782 (972) 11,752 (30) Community services 35,730 36,841 (1,112) 47,981 49,151 (1,170) 45,190 (3,961) Other Programme: Continuing Care services 18,443 19,375 (932) 24,591 25,277 (686) 23,521 (1,756) Primary Care services 45,874 45,735 139 63,122 61,622 1,499 55,399 (6,223) Prescribing 42,795 41,895 900 56,574 55,394 1,180 59,994 4,600 Other Programme services 3,678 3,409 269 4,905 4,813 91 4,862 49 Corporate 5,091 5,039 52 6,841 6,805 36 4,486 (2,319) Reserves 12,985 9,084 3,900 18,316 13,544 4,772 13,565 21 Healthcare Sub Total 421,346 421,688 (342) 564,158 564,319 (161) 541,692 (22,626)

Running Costs 6,222 5,880 342 8,297 8,136 161 7,922 (214)

Total Expenditure 427,567 427,567 0 572,455 572,455 0 549,614 (22,841)

Surplus/(Deficit) 0 0 0 0 0 0 7,622 (7,622)

Of which: CSR CCG Surplus/(Deficit) 0 0 0 0 0 0 3,370 (3,370) GPR CCG Surplus/(Deficit) 0 0 0 0 0 0 4,252 (4,252) * Outturn 2017/18 has been adjusted to reflect the boundary change for NHS Greater Preston CCG with effect from 1 April 2018.

Page 192 Page

Productivity and Efficiency (QIPP) - Joint

Target QIPP 18,529

YTD Risk Net QIPP QIPP overview Plan YTD Plan Actual (Shortfall) / Adjusted (Shortfall) / as at 31st December 2018 Benefit FOT Benefit £000 £000 £000 £000 £000 £000

Out of Hospital 316 103 (178) (281) 1,510 1,194 Elective Care 3,810 2,638 1,969 (669) 3,402 (408)

Urgent Care 2,156 1,594 1,560 (34) 2,051 (105) Mental Health and Learning Disabilities 527 395 395 0 527 0 Medicines Management 5,289 4,414 4,917 504 5,807 518 Other Programme 1,597 804 2,854 2,050 2,523 926

Sub total - assigned QIPP schemes 13,695 9,948 11,517 1,570 15,820 2,125 Unidentified QIPP 4,834 3,546 0 (3,546) 0 (4,835)

Total QIPP 18,529 13,494 11,517 (1,977) 15,820 (2,710)

Month by month performance £000 2500 2000 1500 1000 500 0 M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12

Actual QIPP Planned QIPP Page 193 Page

Main Risks - Joint

Area Current position Action Owners Net risk

£000 Programme costs Contracts and Activity Trajectories Over performance at Lancashire Teaching Hospitals of £5.5m Agreement in principle has been reached with Lancashire Matt Gaunt has been included within the full year forecast outturn. The Teaching Hospitals in relation to an agreed forecast outturn plans for 2018/19 assumed a decrease in non elective activity position for 2018/19. This agreement reflects a £5.7m over and growth in elective. Ongoing activity information shows performance against contract. continued pressure in non-elective activity. (180) The remaining unmitigated risk outside the full year forecast outturn is £180k.

QIPP Under-Delivery Operational Plan Savings Delivery The operational plan is underpinned by a detailed The Operational Plan Delivery meetings monitor actions and Jayne Mellor productivity, efficiency and service redesign programme. appropriate support and measures in place to improve the risk to delivery. The current gap is £2.7m. The reduction is due to the (2,710) utilisation of the remaining CCG contingency.

Other risks 0.5% non-recurrent risk reserve NHS England confirmed in October that the full 0.5% non- Discussions taken place to receive the full risk reserve balance recurrent risk reserve can not be fully utilised by the CCGs due in order to mitigate against the CCGs risks. to retention of a proportion of this funding by the Integrated (793) Care System (ICS).

Gross risk (before mitigations) (3,683)

Mitigations

Net Area Current position Action mitigations £000 Contingency 100% of the planned contingency has been fully committed. 0 Other mitigations Uncommitted budget and forecast underspends primarily 3,159 within primary care co-commissioning 0.5% non-recurrent systems Remaining balance of the 0.5% non-recurrent system risk The Integrated Care System (on behalf of NHS England) have confirmed a risk reserve reserve retained by NHS England. proportion of remaining risk reserve will be made available to the CCGs. 230

Total mitigations 3,389

Net risk position

Total net risk (294)

Page 194 Page

Financial Performance Report 2018/19 As at 31 December 2018 Forecast Outturn to 31 March 2019 Page 195 Page

CCG Summary Financial position

Financial Duties Q1 Q2 Q3 Q4 YTD FORECAST OUTTURN Key

Revenue Resource Limit On plan

Cash Limit Actions in place to achieve plan

Better Payment Practice Code NHS Miss to plan

Non NHS Information not available

Business Rules and Financial Performance Q1 Q2 Q3 Q4 YTD FORECAST OUTTURN Key Messages

0% Revenue Surplus/(Deficit) - The forecast is to achieve an in year break-even £0.0m. This is a £0.0m variance to plan. 0.5% Non-Recurrent system - Efficiency and Productivity is performing £0.8m under plan. risk reserve - 0.5% Non-recurrent system risk reserve is utilised as agreed by the Governing Body in September 2018. Efficiency and Productivity performance - Running costs are within budget. Running costs - Non-recurrent investments are in accordance with plan. - The CCG is currently reporting a net risk position of £0.3m. Main Provider

Page 196 Page

Financial Performance Duties

Revenue Resource Limit (RRL) Total YTD Notes £000 Movements in allocations / funding totals £262k; Programme 274,441 £200k - Quality Premium - tranche 1 (measures 2-6) £62k - Other

Admin (running costs) 3,912

Cash Limit (CL) Total YTD Notes £000

Total 272,208

Better Payment Practice Code (BPPC) Total invoices Year to Date Total invoices Target paid within performance YTD Trend Notes paid in year % target %

Volume 10,895 10,861 95.0% 99.7% The CCG is exceeding all BPPC target

Non NHS levels. Value (£'000) 64,725 64,651 95.0% 99.9%

Volume 1,733 1,706 95.0% 98.4%

NHS Page 197 Page Value (£'000) 127,867 127,588 95.0% 99.8%

Financial Management

2017/18 2017/18 Receivables past their due Summary Statement of Financial Position (SoFP) YTD position as at 31 March YTD position as at date 2018 31 March 2018 £000 £000 £000 £000 Total non-current assets - - NHS 200 207

Non NHS 226 431 Current assets: Total 426 638 Inventories - -

Trade and other receivables 3,875 1,644 Comments Other financial assets 0 0 Cash - the balance on the SoFP is the total of anticipated payments/receipts for the CCG bank account. The month end cash Other current assets 0 0 target has been met. Receivables past their due date - NHS relate to Cash and cash equivalents (600) 36 balances due from West Lancashire CCG, NHS England and Lancashire Teaching Hospitals. Non NHS primarily relate to recharges owed by Total current assets 3,274 1,680 Lancashire County Council.

Total assets 3,274 1,680 Total receivables

NHS Non NHS Current liabilities: 3,000 Trade and other payables (12,895) (13,239) 2,000 Other financial liabilities 0 0 1,000 Other liabilities 0 0 0 (1,000) Borrowings 0 0

Provisions 0 0 Total current liabilities (12,895) (13,239) Cash - achieving 1.25% month end cash balance

Balance % Target % Non-Current Assets plus/less Net Current Assets/(Liabilities) (9,621) (11,559) 1.40 1.20 1.00 Total non-current liabilities 0 0 0.80 0.60 0.40 0.20 Assets less Liabilities (9,621) (11,559) -

Total taxpayers' equity: (9,621) (11,559)

Page 198 Page

Summary I&E

Annual Annual Variance to Forecast 2017/18 Outturn Budget to Expenditure Date Annual Annual Variance Outturn Variance Summary Income and Expenditure Date to Date Budget Forecast

as at 31st December 2018 £000 £000 £000 £000 £000 £000 Favourable £000 £000 Favourable Favourable / (Adverse) / (Adverse) / (Adverse)

In-year Revenue Resource Limit 204,150 204,150 0 272,208 272,208 0 265,783 6,425

Total Revenue Resource Limit 204,150 204,150 0 272,208 272,208 0 265,783 6,425

Acute services Lancashire Teaching Hospitals NHSFT 73,086 74,669 (1,583) 97,681 99,762 (2,081) 93,935 (5,827) NW Ambulance service NHST 3,960 3,907 53 5,280 5,216 64 5,049 (167) Wrightington Wigan & Leigh NHSFT 4,775 4,631 145 6,336 6,202 134 6,182 (21) Blackpool Teaching Hospitals NHSFT 1,398 1,515 (116) 1,864 1,974 (110) 1,826 (148) East Lancashire Hospitals NHST 1,149 1,143 6 1,536 1,470 65 1,483 13 Ramsay 8,168 8,285 (117) 10,944 11,119 (174) 11,258 139 Other Acute service providers 8,060 7,549 511 10,203 9,974 229 12,706 2,733 Total Acute services 100,596 101,698 (1,102) 133,844 135,717 (1,873) 132,438 (3,279) Mental Health Services Lancashire Care NHSFT 13,892 13,892 0 18,439 18,439 0 18,151 (288) Other Mental Health providers 7,385 7,359 27 10,008 10,008 0 8,535 (1,473) Total Mental Health services 21,277 21,251 27 28,447 28,447 0 26,686 (1,761) Community Health Services Lancashire Care NHSFT 13,063 13,196 (133) 17,780 17,869 (89) 16,088 (1,781) Other Community providers 4,095 4,649 (554) 5,252 5,770 (518) 5,545 (226) Total Community services 17,158 17,845 (687) 23,033 23,640 (607) 21,633 (2,007) Other Programme: Continuing Care services 9,650 10,408 (758) 12,867 13,493 (626) 11,911 (1,583) Primary Care services 21,186 21,138 48 29,147 28,897 250 25,849 (3,048) Prescribing 20,179 20,019 160 26,678 26,438 240 28,429 1,991 Other Programme services 1,772 1,569 203 2,363 2,267 96 2,284 17 Corporate 1,984 1,777 207 2,669 2,251 418 2,048 (204) Reserves 7,413 5,688 1,725 9,248 7,229 2,019 7,391 162 Healthcare Sub Total 201,217 201,393 (177) 268,296 268,380 (84) 258,669 (9,711) Running Costs 2,934 2,757 177 3,912 3,828 84 3,744 (84) Total Expenditure 204,150 204,150 0 272,208 272,208 0 262,413 (9,795)

Surplus/(Deficit) 0 0 0 0 0 0 3,370 (3,370) Page 199 Page

Productivity and Efficiency (QIPP)

YTD Risk Net QIPP QIPP overview as at 31st December 2018 Plan YTD Plan Actual (Shortfall)/ Adjusted (Shortfall) / Benefit FOT Benefit

£000 £000 £000 £000 £000 £000

Out of Hospital 125 9 (137) (146) 714 589

Elective Care 1,770 1,231 896 (335) 1,442 (328)

Urgent Care 1,038 770 763 (7) 993 (45)

Mental Health and Learning Disabilities 311 233 233 0 311 0

Medicines Management 2,486 2,056 2,314 258 2,701 215

Other Programme 553 276 1,275 999 960 407

Total QIPP 6,283 4,575 5,344 769 7,121 838 Unidentified QIPP 2,205 1,557 0 (1,557) 0 (2,205) Total QIPP 8,488 6,132 5,344 (788) 7,121 (1,367)

Current position £000

YTD Actual

Plan

Page 200 Page - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000

Financial Performance Report 2018/19 As at 31 December 2018 Forecast Outturn to 31 March 2019 Page 201 Page

CCG Summary Financial position

Financial Duties Q1 Q2 Q3 Q4 YTD FORECAST OUTTURN Key

Revenue Resource Limit On plan

Cash Limit Actions in place to achieve plan

Better Payment Practice Code NHS Miss to plan

Non NHS Information not available

Business Rules and Financial Performance Q1 Q2 Q3 Q4 YTD FORECAST OUTTURN Key Messages

0% Revenue Surplus/(Deficit) - The forecast is to achieve an in year break-even £0.0m. This is a £0.0m variance to plan. 0.5% Non-Recurrent system risk reserve - Efficiency and Productivity is performing £1.2m under plan. Efficiency and Productivity performance - 0.5% Non-recurrent system risk reserve is utilised as agreed by the

Governing Body in September 2018. Running costs - Running costs are within budget. Main Provider Performance - LTH - Non-recurrent investments are in accordance with plan. - The CCG is currently reporting a net risk position of £0.0m.

Page 202 Page

Financial Performance Duties

Revenue Resource Limit (RRL) Total YTD Notes £000 Movements in allocations / funding totals £967k; Programme 300,968 £622k - Maternity Transformation funding £345k - Quality Premium - tranche 1 (measures 2-6)

Admin (running costs) 4,385

Cash Limit (CL) Total YTD Notes £000

Total 300,247

Better Payment Practice Code (BPPC) Total invoices Year to Date Total invoices Target paid within performance YTD Trend Notes paid in year % target %

Volume 10,790 10,770 95.0% 99.8% The CCG is exceeding all BPPC target

Non NHS levels. Value (£'000) 74,764 74,714 95.0% 99.9%

Volume 2,048 2,039 95.0% 99.6%

NHS

Page 203 Page Value (£'000) 137,954 137,850 95.0% 99.9%

Financial Management

2017/18 2017/18 Receivables past their due Summary Statement of Financial Position (SoFP) YTD position as at 31 March YTD position as at date 2018 31 March 2018

£000 £000 £000 £000

Total non-current assets - - NHS 223 66

Non NHS 47 73 Current assets: Total 270 139 Inventories - -

Trade and other receivables 3,625 1,719 Comments Other financial assets 0 0 Cash - the balance on the SoFP is the total of anticipated payments/receipts for the CCG bank account. The month end cash Other current assets 0 0 target has been met for the last twelve months. Receivables past their Cash and cash equivalents (134) 42 due date - NHS relates primarily to one invoice raised to NHS England. Non NHS are recharges primarily to Lancashire County Council. Total current assets 3,491 1,761

Total assets 3,491 1,761 Total receivables

nhs non nhs Current liabilities: 2,500 2,000 Trade and other payables (16,741) (14,682) 1,500 Other financial liabilities 0 0 1,000 500 Other liabilities 0 0 0 Borrowings 0 0

Provisions 0 0 Total current liabilities (16,741) (14,682) Cash - achieving 1.25% month end cash balance

Balance as a percentage Target Non-Current Assets plus/less Net Current Assets/(Liabilities) (13,250) (12,921) 1.40 1.20 1.00 Total non-current liabilities 0 0 0.80 0.60 0.40 Assets less Liabilities (13,250) (12,921) 0.20 -

Total taxpayers' equity: (13,250) (12,921)

Page 204 Page

Summary I&E

Annual Annual Variance to Forecast 2017/18 Outturn Budget to Expenditure Date Annual Annual Variance Outturn Variance Summary Income and Expenditure Date to Date Budget Forecast

as at 31st December 2018 £000 £000 £000 £000 £000 £000 Favourable £000 £000 Favourable Favourable / (Adverse) / (Adverse) / (Adverse)

In-year Revenue Resource Limit 223,417 223,417 0 300,247 300,247 0 291,453 8,794

Total Revenue Resource Limit 223,417 223,417 0 300,247 300,247 0 291,453 8,794

Acute services Lancashire Teaching Hospitals NHSFT 84,506 86,747 (2,242) 112,886 116,279 (3,393) 109,116 (7,163) NW Ambulance service NHST 5,119 5,132 (13) 6,825 6,863 (38) 6,424 (439) Wrightington Wigan & Leigh NHSFT 959 911 48 1,265 1,241 24 1,245 5 Blackpool Teaching Hospitals NHSFT 2,397 2,464 (67) 3,196 3,457 (261) 3,254 (203) East Lancashire Hospitals NHST 1,274 1,340 (66) 1,701 1,824 (123) 1,648 (176) Ramsay 8,950 8,947 2 11,983 11,820 163 12,144 324 Other Acute service providers 7,409 7,551 (142) 9,267 9,554 (287) 11,723 2,169 Total Acute services 110,613 113,093 (2,479) 147,123 151,039 (3,916) 145,555 (5,484) Mental Health Services Lancashire Care NHSFT 15,912 15,983 (71) 21,093 21,187 (94) 20,686 (501) Other Mental Health providers 8,350 8,284 66 11,321 11,321 0 9,309 (2,012) Total Mental Health services 24,262 24,267 (4) 32,414 32,508 (94) 29,995 (2,513) Community Health Services Lancashire Care NHSFT 14,204 14,216 (13) 19,391 19,500 (109) 17,350 (2,150) Other Community providers 4,368 4,780 (412) 5,557 6,011 (454) 6,207 196 Total Community services 18,572 18,996 (425) 24,948 25,511 (563) 23,557 (1,954) Other Programme: Continuing Care services 8,793 8,967 (174) 11,724 11,784 (60) 11,611 (173) Primary Care services 24,688 24,596 91 33,975 32,725 1,249 29,550 (3,176) Prescribing 22,616 21,876 740 29,897 28,957 940 31,565 2,609 Other Programme services 1,906 1,840 66 2,542 2,546 (4) 2,578 32 Corporate 3,107 3,262 (155) 4,172 4,554 (381) 2,438 (2,115) Reserves 5,571 3,396 2,175 9,068 6,315 2,753 6,174 (141) Healthcare Sub Total 220,129 220,294 (165) 295,862 295,939 (77) 283,024 (12,915) Running Costs 3,288 3,123 165 4,385 4,308 77 4,178 (131) Total Expenditure 223,417 223,417 0 300,247 300,247 0 287,201 (13,046)

Surplus/(Deficit) 0 0 0 0 0 0 4,252 (4,252) * Outturn 2017/18 has been adjusted to reflect the boundary change for NHS Greater Preston CCG with effect from 1 April 2018. Page 205 Page

Productivity and Efficiency (QIPP)

YTD Risk Net QIPP QIPP overview as at 31st December 2018 Plan YTD Plan Actual (Shortfall) / Adjusted (Shortfall) / Benefit FOT Benefit

£000 £000 £000 £000 £000 £000

Out of Hospital 191 94 (41) (135) 796 605

Elective Care 2,040 1,407 1,073 (334) 1,960 (80)

Urgent Care 1,118 824 797 (27) 1,058 (60)

Mental Health and Learning Disabilities 216 162 162 0 216 0

Medicines Management 2,803 2,358 2,603 245 3,106 303

Other Programme 1,044 528 1,579 1,051 1,563 519 Total QIPP 7,412 5,373 6,173 800 8,699 1,287 Unidentified QIPP 2,630 1,989 0 (1,989) 0 (2,630) Total QIPP 10,042 7,362 6,173 (1,189) 8,699 (1,343)

Current position £000

YTD Actual

Plan

- 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000

Page 206 Page

Agenda Item 12

Governing Body Meeting

Date of meeting 24 January 2019 Title of paper EPRR - EU Exit Operational Guidance Update Presented by Mr Matt Gaunt, Chief Finance & Contracting Officer Author Ms Stephanie Betts, Corporate Governance Manager Clinical lead N/A Confidential N/A

Purpose of the paper To inform the Governing Body on the contents and requirements of the EU Exit operational guidance document and actions taken/to be taken

Executive summary

On 21st December 2018 the Department of Health & Social Care (DHSC) published EU Exit Operational Readiness Guidance, which was developed and agreed with NHS England and Improvement. This guidance listed the actions that providers and commissioners of health and care services in England should take if the UK leaves the EU without a ratified deal–a ‘no deal’ exit. This will ensure organisations are prepared for, and can manage, the risks in such a scenario.

This guidance has been sent to all health and care providers, including adult social care providers, to ensure the health and care system as a whole is prepared. Adult social care providers are advised to use this guidance as a prompt to test their own contingency plans. A further letter has also been sent in parallel to local authorities and adult social care providers to address specific adult social care issues.

All organisations receiving this guidance are advised to undertake local EU Exit readiness planning, local risk assessments and plan for wider potential impacts. In addition, the actions in this guidance cover seven areas of activity in the health and care system that the Department of Health and Social Care is focussing on in its ‘no deal’ exit contingency planning: • Supply of medicines and vaccines, • Supply of medical devices and clinical consumables, • Supply of non-clinical consumables, goods and services; • workforce; • reciprocal healthcare; • research and clinical trials; • data sharing, processing and access.

EPRR - EU Exit Operational Guidance Update NHS Greater Preston CCG Governing Body meeting Page 207 24 January 2019 Below is a table which details the requirements for commissioners and the action taken/to be taken:

Requirement for commissioners Action To confirm SRO for EU Exit Completed 7 January 2019 – Matt Gaunt is preparation to regional NHS England the SRO for EU Exit for the CCG To note nominated regional NHS Noted: Khaqan Ayaz Lead for EU Exit [email protected] To restate the Government message Meeting held with contract lead, medicines that UK health & Social care providers management lead, GP Directors, SRO and should not stockpile additional corporate governance lead on 10 January medicines or medical devices beyond 2019 their business as usual stocks Communication to be sent to all primary care providers restating the government message. Undertake a risk assessment to A meeting was held on 14 January 2019 with address seven key areas, potential the CCG operational lead, ELCCG EPRR increases in demand and locally Project Manager and LCFT and LTH EPRR specific risks leads to work collaboratively on local risks associated with EU Exit Review Business Continuity Plans Corporate Governance Lead to review CCG Business Continuity Plan by 31 January 2019

Support providers in testing their A meeting was held on 14 January 2019 the Business Continuity Plans CCGs operational lead with ELCCG EPRR Project Manager with LCFT and LTH EPRR leads to gain assurance on steps taken against requirements of issued guidance. Agreement to maintain regular contact in the ongoing months.

The EU Exit Operational Guidance is available on request.

Further guidance will be issued as more information becomes available from central government.

The Governing Body are asked to note the content of this report.

SO4 Ensure patients are at the centre of the planning and management of ☒ their own care, and that their voices are heard SO5 Be a well-run clinical commissioning group and the system leader ☐

EPRR - EU Exit Operational Guidance Update Page 208 NHS Greater Preston CCG Governing Body meeting 24 January 2019

Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome

Were any conflicts of interest identified at previous meetings (mark X in the correct box below) Yes No

If conflicts of interest were identified what were these:

Implications Quality/patient experience Yes ☐ No ☐ N/A ☒ implications? (Potential) conflicts of interest? Yes ☐ No ☐ N/A ☒ Equality Impact Assessment? Yes ☐ No ☐ N/A ☒ Privacy Impact Assessment? Yes ☐ No ☐ N/A ☒ Are there any associated risks? Yes ☐ No ☐ N/A ☒ Are the risks on the CCG’s risk ☐ ☐ ☒ register? Yes No N/A If yes, please include risk description and reference number

Assurance The actions taken will be managed through the NHS England EPRR Regional Leads Meetings

EPRR - EU Exit Operational Guidance Update Page 209 NHS Greater Preston CCG Governing Body meeting 24 January 2019

This page is intentionally left blank Agenda Item 13

Governing Body Meeting

Date of meeting 24 January 2019 Title of paper Equality Annual Report 2018 Presented by Helen Curtis, Director of Quality and Performance Author Dawn Clarke, Equality and Diversity Lead Clinical lead Dr Sandeep Prakash, GP Director Confidential No

Purpose of the paper To ask Governing Body members for approval of the CCG’s Equality Annual Report, which demonstrates how we have met our statutory duties for equality, diversity and inclusion.

Executive summary The Equality Annual Report supports CCGs in demonstrating legislative compliance with the Equality Act 2010, and also its 2011 provision, the Public Sector Equality Duty.

The report highlights a range of equality, diversity and inclusion evidence, and also includes the CCG’s results of the annual Equality Delivery System (EDS) assessment. EDS is a national NHS England framework that we use to assess our delivery against a range of outcomes under four specific equality and diversity goals:

• Goal 1 – Better health outcomes • Goal 2 – Improved patient access and experience • Goal 3 – A representative and supportive workforce • Goal 4 – Inclusive leadership

While EDS is a mandatory process for providers, it is recommended for commissioners, and is also used throughout the year as evidence for the NHS England Improvement and Assessment Framework.

The final results are included in the report for goals 1 and 2, with interim results currently included for goals 3 and 4.

Recommendations Members of the Governing Body are asked to approve the Equality Annual Report, subject to the final results being added for the goal 3 and 4 EDS assessments, and prior to it being published on the CCG website.

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body meeting 24 January 2019 Page 211 Links to CCG Strategic Objectives SO1 Improve quality through more efficient, safer services which deliver a ☐ better patient experience SO2 Commission care so that it is integrated and ensures an appropriate ☐ balance between in-hospital and out of hospital provision SO3 Be an integral part of a financially sustainable health economy ☐ SO4 Ensure patients are at the centre of the planning and management of ☐ their own care and that their voices are heard SO5 Be a well-run clinical commissioning group and the system leader ☒ Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome

N/A Were any conflicts of interest identified at previous meetings (mark X in the correct box below) Yes No X If conflicts of interest were identified what were these: N/A

Implications Quality/patient experience Yes ☐ No ☒ N/A ☐ implications? (Potential) conflicts of interest? Yes ☐ No ☒ N/A ☐ Equality Impact Assessment? Yes ☐ No ☐ N/A ☒ Privacy Impact Assessment? Yes ☐ No ☐ N/A ☒ Are there any associated risks? Yes ☐ No ☒ N/A ☐ Are the risks on the CCG’s risk Yes ☐ No ☐ N/A ☒ register? If yes, please include risk N/A description and reference number

Assurance On-going assurance in relation to equality, diversity and inclusion will continue to be provided in the Patient Voice Committee at each of its meetings, and to the Governing Body on an annual basis.

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body meeting 24 January 2019 Page 212

Equality annual report 2018

Overall we are ‘achieving’ equality in our commissioning of health services and for our workforce.

Page 213 Contents

Foreword 1 (Page 3)

About us and our communities 2 (Page 5)

Statutory equality requirements 3 (Page 11)

Equality delivery system - results 4 (Page 17)

Equality delivery system - evidence 5 (Page 20)

Contact details and alternative formats 6 (Page 60)

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 214

Foreword

Welcome to the equality annual report for Chorley and South Ribble Clinical Commissioning Group and Greater Preston Clinical Commissioning Group (CCGs), the organisations that plan, buy and monitor local health and care services on behalf of the local population in central Lancashire.

This report highlights some of the work we have done in 2018 to improve local health and care services for our vulnerable and protected communities (Equality Act 2010). 2018 was our fifth full year in operation, and has also been the most challenging year we have faced to date. It is recognised nationally that the NHS has to change in order to keep providing high quality, safe care that is free at the point of delivery, within the limited resources that are available.

Our CCGs are entering a new era in ensuring local health and care services are fit for the future. It's been another busy year with lots of change taking place across the health economy, but equality and diversity remains integral to our effective leadership.

Messages from our equality and diversity leaders

Denis Gizzi, Dr Sumantra Dr Ann Chief Officer Dr Gora Bangi, GP Dr Sandeep Helen Curtis, , Chair and Mukerji, Chair Robinson, GP Chorley and Director, Prakash, Director of Clinical Leader, and Clinical Director, South Ribble Chorley and Quality and Chorley and Leader, Greater Greater Preston CCG and South Ribble Performance Preston CCG CCG - equality Greater Pres ton South Ribble CCG - equality CCG CCG and diversity and diversity

Denis Gizzi

This year the NHS has taken decisive steps to break down the national barriers in how health and care are provided between family doctors and hospitals, physical and mental health, and health and social care. England is too diverse for a ‘one size fits all’ health and care model to apply everywhere, therefore all CCGs are required to see more health and care being designed and delivered in line with the needs of our local communities.

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 215 We are facing a number of health and care challenges across the country, such as:

• A growing population • An increased demand on services • Not enough funding • Not enough qualified staff

There are no short-term or easy solutions, so we have developed some ambitious plans with the help from our partners in health and social care across central Lancashire and as part of the wider Healthier Lancashire and South Cumbria integrated care partnership, and people in our local communities.

As clinical commissioning groups we have ensured that we have engaged with a number of people that represent different local communities. If you are a member of a community that would like to be involved in future engagement and consultation events, please email our equality and diversity lead or telephone 01772 214 396 for more information.

Dr Gora Bangi

This year we have focused on the development of a sustainable model of primary care, challenging local GPs to form collaborations and work closer together to deliver the improvements that are needed. This includes the management of redirected budgets and provides more services across central Lancashire. We have improved the integrated urgent care services at Chorley and Preston hospitals which will help the hospitals to manage the demand on their services more effectively, especially over the winter period.

Dr Sumantra Mukerji

The CCGs develop business cases to design health services for all the people in our communities. The process for this includes the need to undertake a number of assessments, such as a financial impact assessment, quality impact assessment, data privacy impact assessment and an equality impact assessment. This ensures that we design services that enable everyone to access the best quality of care possible whilst receiving the best patient experience we can deliver to result in the most effective health outcomes at the best cost.

The Equality delivery system (EDS) assessment we undertake highlights how we monitor the way we commission services with support of people in our communities to provide assurance that we are compliant with equality legislation and reduce health inequalities within central Lancashire in line with the NHS 5 year Forward View, 2014.

Dr Ann Robinson

This year our equality strategic group focused on NHS England’s GP contract to enable GP staff to support patients more effectively. This has included the need to have leads within each practice, clinical or managerial, for a number of conditions, such as atrial fibrillation (AF), cancer – breast,

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 216 bowel and cervical, dementia, end of life care, asthma, heart failure, chronic obstructive pulmonary disease (COPD) and learning disabilities. There was also a requirement to have a medicines optimisation lead and a carers’ lead, both of which will support people by ensuring that they are given and are taking the correct medications.

The CCGs provided support to GP practices in the form of identifying specialists for hot topic sessions to represent the GP lead requirements in the GP contract. The CCGs have also recruited people who support GP practice patient participation group (PPG) members to ensure that we are working more collaboratively together.

Dr Sandeep Prakash

The CCGs fund the use of translation and interpretation services for GP services in central Lancashire. This is an excellent support for people who do not speak English as their first language and require telephone translation and also for people who have hearing loss and use British Sign Language as their first language.

This year, the CCGs provided equality and diversity training to GP administration staff, using practical examples of patient feedback on primary care issues. The feedback from the training sessions was extremely positive with a number of staff making personal pledges to improve their services by being more patient-focused, especially for the most vulnerable people in our communities.

The CCGs have also developed an equality and diversity policy for GP practices to adopt to ensure all patients are treated equitably across central Lancashire. This will be shared in February 2019 with GP practices to adopt, should they wish to do so.

Helen Curtis

The CCGs are committed to ensuring that equality and diversity is integral to the work we do with respect to our local populations and our employees. Equality and diversity came under my responsibility this year, which fits in nicely with the quality and performance business unit, specifically around the equality delivery system (EDS) assessment, workforce race equality standard (WRES) requirements and the management of consultations with patient advisory group members.

I am pleased with the year on year progress we are making against this commitment, specifically in the consistent improvement in organisational processes and the targeted engagement implemented as part of the Healthier Lancashire and South Cumbria digital transformation work and the Our Health Our Care programme.

We have engaged with a number of people who represent the protected characteristics (Equality Act, 2010), such as young people who represent lesbian, gay, bisexual and transgender communities; people with sensory loss (sight and hearing); ethnic minority groups and people with

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 217 learning disabilities. I would personally like to offer my sincere gratitude to all those who have supported us and hope you continue to support us going forward.

About us and our communities

We are two clinical commissioning groups that plan, organise and buy a range of healthcare services for people in our local communities.

The population we cover is approximately:

• 184,000 people in Chorley and South Ribble • 209,000 people in Greater Preston

We are part of the National Health Service (NHS), but being a clinical commissioning group means that we are run by local healthcare professionals, such as family doctors, hospital doctors and nurses. We are also a member organisation. Our members are made up of all of the 30 GP practices in Chorley and South Ribble and all 26 GP practices in Greater Preston.

Our people

Chorley and South Ribble CCG employs 72 people who are seconded to also work on behalf of Greater Preston CCG. We also work closely with a local NHS commissioning support unit, with some of these support unit staff ‘embedded’ within the CCGs at our head office at Chorley House in Leyland.

CCGs’ vision, values and objectives

Our vision:

Ensure equal and fair access to safe, effective and responsive health and social care for our communities that represent value - now and in the future

Our values:

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 218

Our strategic objectives:

Commission care Ensure that Improve quality so that it is patients are at the through more integrated and Be a well run Help engineer a centre of the effective, safer ensures an clinical financially planning and services, which appropriate commissioning sustainable health management of deliver a better balance of in- group and the their own care patient hospital and out- economy and their voices system leader experience of-hospital provision are heard

Equality and diversity is the delegated responsibility of the Patient Voice Committee, which is embedded into the governance of the organisation, and links closely with a patient advisory group, as detailed below.

Our engagement framework:

OPERATIONAL OPERATIONAL STRATEGIC ACCOUNTABILITY Patient Advisory Group Involvement Network Patient Voice Committee NHS Chorley and South Young People's Health (scrutiny and assurance) Ribble CCG Governing Young People's Body Involvement Network Advocates NHS Greater Preston (e-networks) (public involvement and consultation) CCG Governing Body

The CCGs also have an ‘equality strategic group’ to help plan direction of travel and implement change. The group is made up of the operational and strategic leads for equality and diversity, the GP directors with responsibility for equality and diversity, and the CCGs’ staff equality champions.

CCGs’ equality strategy, aims and objectives

The CCGs’ equality and diversity strategy has been developed in recognition of our position as a commissioning organisation responsible for improving health outcomes of our local population.

The strategy outlines the challenges and opportunities we face and identifies how we can address the former and embrace the latter. It recognises our past and current efforts on equality and diversity issues, and provides a tangible vision for the future.

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 219 The strategy responds to the legislative framework for equality and diversity under the Equality Act 2010, along with the regulatory requirements set by the Department for Health and NHS England. However, it should be noted that the overall approach of the strategy is to deliver over and above the law and regulation, to ensure that equality and diversity underpins all of our activities, plans, processes, policies and organisational development. Our aim

Deliver the equality function objectives to support the CCGs to meet their overarching business objectives for the financial year 2017/18

Our objectives

Engage member Deliver efficient and Meet statutory Engage staff in practices in equality, strategic equality, equality, diversity equality, diversity and diversity and inclusion diversity and inclusion and inclusion inclusion issues issues activities requirements

Examples of how we meet our equality objectives

• Internal learning and • GP directors have • Equality and diversity • Demonstration of training sessions responsibility for governance structure compliance with equality and diversity • Equality and diversity • Protected national equality mandatory training • GPs participate in characteristic requirements procurement panels - • Equality impact membership and high focus on recruitment plans for assessments - clinical population needs policies, HR policies the patient groups and and business case • Direct support for networks proposals equality and diversity issues, including translation

Other examples of how we achieve our equality objectives are embedded within the evidence section of this report.

Local issues and solutions

From the list of protected characters, age and disability are the highest priorities for our CCGs. As the population ages, the demand on health and care services increases because more people need care and treatment.

In our area, the number of people over the age of 65 has increased more than the England average. In the past 12 months 39.6% of unplanned hospital admissions have been by people over 65 years of age. People who are over 65 years of age represent 17.8% of the population in central Lancashire.

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 220 The increase in ageing population has also increased the number of people identifying with either a long term condition or a disability.

The most common long term condition areas we need to think about are circulation, musculoskeletal, gastrointestinal, respiratory and mental health.

Our communities

We provide healthcare for approximately 393,600 people. The chart below provides a breakdown of the people in our communities and their health profile in December 2018.

6.4% people have 2.7% people have been diagnosed with been diagnosed with asthma cancer

14.2% people have 196,643 females 0.7% people aged 65+ been diagnosed with (49.96%) are recorded as having hypertension 196,957 males dementia (50.04%)

66.5% people are 88.5% people are

physically active White British

Population age

22435people are >5

66518 people are 5-19 235373 people age 19-65 11.7% people are 53136 people age 65-79 6.8%people over17

diagnosed with 16925 people are 80+ have diabetes

depression

3.6% people have 1.9% people have had been diagnosed with a stroke coronary heart disease

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 221

Protected characteristics

The ‘protected characteristics’ have been identified in the Equality Act 2010. The equality delivery system identifies additional characteristics that organisations might want to consider when commissioning or providing services for people.

Our CCGs are aiming to ensure that membership of our patient and public groups represent people in the wider communities. The chart below highlights the main protected characteristics in the inner circle and the extended characteristics in the outer circle.

Children and young people (0- 25) Adults (25-55) Older adults Deprivation (55+) Physical and Homelessness mental health Social isolation Sensory loss Unemployed Learning Veterans disability Substance Long term misuse Age condition

Vulnerable Disability groups

Our Lesbian communities Male Gay Gender Sexual (sex) Female Bisexual Orientation in central Transgender Heterosexual Lancashire

Pregnancy Religion and and belief maternity

Race Christian Pregnant woman Islamic Partner Hindu Parent of child Jewish up to 3 years Carer

White British Black Asian Mixed

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 222

Statutory equality requirements

The CCGs have a number of legal requirements with regards to equality and diversity.

The table that follows shows the national requirements and the CCGs’ position in relation to these.

Legislation and requirements Our CCGs’ position Equality Act (2010) General duties Our CCGs ensure we show due 'Public authorities' must show due regard to our workforce and people regard to the need to: who use the services we • Eliminate discrimination, commission in the following ways: harassment, victimisation and any • HR policies other conduct that is prohibited by • Clinical policies or under the Act. • Business cases and operational

• Advance equality of opportunity procedures between persons who share a • Procurement processes relevant protected characteristic • Public consultations and and persons who do not share it. engagement • Training and development • Foster good relations between persons who share a relevant opportunities protected characteristic and persons who do not share it. • Our CCGs publish a new Equality Specific duties • Public authorities to publish Annual Report by 31 January every information annually to year. demonstrate compliance with the • We published the CCGs’ equality general equality duty from 31 strategy (2017-2019) on our

January 2012. websites in July 2017. • Public authorities to prepare and publish one or more equality objective it thinks it should achieve to meet the general equality duty.

To be done at least every four years from 6 April 2012. Public Sector Equality Duty • All our business cases are equality (PSED) impact assessed.

• Better informed decision making. • Our Patient Advisory Group (PAG)

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 223 Legislation and requirements Our CCGs’ position • A clearer understanding of the and Young People’s Health needs of patients. Advocates (YPHAs) are consulted • More effective targeting of policy, on clinical policies, service resources and the use of regulatory redesign projects, and CCG powers. activity. • Better results and greater • Our CCGs have not received any confidence in and satisfaction with, claims of discrimination. public services. • A reduction in instances of discrimination and claims. Equality Delivery EDS Our CCGs undertake the EDS self- System 2 (2013) In order to support compliance with assessment every year to ensure we the Equality Act (2010) the NHS has meet the General Duties of the developed an Equality and Diversity Equality Act (2010).The outcomes Framework: The Equality Delivery for 2017 indicates: System 2 (EDS2). The aims of the • We are ‘achieving’ or ‘excelling’ in EDS2 are to: improving health outcomes for • Help the NHS deliver on the patients and improving access and government’s commitment to the experience of patients. fairness and personalisation, • We are ‘achieving’ or ‘excelling’ in including the equality pledges of having a representative and the NHS constitution. supported workforce and inclusive • Deliver improved and more leadership. consistent performance on equality • Our CCGs employ a number of key across the NHS. stakeholders with responsibility for • Help NHS organisations respond equality and diversity. more readily to public sector duties • By ensuring all commissioning imposed by the Equality Act 2010. business cases have an equality

impact assessment (EIA) our CCGs are improving access to services and are therefore contributing to NHS Outcome Framework domains. NHS Constitution The NHS Constitution aims to • NHS Constitution targets are (2015) improve our health and wellbeing, monitored via the CCGs’ quality supporting us to keep mentally and and performance team and physically well, to get better when assurance is provided to the we are ill and, when we cannot fully Governing Bodies via the Quality recover, to stay as well as we can to and Performance Committee. the end of our lives. NHS principles: • These are published every year in • The NHS provides a the statutory and audited annual comprehensive service, available report and accounts. to all. • Access to NHS services is based on clinical need, not an individual’s ability to pay.

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 224 Legislation and requirements Our CCGs’ position Care Quality The CQC’s strategic approach to Our CCGs have provided EDS Commission equality in regulation focuses on evidence that evidences the CQC’s (CQC) Regulations being: regulations: (2016) • Safe • EDS 1.4 • Effective • EDS 1.1

• Caring • EDS 2.3 • Responsive • EDS 1.2 • Well-led • EDS 4.1

There will be additional evidence that may cover the CQC regulations embedded in the remaining EDS outcomes. Workforce Race Implementing the Workforce Race • Our CCGs have completed the Equality Standard Equality Standard (WRES) is a WRES template since 2015. (WRES, 2016) requirement for NHS commissioners • We have monitored our main and NHS healthcare providers, providers’ WRES submissions including independent organisations, since 2015. through the NHS Standard Contract. • There are some gaps in our data and this has been addressed within our staff survey.

Modern Day All public authorities are required to • Our CCGs believe there is no room Slavery Act (2015) co-operate with the police in our society for modern slavery commissioner under the Modern and human trafficking. Day Slavery Act (2015). This • We have a zero tolerance for means that police and health and modern day slavery and breaches care services, together with of human rights, and ensure this voluntary organisations, are legally protection is built into the

required to work together to support processes and business practices people who have experienced that we, our partners and suppliers slavery. This includes: use. • Working with identified advocates

to ensure ‘due regard’ has been given. • Provide advocates with the relevant information to enable them to carry out their function

effectively. Slavery is a violation of a person’s human rights. It can take the form of trafficking, forced labour, bonded labour, forced or servile marriage,

descent-based slavery and domestic slavery.

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 225 Legislation and requirements Our CCGs’ position Accessible The AIS standard applies to service The CCGs ensure that providers Information providers across the NHS and adult have implemented the five basic Standard (AIS, social care system, and effective steps within the Accessible 2016) implementation requires such Information Standard. They are: organisations to make changes to • Ask – about communication policy, procedure, human behaviour needs. and, where applicable, electronic • Record – needs on electronic systems. systems. Commissioners of NHS care and • Highlight – needs when records publicly-funded adult social care are accessed. must also have regard to this • Share – data sharing agreement. standard, in so much as they must • Act – monitor feedback for ensure that contracts, frameworks effectiveness. and performance management arrangements with provider bodies enable and promote the Standard’s requirements. Sexual Orientation The SOM provides a mechanism for Our CCGs have required assurance Monitoring recording the sexual orientation of all from providers on the following: Information patients/service users aged 16 years • Both the CCGs and our providers Standard (SOM, and over across all health services are able to demonstrate the 2017) and local authorities with provision of equitable access for responsibilities for adult social care LGB individuals (EDS 2.1). in England, and in all service areas • Our CCGs are monitoring our where it may be relevant to record providers to determine if there is this data. an improved understanding of the impact of inequalities on health LGBQ = Lesbian, gay, bisexual and and care outcomes for LGB questioning populations in England (EDS 1.1,

1.2, 4.1). We have ensured that all business cases and clinical policies include an equality impact assessment and

quality monitoring: • Both the CCGs and our providers can identify health risks at a population level that supports targeted preventative and early

intervention work to address health inequalities for LGB populations.

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 226 Legislation and requirements Our CCGs’ position Workforce The WDES will be mandated in the Our CCGs have provided feedback Disability Equality NHS Standard Contract from April to the Equality and Diversity Council Standard (WDES, 2018. to support the development of 2018) WDES, and we have reviewed the draft metrics for WDES in preparation for our submission and the monitoring of our healthcare providers.

Carers Act (2014) The Carers Act 2014 sets out Our CCGs have people on our carers' legal rights to assessment Patient Advisory Group membership and support. It came into force in who represent adult carers. April 2015. The Care Act relates mostly to adult carers – people aged We commission services to support 18 and over who are caring for carers and we are members of a another adult. This is because young Lancashire-wide ‘carers together’ carers (aged under 18) and adults strategy group.

who care for disabled children can be assessed and supported under children's law.

Finance and the Public Sector Equality Duty (PSED)

The Government Equalities Office published its Regulatory Impact Assessment for the costs and benefits of creating a single set of specific duties to underpin the Public Sector Equality Duty.

Costs to NHS service Benefits • One-off costs • Implementation and response to one piece of equality o Staff training and legislation (Equality Act 2010) as opposed to the development of PSED. number of previous Acts. • Annual costs • Wider benefits o Employment of staff to o Takes account of the needs of disadvantaged undertake this programme of people (employees and service users) work o Improves consideration of hidden discrimination o Gathering evidence for EDS and reduction of systematic barriers o Publishing evidence of EDS o Enables informed decisions to be made on activity and grading available evidence. • Outcomes o Inclusive reporting of all protected characteristics together improves equity of outcome (before this was gender, disability and race separately) o Improved access o Improved patient experiences

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 227

o Improved workforce experiences

o Improved reputation o Reduced social costs of inequity *Although it is not possible to robustly monetise these benefits, these are nonetheless significant. • Transparent about the impact we NHS England has estimated cost savings for small and are seeking on equality large organisations. The following figures are based on • Develop, publish and review possible net benefits for small organisations when equality objectives which includes implementing the Public Sector Equality Duty (PSED). statistical / research support (3 days) average annual cost Activity Cost £5,000. One off cost of familiarisation £149,977 • Assess the impact on equality of Annual reoccurring cost of new £767,871 their policies and service delivery specific duties initiatives Annually reoccurring benefits of £1,201,369 o Evidence and discussions (5- having one Act to respond to 7 sessions a year) Net benefits (Year 1) of new £67,448 o Analyst (1 day on each) specific duties *There is no legal requirement to Net benefits (Year 2) onwards of £267,417 publish this information. specific duties

Finance and the Equality Delivery System (EDS)

As the Equality Delivery System (EDS) has been designed by the NHS to help organisations respond more effectively to the Public Sector Equality Duty (PSED), the costs and benefits given above may apply to the EDS. The EDS provides an approach to delivering on the PSED that directly relates to health outcomes for patients and better working environments for staff. EDS can help organisations to identify poor performance and poor workforce practice. If the EDS outcomes are analysed and implemented, the benefits would be:

Activity Outcome Prevention: Public health campaigns • Reduction of illness and long term conditions reach more people, change lifestyles • Improved mortality rates by saving lives or regimes and increase the take up of screening and vaccination programmes. Access: improving patient and carer • Reduction of illness and long term conditions access and experience of services • Improved mortality rates by saving lives Self-care: helping people to regain / • Improves mental health and wellbeing retain their health • Increases social and financial benefits – contribution to family, community and employers Workforce: investing in the health and • Improves employees’ working life balance

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 228 wellbeing of their staff, outlaw bullying • Increases staff morale and harassment and promote flexible • Reduces staff illness working options. • Improves wider recruitment talent • Improves retention rates • Improves business outcomes • Improves organisational reputation • Creates a confident and competent workforce • Deliver better health outcomes to patients and the public

Equality delivery system - results

The main purpose of the Equality Delivery System (EDS) is to help NHS organisations show how they work in partnership and for local people and the workforce to review how we deliver for people with protected characteristics (Equality Act 2010).

EDS also helps organisations show that they are delivering the Public Sector Equality Duty. While the application of the EDS process can be applied differently in different organisations, it is the only process that has been nationally implemented to assess equality activity within NHS commissioned and provider services, and is therefore utilised within our CCGs to highlight our equality performance on a year-on-year basis.

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 229 EDS grading process

Our CCGs have adapted the national scoring framework for EDS to include the frequency and quality of activity undertaken.

• Undeveloped: We are undeveloped if we are considering the needs of people representing less than two protected characteristics, if we never consider the needs of people with protected characteristics when we buy health services, or if we are poor at monitoring how a service is delivered for people with protected characteristics.

• Developing: We are developing if we are considering the needs of people with between three and five protected characteristics, if we sometimes meet the needs of people with protected characteristics when we buy health services, or if we are average at monitoring how a service is delivered for people with protected characteristics.

• Achieving: We are achieving if we are considering the needs of people with between six and eight protected characteristics, if we usually meet the needs of people with protected characteristics when we buy health services, or if we are good at monitoring how a service is delivered for people with protected characteristics.

• Excelling: We are excelling if we are considering the needs of people for all nine protected characteristics, if we always meet the needs of people with protected characteristics when we buy health services, or if we are excellent at monitoring how a service is delivered for people with protected characteristics.

CCGs’ EDS results 2018

The EDS process enables our CCGs to share evidence of our equality and diversity activity with members of the public and our workforce. Our Patient Advisory Group (PAG) grades us on goals 1 and 2, the patient focused outcomes, and our staff and office holders grade us on goals 3 and 4, relating to workforce and leadership. We were graded for goals 1 and 2 on 24 October by the Patient Advisory Group (PAG) members using a world café presentation. The results are shown below:

Goal 1: Better health outcomes 14 15 16 17 18 1.1 Services are commissioned, procured, designed and delivered to meet the health needs of local communities. 1.2 Individual people’s health needs are assessed and met in appropriate and effective ways. 1.3 Transitions from one service to another for people on care pathways are made smoothly with everyone well informed.

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 230 1.4 When people use NHS Services their safety is prioritised and they are free from mistakes, mistreatment and abuse. 1.5 Screening, vaccination and other health promotion services reach and benefit all communities. Goal 2: Improved patient access and experience 14 15 16 17 18 2.1 People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds. 2.2 People are informed and supported to be as involved as they wish to be in decisions about their care. 2.3 People report positive experiences of the NHS. 2.4 People’s complaints about services are handled respectfully and efficiently.

We are awaiting the latest results of goal 3 and goal 4, once an assessment panel has conviened. Interim results featurefor these goals in the evidence section of this report.

Goal 3: A representative and supported workforce 14 15 16 17 18 3.1 Fair NHS recruitment and selection processes lead to a more representative workforce at all levels 3.2 The NHS is committed to equal pay for work of equal value and expects employers to use equal pay audits to help fulfil their legal obligations 3.3 Training and development opportunities are taken up and positively evaluated by all staff 3.4 When at work, staff are free from abuse, harassment, bullying and violence from any source 3.5 Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives 3.6 Staff report positive experiences of their membership of the workforce Goal 4: Inclusive leadership 14 15 16 17 4.1 Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their organisations 4.2 Papers that come before the Board and other major Committees identify equality-related impacts including risks, and say how these risks are to be managed 4.3 Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination

Equality Annual Report 2018 NHS Greater Preston CCG Governing Body Meeting 24 January 2018 Page 231 EDS key outcomes

Our CCGs have undertaken a desktop review to identify how well we are doing in comparison to CCGs with similar demographics and communities. The tables below highlight the EDS scores for all eighteen outcomes for each comparator CCG. There are gaps if either no data is available, or where some CCGs have not undertaken an assessment on all outcomes.

NHS Chorley and South Ribble CCG

Similar NHS CCG organisations 1.1 1.2 1.3 1.4 1.5 2.1 2.2 2.3 2.4 3.1 3.2 3.3 3.4 3.5 3.6 4.1 4.2 4.3 NHS Bassetlaw NHS Barnsley NHS Chorley & South Ribble NHS Darlington NHS Hardwick No data NHS Newark & Sherwood No data NHS Nottingham North & East No data NHS Redditch and Bromsgrove NHS South Cheshire CCG NHS Warrington CCG NHS Warwickshire North CCG

NHS Greater Preston CCG

Similar NHS CCG organisations 1.1 1.2 1.3 1.4 1.5 2.1 2.2 2.3 2.4 3.1 3.2 3.3 3.4 3.5 3.6 4.1 4.2 4.3 NHS Calderdale CCG NHS East Lancashire CCG NHS Leeds North CCG & NHS Leeds South and East CCG NHS Lincolnshire West CCG NHS North East Lincolnshire CCG NHS Greater Preston CCG NHS South Tees CCG NHS Stoke on Trent CCG NHS Tameside and Glossop CCG NHS West Lancashire CCG

Page 20 of 64 Page 232 5 Our equality delivery system evidence

The role of NHS commissioners

To ensure that those who are grading us understand what they need to consider and actually grade us as a commissioner of health services, we give them the following information as context:

• We are clinically-led statutory NHS bodies responsible for the planning and commissioning of health care services for their local area. • Commissioning is about buying the best services to ensure we get the best possible health outcomes for the local population. • This involves assessing local needs, deciding priorities and strategies, and then buying services on behalf of the population from providers such as hospitals, clinics, community health bodies, etc. • It is an ongoing process and CCGs must constantly respond and adapt to changing local circumstances. • We are responsible for the health of the entire population of central Lancashire.

We provided evidence for each of the equality delivery system (EDS) outcomes. This evidence is highlighted in this report.

In 2017, we were asked by the people who graded us to remind them of the evidence we presented from the previous year. We have continued this as good practice in 2018.

The CCGs’ world café EDS 2018

A session was introduced by the director of quality and performance, Helen Curtis, who in 2018 became responsible for the equality and diversity function for both CCGs. gtd healthcare

Samuel Eaton, general manager at gtd healthcare, provided an overview of the urgent care service along with the referral process and some themes and trends that had been identified within the first year of operation. He provided evidence for EDS outcomes:

1.4 Patient safety 2.1 Patient access 2.3 Patient experience

The evidence has been published in the appropriate EDS outcome sections.

Page 21 of 64 Page 233 Goal 1: Better health outcomes – patient focused

1.1 Services are commissioned, procured, designed and delivered to meet the health needs of local communities.

This outcome focuses on the comparisons of how people from all protected groups fare, in relation to services meeting their health and care needs, compared to people overall.

CCGs are responsible for the local commissioning of community and hospital health services. We are privileged to have supportive patient groups who provide their time and expert knowledge at different stages in the commissioning cycle process to ensure we are designing health and care services that meet the needs of our local communities. The boxes below outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

We scored 'achieving' in We scored 'achieving' in We scored 'achieving' in 2016 2017 2018 • CCG priorities • Commissioning cycle and • Procurement of a mental • Equality in the commissioning activity health crisis cafe (the Haven) cycle • Primary Care Strategy • A stand and a member of staff • Equality impact assessment • Health care services to provide information process • ERIN (under 5's) • CCG specialist undertaking a • Procurement process • IMSK (procurement) questions and answers for this • Service redesign projects • Urgent Care Centre goal on a one-one / group basis. • Monitoring and evaluation • Eating disorder service process • Equality proceses and mandated requirements

The CCGs’ commissioning cycle process

When we commission services, we know that people access services differently. Therefore we include the following requirements in our commissioning processes.

Strategic planning

• Research is undertaken to identify the most likely people who will need to access the identified service as part of the business case. • All business cases have an equality impact assessment (EIA). • All new and reviewed clinical policies have an EIA. • All new and reviewed HR policies have an EIA. • All EIAs are quality assured by the equality and diversity specialists.

Page 22 of 64 Page 234 Procuring services

• Services are designed to meet the needs of all people in local communities (identified in the EIA), and includes public engagement where appropriate. • Service users take part in the procurement process and score potential providers in-line with the CCGs’ procurement process.

Monitoring and evaluation

• Public engagement is undertaken to collect feedback on the commissioned services. This can be through patient stories, friends and family tests, workshops, surveys, etc. • Provider services provide evidence of the options they offer people accessing their services as part of the monitoring process. • Services are monitored on their performance.

Evidence: The Haven crisis café

Based on evidence, we decided to commission a crisis café that would be initially procured by the CCGs and then in the third year become a social enterprise. We shared the following information with the graders at the event.

The procurement manager, supported by the Head of Urgent Care and Mental Health presented the evidence below:

• A needs analysis – why do we need a crisis support service? • Population demographics – focusing on prime attributes to people who may require a crisis service, such as the levels of deprivation, alcohol and substance misuse, depression and smoking prevalence. • Expected outcomes – reductions in self harm and suicide, reduction in A&E attendances, reduction in hospital admissions, reduction in out of area placements, new staff skills and techniques to support self-management and recovery, prevention of future crisis and improved community resilience and coping strategies. • How we are procuring a crisis café – aims, expected benefits and public involvement. • Input on the design of the crisis café from the CCGs’ equality and diversity lead and in the procurement process.

Page 23 of 64 Page 235 1.2 Individual people’s health needs are assessed and met in appropriate and effective ways.

This outcome focuses on the comparisons of how people from all protected groups fare, in relation to services meeting their health and care needs, compared to people overall.

The CCGs are responsible for ensuring that we commission equitable services for all individuals in line with equality legislation (section 3). Midlands and Lancashire Support Unit supports the CCGs to assess personal health budgets and we have shared our processes for ensuring that the focus was on meeting individual people’s needs and those who represent different protected groups. The boxes below outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

We scored 'achieving' in We scored 'achieving' in We scored 'achieving' in 2016 2017 2018 • CCG priorities • Different ways we consider • Preston care and repair • Transation and interpretation individual peoples needs • Galloways Society for the blind process • Case study for clinical • Chorley women's centre • Mobilisation plans processes • Fit for surgery framework • Mazars reports - reporting the • Clinical policy example: • Fit for surgery pathway individual deaths of people assisted conception with a learning disability

We have provided evidence of services that we commission in relation to age, disability, sensory loss, gender, obesity and smoking for the people in our local communities.

Preston Care and Repair

This service focuses on frailty and long term conditions, which mostly caters for older people with long term conditions and disabilities. It provides:

• Support for safe independent living. • Minor home repair services such as grab rails and repairing paving tiles to help prevent injury. • Outcomes: o 49% of people felt less at risk of having a fall or accident in their own home o 62% of people felt safer and more secure in their own home o 54% of people feel more independent in their own home

Galloways Society for the Blind

This service focuses on supporting people who are visually impaired which caters for people of all ages and backgrounds with sight loss. It provides:

• Trained eye clinic liaison officers provide practical solutions and tailored support to those living with sight loss • Help people stay safe in their own homes • Provides peer support and signposting to other relevant support Page 24 of 64 Page 236 Chorley Women’s Centre

This service focuses on supporting women and a small number of men which mostly focuses on gender. It provides:

• Helping women become more independent. • Providing support for physical and mental health conditions. • Counselling on bereavement, relationships and family issues. • Counselling for men and women for sexual assault.

Fit for surgery

This service focuses on offering people the opportunity to stop smoking or lose weight before they have elective surgery which focuses on all protected groups. It provides:

• Weight management and quitting smoking options prior to non-urgent surgery. • Fit for surgery framework and pathway developed (endorsed by the CCG patient advisory group).

1.3 Transitions from one service to another for people on care pathways are made smoothly with everyone well informed.

This outcome focuses on the comparisons of how people from all protected groups fare, in relation to services meeting their health and care needs, compared to people overall.

The CCGs’ planning and delivery teams have made improvements to a number of service pathways to improve the transitions across or into services. The boxes below outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018. The boxes below outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

We scored 'achieving' in We scored 'achieving' in We scored 'achieving' in 2016 2017 2018 • CCG priorities • We provided an overview of • ERIN initiative - children under • Transforming care agenda NHS RightCare and aligned 5 years old • Children and young people our EDS scores to this • IMSK - Movng Well service - transformation programme process - highlighting that we operational pathway are the best for EDS our of • Emergency department services our peer CCGs • Crisis services • Out of hours services • Perinatal services

We have provided evidence of services that we commission in relation to younger and older age, learning disability, autism, physical disabilities and long term conditions for the people in our local communities.

Page 25 of 64 Page 237 ERIN Initiative

This service focuses on providing a diagnosis for pre-school age children for possible learning disabilities or autism, focusing on the age and disability protected groups. It provides:

• Identification of pre-school age (under 5) children who require a local accessible, responsive early assessment and intervention service for referral to the learning disability and autism pathway. • Evidence based: o Evidence has highlighted significant gaps within this service provision o Lack of support for parents and carers who care for children with challenging behaviours when no diagnosis has been provided o Parents and cares are unaware of coping techniques • Expected outcomes: o Increased diagnostic rate to 88% o Additional home information considered to provide the missing piece of the jigsaw o Parental confidence in process strengthened o Parents /carers are included in the child’s assessment and feel they are listened to o Reduction in onward referrals to school age ASD pathway

Moving Well Service (IMSK)

This service is one of the biggest improvements for patients in central Lancashire. The ‘moving well service’, originally called the integrated musculoskeletal (IMSK) service, has enabled GPs to send one referral into five services to be triaged and managed more appropriately. This project started in 2017 and some services have been operational since 1 August 2018 and others from 1 October 2018. A number of elements of this service have been introduced to make treatment more accessible to patients, focusing mostly on the age and disability protected groups. It provides:

• E-referral service pathway via a single point of access to physiotherapy / tele-physiotherapy services, musculoskeletal, rheumatology, community pain and chronic fatigue syndrome (CFS) service? • Ascenti patient portal – provides patients with general exercise videos, guidance and advice. • I-GRO star app – a patient-defined wellbeing measure and therapeutic solution-focused tool to improve the patient’s quality of life. • ESCAPE – enables self-management and coping with arthritic pain using exercise.

1.4 When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse.

This outcome focuses on the comparisons of how people from all protected groups fare, in relation to services meeting their health and care needs, compared to people overall.

The CCGs’ quality and safeguarding teams review the provider services activity to ensure that the people who use the services we commission are safe and free from mistakes, mistreatment and abuse. The boxes on the next page outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

Page 26 of 64 Page 238 We scored 'achieving' in We scored 'achieving' in We scored 'achieving' in 2016 2017 2018

• CCG priorities • CQUINS for patient safety • Urgent care • Falls collaborative action • React to red • Qualityimprovement falls group collaborative • Female Genital Mutilation • HCAI / pressure ulcers • HCAI Newsletter (FGM) • Staff training for vulnerable • CQUIN schemes people • Seerious Incident reviews • Stool sampling guidance • Safety thermometer • Wound care training • React to red • Care home training • C-Difficile case review.

We have highlighted some examples of the services we commission that focus on age, disability, vulnerable adults, urgent health needs and people acquiring hospital infections from within our local communities.

Urgent care: Workforce equality and diversity training

This service focuses on providing an urgent care service for all local people, focusing on all protected characteristics groups. It provides:

• gtd healthcare’s board has received development in equality and diversity to ensure that all policy decisions and service developments are focussed on protecting equality and diversity. • Routine audit of every clinician to ensure that their consultations meet the required standards. • Mandatory training around equality and diversity which supports professional standards. • Whistleblowing and incident reporting policies in place across the organisation to enable staff to report issues wherever they arise.

There are a number of key performance indicators that we put into our contracts to support a positive patient experience:

• To provide assurance that the care patients receive is safe – in every contract. • National quality indicators are monitored locally by us. • Develop local indicators that provider organisations must meet. • Evidence is reported using qualitative and quantitative formats to include facts and figures.

Pressure ulcer prevention (React to Red)

This service focuses on providing training for provider staff for vulnerable people, mostly focusing on age and disability protected groups. It provides:

We have continued to train pressure ulcer prevention champions including carers, managers and nurses in care homes and hospital wards by working in partnership with: • Lancashire Care NHS Foundation Trust • Lancashire Teaching Hospital NHS Trust • Lancashire County Council Page 27 of 64 Page 239 In 2018 we have successfully commissioned:

• Delivery of staff training to four cohorts of new champions. • Delivery of staff training to two annual update sessions for existing champions, which has included guest speakers, presenting on topics relating to pressure ulcers: Continence – LCFT Continence Service, Nutrition – LCFT Community Dietetics Service, and Hydration – LCC Infection Prevention and Control Nurse. • 59 new champions were trained and had competencies signed off in 2018. • A total of 37 care home implementing React to Red by the end of 2018. • We have a further three care homes signed up to join the ‘React to Red’ programme in 2019.

Encouraging self-care and promoting independence:

• Checking that footwear fits correctly. • Raising self-awareness amongst service users in order to prevent pressure ulcers.

React to Red outcomes – prevention

• Patients are at less risk of getting pressure ulcers as a result of React to Red. • Feedback was positive and people thought the training was innovative. • There is now a better understanding of pressure ulcers within our care homes and good practice is being rolled out to sustain good practice.

Comments from React to Red champions:

• “Excellent presentations, group work, friendly atmosphere, lots of useful information. • “The training delivered fantastic information. I am going to take a lot of knowledge back with me”. • “Course was excellent. Trainers kept the information fun, concise, memorable. Course was interactive and very welcoming. Lots of information given via leaflets etc. to continue learning and cascade information. Would definitely recommend. Thank you.”

Page 28 of 64 Page 240 Comment from Student Nurse:

• “Good experience for student nurses as the learning can be put into practice during placements, both in the community and hospitals.”

Quality Improvement Falls Collaborative

This service focuses on the hospitals and care homes across Lancashire who are working together to reduce the number of people who are falling. The service has reduced the number of falls by focusing on the following areas, mostly focusing on age and disability protected groups. It provides:

• Marketing campaign • Steady on campaign • Continence • Strength building exercising • Eye care • SWARM – post fall rapid reviews • Footwear • TABS – alarms and sensors • Lighting • Trip hazards • Pimp my Zimmer • Diet and nutrition

Serious incident reviews

All provider services that we commission are required to inform us of all serious incidents that occur in their services. The CCGs work with the providers to undertake an analysis of the incident to ensure lessons are learned and the likelihood of a similar incident occurring is reduced or eliminated.

Health care acquired infections (HCAI)

The CCGs monitor the health care acquired infections. The CCG C-Diff panel, which also discuss E-coli, has developed a health-economy action plan across Lancashire County Council, Lancashire Teaching Hospitals and Lancashire Care Foundation Trust aiming to reduce infection identifying themes and trends from cases and share the learning.

C-D ifficile cases

Over a 12 month period, September 2017 to August 2018, there were 59 cases of patient testing positive for C-Difficile: • 30 cases in Chorley and South Ribble • 29 cases in Greater Preston

Escherichia coli (E-coli)

Over a five month period, there have been 41 cases of E-coli bacteraemia cases reported between April and August 2018. • 5 cases were apportioned as acute cases. • 36 cases were apportioned as non-acute cases. Page 29 of 64 Page 241 Home First

‘Home First’ enables patients who are clinically well to be discharged from hospital to return to their usual place of residence sooner by providing the relevant support and ensuring their recovery and safety.

1.5 Screening, vaccination and other health promotion services reach and benefit all communities.

This outcome focuses on the comparisons of how people from all protected groups fare, in relation to services meeting their health and care needs, compared to people overall.

The CCGs promote public information about screening, vaccinations and health promotions that benefit all local communities. This includes all people with protected characteristics, specifically the most vulnerable. The boxes below outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

We scored 'excelling' in We scored 'achieving' in We scored 'achieving' in 2016 2017 2018 • CCG priorities • Different formats of promoting • National public healh • Stand up to racism health messages campaigns • Domestic violence • National campaigns • Local campaigns • NHS 111BSL • Local topical promotions • Communication channels • Dementia • Local opportunities • Fab change day • Cancer awareness • Movember - lunch and learn • VCFS collaborative events

We have highlighted some examples of the communication channels and health promotions we have undertaken in 2018.

Communication channels

The CCGs’ communications team uses a variety of different formats to promote health improvement initiatives and campaigns to the people in our local communities. This includes:

• Campaign materials sent to GP practices • Lunch and learn sessions • Campaigns to staff - internal bulletin • Materials shared with partner organisations • CCG Annual General Meetings • Primary care newsletter • CCGs’ websites • Stakeholder newsletter - Health Matters • Facebook • Newsletter to care home staff • Twitter

The information we share ranges from national promotions to focused local promotions.

Page 30 of 64 Page 242 Health promotions in 2018

The CCGs promoted a number of health campaigns that targeted different people in our communities, focusing on age, disability, gender, race, religion and belief, sexual orientation and pregnancy and maternity.

This outcome focuses on the comparisons of how people from all protected groups fare, in relation to services meeting their health and care needs, compared to people overall. The CCG health promotions in 2018 included:

Measles Stay well this Stop smoking Resistance (young Pregnancy winter people)

Flu Cervical NHS 111 Ramadan Balls to cancer vaccination cancer

Breast cancer LGB and HIV Pharmacy Sexual health Diabetes

BME Blood groups contrbution to Fit for surgery and ethnicity NHS

Accessible information

We provide accessible information to people in our communities and our stakeholders where requested and ensure that providers have implemented the five basic steps within the Accessible Information Standard as part of their contract with us. The five steps are:

• Ask: patients are asked about their communication needs. • Record: patients’ needs are recorded on electronic systems. • Highlight: patients’ needs are highlighted when records are accessed. • Share: patient information has a data sharing agreement. • Act: feedback is monitored for effectiveness.

Page 31 of 64 Page 243 Goal 2: Improving patient access and experience – patient focused

2.1 People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds.

This outcome focuses on the comparisons of how people from all protected groups fare, in relation to services meeting their health and care needs, compared to people overall.

The CCGs’ have processes in place to ensure all services we commission are accessible. The boxes below outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

We scored 'achieving' in We scored 'achieving' in We scored 'achieving' in 2016 2017 2018 • CCG priorities • Referral management centre • Urgent care services • Equality assurance • Different methods for • Translation amd interpretation • Engagement framework considering peoples health • Hearing loops • CQUIN schemes needs • Wheel chair accessability • E-access to services • CQUIN outcomes • Beacon medeical services • Communication formats • Transport requirements • Patient feedback

The CCGs have a number of considerations to ensure that all people in our local communities can access the services we commission. This information will be identified in the equality impact assessment of the business case and includes:

• Location is public transport available? Are there adequate parking places? Is the location accessible to the people that may need to use it? • Premises is the building accessible for all people with a diversity of disabilities • Personal barriers what personal barriers may potential service users have? Language, disabilities (sensory loss, mental health, learning disability, physical and long term condition), religion – female clinician required / valuing personal beliefs • Provider policies reflect the delivery of the service. • Provider contract is monitored to ensure the provider is compliant with equality requirements • Procurement process ensures that all people in the local communities can access the service • Closer to home services will be commissioned in the community wherever possible

Page 32 of 64 Page 244 Urgent care services

• gtd healthcare builds services around our vision. Patient safety, quality and patient experience forms the cornerstone of any service development. • gtd healthcare’s vision: To inspire trust and confidence by making a positive difference, every time. • We respond to all complaints and incidents raised by patients and staff. These are collated and inform our service developments. • The services offered in Central Lancashire can be accessed via a number of pathways. • Urgent Care Centres are generally accessed as a walk-in service. You may be streamed to urgent care from A&E or when arriving by ambulance. • GP out of hours services are accessed via the NHS 111 provided by North West Ambulance Service. Patients who call 111 but who need a face to face appointment with a GP will be referred automatically to gtd healthcare that will provide either an appointment or a home visit. Sometimes they will be contacted by an ambulance crew when they have attended a patient who might benefit from a GP home visit. • The DVT service may be accessed as a walk-in service however most patients are referred from their own GP.

Beacon Medical Services

• Disability: A patient became upset during a consultation due to a temporary hearing loss, which had greatly impacted her life. Beacon staff showed ‘due regard’ by writing what the consultant was saying to her, ensuring the patient could make informed decisions about her care and improving her experience of the service.

• Disability: Staff ensured that the clinic access routes were clear for a patient who required a wheelchair and that the patient could be seated directly in front of the doctor during his consultation, then escorted him to the lift where he could access the patient transport they had arranged. Here, this highlights that some people need to have reasonable adjustments in place so that they can access a service.

• Race: A non-English speaking person had an appointment that required a translation service to enable the patient to access the service more effectively. This reasonable adjustment enabled the consultant and the patient to have an appropriate conversation and make an informed decision for the next course of treatment for this patient.

2.2 People are informed and supported to be as involved as they wish to be in decisions about their care.

This outcome focuses on the comparisons of how people from all protected groups fare, in relation to services meeting their health and care needs, compared to people overall.

The CCGs have processes in place to ensure all services we commission inform people about their healthcare options and advise them on what the specialist thinks is the best clinical option for them. We have provided different examples of how we have done this over the last three years. The boxes on the next page outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

Page 33 of 64 Page 245 We scored 'achieving' in We scored 'achieving' in We scored 'achieving' in 2016 2018 2017 • CCG priorities • National context • GP quality contract • Shared decision making • Urgent • Building equity in primary • What matters to you? • IMSK services care • Personal health budgets • Information to support healthy lifestyles

• Pledges to support heathy / community living

What matters to you?

The ‘what matters to you?’ campaign was developed by NHS England to encourage and support more meaningful conversations between people who provide health and social care and the people, families and carers who receive health and social care services.

This campaign supports this EDS outcome by raising awareness of patient information and possible options they may have about their care.

Our CCGs promoted this campaign in an effort to encourage our provider and primary care services to work collaboratively with social services to obtain the best results for the people in our communities.

Personal health budgets

A personal health budget is an amount of money to support a person’s identified health and wellbeing needs, planned and agreed between the person and the local NHS team.

The aim of personal health budgets is to offer people and their families /carers greater choice, flexibility and control over the health care and support they receive. Provide an opportunity to work in equal partnership with NHS services to achieve the best outcomes whilst understanding that personal health budgets are about using resources more appropriately for each individual.

There are six key features of a personal health budget:

• Personalised care and support plan, agree who is involved. • Agree health and wellbeing outcomes with the relevant health, education and social care professionals. • Available funding for healthcare and support. • Is the funding sufficient for the health and care plan to be delivered? • Review the options of payment (direct, notional or third party). • Ensure the funding is used appropriately and effectively for the individual.

Page 34 of 64 Page 246 We have a duty under the NHS Act 2006 to promote the involvement of patients, and their carers or representatives in decisions that relate to: • The prevention or diagnosis of illness in their patients. • Their care or treatment.

National context The NHS has committed to • NHS Mandate: “no decision about me, without me”. • Part of CCGs’ constitutional requirements. involving • It is accepted that encouraging patients to play a more patients in their active role in their healthcare improves quality of care, efficiency and health outcomes. care

The benefits of shared decision making (SDM)

Perception of higher quality care Studies have shown that SDM leads to higher judgements of the quality of care, hospitalised patients’ participation and its impact on quality of care and patient safety.

Better health outcomes Involvement in the approach to care or SDM leads to greater self-efficacy in patients, which in turn, leads to better health outcomes, such as decision aids for people facing health treatment or screening decisions and the relative importance of physician communication, participatory decision - making, and patient understanding in diabetes self-management.

More information, more participation in self-care The more an individual remembers information given by a clinician, the more the patient participated in self-care behaviours at home, provider communication and patient participation in diabetes self-care.

Self care management

• Greater self-efficacy in Support for self care patients • Decision aids for patients, Impact on health • Patient participation in self familites and carers care at home • Information on self- • Patient's health is management improved • Patients are more involved in decisions about their care - improving their mental health and wellbeing

Page 35 of 64 Page 247 2.3 People report positive experiences of the NHS.

This outcome focuses on the comparisons of how people from all protected groups fare, in relation to patient experiences.

The CCGs gather patient experiences in a number of ways, such as patient operational groups and networks, public events and workshops, quality visits to the services we commission and also through people contacting us through the customer care team. The boxes below outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

We scored 'achieving' in We scored 'achieving' in We scored 'achieving' in 2016 2017 2018 • Our health our care work • Healthwatch report • Feedback from commissioned programme • Outcomes of local services • Case studies of patient engagement • Patient stories experience • Governing body patient stories - mental health Case studies of patient care

Patient experience data collection

The CCGs use patient feedback in the form of complaints, patient stories, workshops, surveys and provider performance data to gather the experiences of the people who use our provider services.

How we CCG data collection and analysis (includes design, buy Patient experiences performance and and monitor finance) health services

This information is then used to make informed decisions on how we commission health services.

Patient stories at Governing Body meetings

The CCGs regularly have a patient story at both of the CCG Governing Body meetings. The patient stories are based on topics that are relevant to the CCGs’ current commissioning activity or intentions. In 2018, the topics included:

• January – Change Talks, mental health support. • May – CATCH (discharge to access) patient story.

Page 36 of 64 Page 248 • July – MH:2K Team. Mental health support • November – Perinatal mental health servicefor pregnant women

The NHS contract, which our providers sign up to, requires all providers to ensure that people are treated with dignity and respect whilst receiving an equitable service provision in comparison to people who represent the diversity of protected characteristics.

Feedback from people in our communities

Some people in our local communities choose to provide feedback direct to the customer care team at the CCGs. We have provided some examples of the feedback and listed it by the main protected groups that the services represent. However all services provide healthcare for all people in our communities, some of which may represent a number of characteristics.

Moving Well service (protected groups: age, adults and disability, physical health) • “Excellent – lots of practical tips to put into use, thank you.”

Respite (protected groups: age, adults and disability, physical health) • “Thank you I was enabled to return to my home sooner than planned, which helps me a lot!”

Bone cancer and mobility issues (protected groups: disability, long term conditions and physical disability) • ”Genuine help and advice from a friendly service!”

Erin Initiative

Protected groups: age, under 5 and disability, autism and learning disability

• “Further courses needed on supporting parents with children who a ‘fussy eaters’ and sensory processing disorder.” • “I enjoyed meeting other parents, carers and grandparents of children with ASD. This was a much needed support and has helped to not feel so alone as I was able to share my concerns with people who understood me.” • “I feel more confident about toilet training my child after taking the course and I have additional information to apply to my parenting when my child is ready.” • “It is really good to have the resources and information to take away and read in your own time.” • “We all have varied experiences, which have made for good group interaction.”

Case study: Quality monitoring

We monitor our provider services on a regular basis to find out what the impact is when the people in our communities access local services. We highlight the targets and incidents that are reported as not meeting the agreement within the provider contract with members of the provider service and then support providers to improve their services by putting special measures in place. Our main providers are Lancashire Teaching Hospitals, Lancashire Care Foundation Trust and Ramsay Health Care.

Page 37 of 64 Page 249 2.4 People’s complaints about services are handled respectfully and efficiently.

This outcome focuses on the comparisons of how people from all protected groups fare, in relation to patient experiences.

The CCGs gather patient experiences in a number of ways, such as patient operational groups and networks, public events and workshops, quality visits at the services we commission and also through people contacting us through the customer care team. The boxes below outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

We scored 'excelling' in We scored 'excelling' in 2016 We scored 'excelling' in 2018 2017 • Customer care services • The process we follow for employed by the CCGs - • Customer care service shared regulations, processes, complaints and how we can support patients. • Patient experience feedback collaborative work and the on cusotmer care complaints complaints activity in that year. • How we use the complaints intelligence to support service development and improvement for patients..

CCG customer care service

The CCGs have a customer care team which answer all enquiries from members of the public and professional colleagues. They:

• Support all patients to make a complaint by offering advice and information. • Offer local resolutions by asking the patient how they would like the issue to be resolved and then working with all stakeholders to resolve the issue. • Signpost patients to other organisations as applicable. • Update patients on the status of their complaint as required. • Provide a response to a complaint, formal or local resolution. • Promote the use of the advocacy service. • Collect trends and themes and report them to the Patient Voice Committee to enable the Chairs / CCG lay members to raise issues and provide assurance at the Governing Body meetings. • Share intelligence with other CCG teams to improve services for local communities. • Invite people to ‘get involved’ who are passionate about commissioning or provider issues. This is in the form of patient stories, focus groups, staff lunch and learn sessions, etc.

Our policy

• We follow due process – we have no breaches for complaints made in 2018. • We support patients to resolve any health provider issues. • We use complaints data to support service development and improvement for wider communities.

Page 38 of 64 Page 250 Our customer care service:

• Is available Monday to Friday (9am to 5pm) excluding bank holidays. • Works in compliance with NHS complaints regulations (2009) and the NHS constitution. • Has a complaints policy, which is published on our websites. • Uses a secure database to record all patient complaints. • Reports to our Governing Bodies and other Committees.

Patient experience feedback on the handling of our customer care complaints

The customer The customer care I was very grateful to care team helped listened to me and I would like to thank the customer care me to get the then gave me advice the customer care team. I was being equipment I on what I could do tram from the bottom passed around the need to care next to make a of my heart for new IMSK system for my complaint about a GP speaking to my GP and they sorted it out husband. practice - resulting in for me! an ophthalmology referral

My surgery appointment was cancelled. I contacted I was told by the the customer care team customer care team and they liaised with the that they couldn’t hospital to expedite help me because the another date for surgery – provider had already can’t thank them enough! investigated my compliant.

Page 39 of 64 Page 251 Goal 3: A representative and supported workforce – organisational

3.1 Fair NHS recruitment and selection processes lead to a more representative workforce at all levels.

This outcome focuses on the comparison of how members of staff from all protected groups fare, in relation to recruitment and selection, compared to members of the overall workforce and if this information is available.

The CCGs use ‘NHS Jobs’ and ‘Trac’ to recruit people. This process is supported by Midlands and Lancashire Commissioning Support Unit (MLCSU). The boxes below outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

We scored 'achieving' in Our INTERIM score is We scored 'achieving' in 2016 'achieving' in 2018 2017 • Evidence on recruitment, • NHS Jobs / trac jobs standard operating procedures, • Tthe application process via • New HR process for NHS jobs, characteristic • CCG competency framework recruitment. • Demographics monitoring, disability confident, • Diversity awards are removed as part of the band specific interview packs, • Disability confident values based competencies, shortlisting process • Quality Mark LGBT internal and external Lancashire • Interview questions are in line recruitment, professional HR with the CCGs' competency support, workforce • Personal, Fair and Diverse framework and values. representation and apprentice • Workforce representaton • Case study = Apprentice. case study. • Awards.

Recruitment and selection

NHS organisations use ‘NHS Jobs’ to recruit new employees. Some organisations are also using ‘trac jobs’. Both websites provide an opportunity to search for relevant jobs and apply for the job online. There are a number of services, such as the job centre and voluntary services who support people to apply if they need additional support.

Our CCGs have external and in-house human resources advice and support available for all staff. We use ‘NHS jobs’ website to recruit new members of staff. We commission a service to manage this process and send us the application forms for the people who meet the criteria for the role. All applications are anonymised prior to us shortlisting the applicants for interview. We ensure that people who have identified that they have a disability and meet the criteria for the role are offered an interview. We also ensure that any reasonable adjustments are in place to undertake the interview, such as interviewing on the ground floor for people with mobility concerns.

Page 40 of 64 Page 252 Value-based competencies

The CCGs have a competency framework to ensure that the workforce meets the quality standards expected of CCG staff and that all staff are recruited to the most appropriate band in line with their knowledge and skills.

We have developed band-specific and standardised interview packs that represent the values-based CCG competencies. The value-based competencies supports the CCGs to create equity of employment, as all staff are required to discuss the level of competency they have reached during their ‘talent and performance conversations with their line manager. Examples of this are shown for team working and responsibility and ownership in the tables opposite.

Diversity awards

Disability confident employer: We are now in the second year of our membership of the ‘disability confident’ award. Disability confident is a scheme that was designed to help organisations recruit and retain the talent and skills of people with a disability by focusing on their abilities.

Quality Mark LGBT Lancashire: The CCGs do not discriminate in any of our HR policies or procedures against people who identify as lesbian, gay, and bisexual or transgender (LGBT). This year we have received at least one application from a person who has identified as transgender. Whilst this person withdrew their application before interviews had been offered, they did raise some questions that prompted conversations within the CCG. The questions included things like which toilet facility can they use, for which the response was for the toilet of their chosen gender and there is an accessible toilet if they felt more comfortable with that. Another question was about appropriate clothing, to which the response was smart casual, again in their preferred gender.

Personal, Fair and Diverse: in 2015, we signed up to NHS Employers’ Personal, Fair and Diverse campaign and encouraged our members of staff to join. The ethos of the campaign is to ensure:

• everyone counts. • services are personal, designed to give patients what they want and need. • fairness is built in so that everyone has equal opportunities and treatment. • the skills and experiences of employees from all backgrounds are used and valued. • people can choose the services they want and have as much support as they need. • everyone is treated with dignity and respect, and when they complain, we listen and put things right. • talent flourishes and nothing stops people going as far as they want. • we are accountable and patients are informed and have more control. • care doesn't stop at the door, but helps people live healthier lives

Page 41 of 64 Page 253 Examples of this in the CCGs include:

• Providing all members of staff (CCG and CSU embedded) the opportunity to have their say when they see things that don't feel right. • Undertaking equality impact assessments to support our organisations to deliver more inclusive services. • Undertaking staff surveys to ensure the workplace is an accessible environment. • Triangulating feedback from patients about how to improve services or make them more inclusive across the customer care, quality.

Workforce representation

The CCGs’ aim is to become representative of the local communities as we continue to commission health services over the years. This year we have:

• Identified that people need workplace adjustments to work in our building • Improved on the number of males in our workforce • Increased the number of BME staff in our workforce

The CCGs employ 72 people and 22 office holders, therefore some data cannot be shared as this may result in identifying individual staff. However, we can report:

• Some appropriate demographic data of the staff that have shared this information with HR. • How we monitor the data within the confines of confidential HR.

The band levels for the employed workforce, Number of staff as with all organisations, are determined by 25% the requirements of the organisation. The 20% CCGs developed apprenticeship 15% opportunities in 2015, which has continued 10% 5% into 2018, to help the workforce further. We 0% have now employed six apprentices since the scheme started, with two currently in post. The apprenticeship programme extended in 2018 to include the provision of a school work placement.

Gender

16 The community we serve in central 14 Lancashire represents a female population of 12 51% and a male population of 49%.Across 10 the CCGs’ office holders, 36% are female 8 and 64% are male. Amongst employees, VSM 6 78% are female and 22% are male. For office CSRCCG 4 holders and employees combined, this GPCCG 2 equates to 68% of the workforce being Both CCGs 0 female and 32% of the workforce being male. Male Female Total Page of 42 64 Page 254 Ethnicity

The community we serve represents a black and Asian minority ethnic (BAME) population across central Lancashire of approximately 14%.

27% of the office holders across both CCGs identify as BAME. This is around 4% for employees.

Other characteristics

Disability

The CCGs have a low number of employees Age who have identified that that they have a disability. However, there Amongst the CCG workforce are a number of people (combined for employees and Religion or belief who have identified that office holders), 2% are 24 they require ‘reasonable and under, 3% are 25 to 29 53% of CCG employees Marriage or civil adjustments’ in the years old, 56% are aged and office holders identify workplace due to a long between 30 and 49, and 39% as Christian, with 18% partnership term condition. All are over the age of 50. declaring other religions or adjustments have been beliefs. 73% of the combined considered and the workforce of employees najority have been and officer holders state provided staff. that they are married.

Due to the workforce being so small we are not able to publish the data in relation to sexual orientation, pregnancy or maternity, or gender reassignment.

EDS workforce survey

6 2 The majority of staff think that the 10 6 CCGs are ‘achieving’ in the in the implementation of a ‘fair NHS

Undeveloped recruitment and selection processes (3.39%) that leads to a more representative Developing (16.69%) workforce at all levels’. Achieving (59.32%) 35 Excelling 59% of staff and office holders (10.17%) combined responded.

3.2 The NHS is committed to equal pay for work of equal value and expects employers to use equal pay audits to help fulfil their legal obligations.

This outcome focuses on the comparison of how members of staff from all protected groups fare, in relation to equal pay, compared to members of the overall workforce. Page 43 of 64 Page 255 The CCGs have shared our processes that highlight how we promote equal opportunities. The boxes below outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

Our INTERIM score is We scored 'achieving' in We scored 'excelling' in 'achieving' in 2018 2016 2017 • NHS pay system • Agenda for Change • What is an equal pay audit? • Agenda for Change which • Apprentice pay scheme • Agenda for change ensures that all people are recruited based on their • Very Senior Manager pay knowledge and skills not their process characteristic. • Equal pay audits and current pay bands.

What is an equal pay audit?

Equal pay has been a statutory entitlement since the Equal Pay Act came into force in 1970. The Agenda for Change pay system was introduced in October 2004 to ensure that pay in the NHS was consistent with the requirements of equal pay law.

Agenda for Change, and its national job evaluation scheme, complies fully with anti-discrimination legislation. Claims can still be brought against organisations locally if it is believed that the scheme has not been implemented correctly, leading to equal pay issues. An equal pay audit involves comparing the pay of men and women doing equal work in your organisation. It has three main purposes:

• Identify any differences in pay between men and women doing equal work. • Investigate the causes of any (differences in pay between men and women doing equal work). • Eliminate instances of unequal pay that cannot be justified.

An audit entails a commitment to put right any unfair pay inequalities. This means that the audit must have the involvement and support of managers with the authority to deliver the necessary changes. It is also important to involve workforce representatives to maximise the validity of the audit and the success of any subsequent action taken.

Agenda for Change

The framework agreement on the reform of the pay structure for Agenda for Change staff:

• Enables staff (band 2 to 7) to reach the top of their pay bands more quickly, between 2 and 5 years. • Describes minimum periods of time before progression to the next pay-step point. • Not be automatic – demonstrated by a clear process. • Improve appraisal processes to enable staff to demonstrate they have met the standards required. Page 44 of 64 Page 256 • Alignment between very senior managers and Agenda for Change staff pay arrangements. • Employers need to monitor and report to the NHS Staff Council – this will highlight any disparity between people with protected characteristics.

Equal opportunities review

A comparison for equal opportunities was presented to the EDS panel for grading and the outcome highlights that we have a male member of staff who is undertaking the same role as a number of females and the jobs are comparable.

EDS workforce survey

Our CCGs are not required to undertake equal pay audits. However, we are committed to ensuring that there is no inequity between males and females undertaking the same role. We have not had any cases of this during 2018.

8 4 The majority of the workforce 8 6 believe that the CCGs are Undeveloped (6.78%) ‘achieving’ by being committed to Developing equal pay for work of equal value (13.56%) Achieving and expects employers to use equal (55.93%) pay audits to help fulfil their legal Excelling (10.17%) obligations. 59% of staff and office 33 Don’t know holders combined responded. (13.56%)

3.3 Training and development opportunities are taken up and positively evaluated by all staff.

This outcome focuses on the comparison of how members of staff from all protected groups fare, in relation to equal pay, compared to members of the overall workforce.

The CCGs’ have focused on the processes for providing opportunities to members of for training and development. The boxes below outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

Page 45 of 64 Page 257 Our INTERIM score is We scored 'achieving' in We scored 'achieving' in 'achieving' in 2018 2016 2017

• Staff survey including outcomes • Information about training and • Mandatory training complaince and response rate; creating a development policies, capacity • Non-mandatoty training activity coaching culture, staff training, and skills audit, essential training, • Development initiatives including NHS Leadership non-mandatory training, Belbin Academy programmes, 360 roles, talent conversations, lunch • Optional additional courses and learn sessions and appraisals, bespoke courses, • Additional opportunities lunch and learn sessions, team compliance rates. away days, talent conversations, . staff competencies and staff turnover.

Mandatory training

The CCGs have a mandatory training programme that all employees and office holders must complete so that they regularly learn and refresh core skills and gain knowledge on a wide range of essential topics. All new starters have to complete the full programme of training within the first month of them joining the CCGs.

Mandatory training requirements Frequency

• Equality, diversity and inclusion • Every 3 years • Introduction to safeguarding of adults • Every 3 years • Introduction to safeguarding of children • Every 3 years • Prevent for healthcare • Every 3 years • Fraud and bribery awareness • Every 2 years • Information governance • Annually • Fire safety awareness • Annually • Health and safety awareness • Every 3 years • Moving and handling • Every 3 years • Infection control • Every 3 years

In addition, depending on their roles, some employees and office holders also have to undertake enhanced safeguarding training, enhanced ‘prevent’ training and conflict of interest training.

As of the end of 2018, the CCGs’ compliance for all employees and office holder for completion of the mandatory training modules was 98.5%. Training compliance for equality, diversity and inclusion was at 100%.

Non-mandatory training, development and talent management

To complement the mandatory training programme, the CCGs also provide regular access to a range of non-mandatory training and development initiatives for both employees and office holders.

Page 46 of 64 Page 258 During 2018, all staff were given the opportunity to generate a BELBIN team role development profile, to help show every individual how they can best contribute to high performing teams using their preferences and aptitudes. Other than some recent new starters, 100% of staff and GP directors have these profile reports in place that they can use for their own development.

Staff are regularly provided with bespoke support and access to leadership programmes, and they can access a range of online training via the online training system.

As detailed in the results of the annual staff survey:

Around 25% of employees have benefited from 86% of staff feels that they have an interim or a permanent promotion, or a secondment within the central Lancashire health the tools to do their job effectively and care economy, as part of the CCGs’ talent management programme.

And as detailed in the results of the annual 64% of staff feels that they have staff survey: opportunities to develop and grow

Collaborative planning and development

Planning activities within the CCGs provide a key opportunity to support employee development. As well as regular business unit planning and development sessions for the finance and contracting team, the transformation and delivery team and the quality and performance team, the CCGs also had a large scale planning and development day where employees could ask questions about national and local NHS issues, look at strategic and business objectives, and undertake collaborative learning and action in relation to the commissioning cycle.

EDS workforce survey

2 3 The majority of the workforce 6 15 believes that the CCGs are ‘achieving’ in providing training and Undeveloped development opportunities which are (5.08%) Developing taken up and positively evaluated by (25.42%) Achieving all staff. (55.93%) 33 Excelling (10.17%) 59% of staff and office holders Don’t know (3.39%) combined responded.

Page 47 of 64 Page 259 Additional opportunities

Case study: Development opportunities

Previously we have reported that the CCGs recruited to the Head of Performance post. The successful candidate was supported by the CCGs in his application to the NHS Leadership Academy to undertake the Nye Bevan course for senior leaders, which he successfully completed.

In 2018, following his graduation from the course, the Head of Performance has now been offered a promotion to Director of Planning, Performance and Delivery with Liverpool CCG.

Lunch and learn sessions

Lunch and learn sessions are held each month, with the addition of weekly sessions in May for our ‘Equali-tea and Biscuits’ campaign as part of Equality Month. All sessions have a number of benefits for staff:

• All staff are welcome to attend all or as many sessions as they choose to attend. • The session usually lasts for an hour, which is longer than the half hour lunch break; therefore any member of staff who attends the session is automatically given an additional half an hour from the CCGs to attend to enhance their personal development. • All staff are invited to propose new topics for the session. • All staff who attends are asked to complete a feedback survey.

We have delivered 13 lunch-and-learn sessions during 2018, four of which focused on organisational governance (shown in blue below):

Our Health Diabetes Substance misuse Domestic violence Dying matters Our Care

Young peoples mental health WRES & WDES Personal health independent living budgets (MH2K)

Anti-fraud Freedom to speak Cyber security Risk management awareness up

Page 48 of 64 Page 260 Feedback from the lunch and learn sessions

The surveys from the lunch and learn highlighted the following:

The session The DV session made learning highlighted was The Mindfulness new concepts session should we can all work The session fun be done on a better together was very regular basis informative and Love the interesting patient stories! I find the It was great to sessions are find out more a good way to about OHOC and meet new what we are staff doing.

The feedback from all sessions is reviewed and any amendments are considered and utilised, if appropriate.

3.4 When at work, staff are free from abuse, harassment, bullying and violence from any source.

This outcome focuses on the comparison of how members of staff from all protected groups fare, in relation to abuse, harassment, bullying and violence from any source, compared to members of the overall workforce. The CCGs’ have focused on the HR processes and other schemes in relation to being discriminated against. The boxes below outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

Our INTERIM score is We scored 'achieving' in We scored 'achieving' in 'achieving' in 2018 2016 2017 • HR Policies In 2016, we presented evidence We provided information about • • Policies • Whistleblowing policy • Disciplinary process • Procedures and training that • Freedom to speak up • GB Guardians we have in place to protect staff. guardians • PAM assist: employee • No cases of abuse, • Awareness training assistance programme harassment, bullying or violence • Grievance training • EDS workforce survey were reported in 2016. • Employee assistance service • Monitoring and reporting (PAM assist) • Staff survey

Page 49 of 64 Page 261 CCG support

We have a number of policies to support staff when they have a concern about abuse, harassment, bullying or violence. All policies are published on the intranet for all staff to access. The main policies are:

• Equality and diversity policy • Grievance policy • Harassment and bullying at work policy • Whistleblowing policy

The CCGs are supported by Midlands and Lancashire CSU to develop, and deliver the procedures to implement the policies. We have also appointed the Lay Members of the Governing Body with responsibility for:

• Conflict of interest • Freedom to speak up

We also provide all employees with access to an employee assistance programme, ‘PAM Assist’, which is available 24 hours a day, 7 days a week.

Reporting The CCGs monitor the number of complaints made by or against staff based on abuse, harassment, bullying and violence from any source. However, due to the small size of the organisation and the low number of complaints made (less than 5) within 2018, we are unable to report them by protected characteristics.

88% of CCG employees responded to an annual staff survey, which included some specific questions on bullying and harassment. The results showed that:

6.9% have experienced And that 75% of some bullying or those people harassment in the reported it workplace in the last 12 months And that 100% of the people who reported it felt the issue was dealt with The results also showed that:

89% know how to report workplace bullying or harassment Page 50 of 64 Page 262 EDS workforce survey

2 9 The majority of the workforce 17 believes that the CCGs are ‘achieving’ in managing issues Undeveloped (0%) relating to abuse, harassment, Developing (15.25%) bullying and violence from any Achieving (52.54%) source within the CCGs. Excelling 59% of staff and office holders 31 (28.81%) Don’t know combined responded. (3.39%)

3.5 Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives.

This outcome focuses on the comparison of how members of staff from all protected groups fare, in relation to flexible working, compared to members of the overall workforce.

The CCGs have focused on the HR processes in relation to supporting our workforce to improve their work life balance. The boxes below outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

We scored 'excelling' in We scored 'excelling' in Our INTERIM score is 2016 2017 'achieving' in 2018 • We presented information • Supporting flexible working • How we carry out equality about our HR policies • Policies impact assessments on HR • Flexible working • Schemes policies. • Special leave • Opportunities • How we provide opportunities • Annual leave to amend staff contracts to offer • Case study a greater work-life balance • Car lease • EDS workforce survey • Cycle scheme

Support for flexible working

We have developed a number of policies and schemes to enable staff to work more flexibly. We now monitor the usage of the flexible opportunities we offer to identify the number of people who use them. Due to the small number of staff we are not able to break this down into their protected characteristics as this may identify the individual employee.

Page 51 of 64 Page 263 Supporting policies Supporting schemes Take up of opportunities

Flexible working policy Childcare vouchers 5 employees using the car lease scheme

4 employees use the cycle to Special leave policy Car lease schemes work scheme

Annual leave policy Cycle to work 8 employees have purchased additional annual leave

Maternity, paternity and adoption Option to buy annual leave flexible working agreement in leave policy scheme (up to 5 days a year) place (30% in 2017)

All policies are equality impact assessed by an external Prayer room commissioned service

How do people feel?

In the CCGs’ annual staff survey, 88% of respondents stated that they feel that their manager cares about wellbeing.

Case study: Work life balance

I found out I was pregnant in October 2014 and told my line manager at the time in early November after I had my first midwife appointment. During my pregnancy there were forms that needed to be completed, risk assessments etc. that were completed with ease. I used some annual leave and left for maternity leave in May 2015 and returned back to the CCG in April 2016.

One month prior to my return I requested in writing to reduce my hours from full time (37.5 per week) to 32 hours over four days with a Friday off. This was all approved, no questions asked. Within six months of my return from maternity leave my husband changed jobs and started working nights, due to the costs of childcare being so high. We found this extremely difficult at home as I was working until 5pm, then as soon as I returned home he was leaving for his night shift. I was finding this really difficult and felt like I didn’t see my husband for five days every week.

Again in writing I requested to reduce my hours to 30 hours per week to enable me to leave work half an hour earlier each day to gain a better work life balance. This was approved quickly and I was able to start my new hours at the beginning of the following month. I have been working these hours ever since and feel a lot more at ease at work and at home.

Page 52 of 64 Page 264 EDS workforce survey

The majority of the workforce 2 9 believes that the CCGs are 17 ‘achieving’ in ensuring that all staff are provided with options that are Undeveloped (0%) consistent with the needs of the Developing service and the way people lead their (15.25%) Achieving lives within the CCGs. (52.54%) Excelling 59% of staff and office holders 31 (28.81%) Don’t know combined responded. (3.39%)

3.6 Staff report positive experiences of their membership of the workforce.

This outcome focuses on the comparison of how members of staff from all protected groups fare, in relation to their experience of working for the CCGs, compared to members of the overall workforce.

The CCGs’ have focused on the opportunities provided for staff to report their experiences of working or being an office holder for the CCGs. The boxes below outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

We scored 'achieving' in We scored 'achieving' in Our INTERIM score is 2016 2017 'achieving' in 2018

• Evidence about our staff survey • Evidence about our annual • Annual staff survey and results staff survey and highlights of the and results, and development • How well are we doing? opportunties. results of the survey, which included what's going well and • What opportunities do we have what could be improved. to improve? • EDS workforce survey results

Annual staff survey

We undertake a CCG designed annual staff survey that is independent from the national staff survey but is more relevant for our organisations. Questions include a range of key workplace themes related to feeling of value, job roles, training and development, environment and support. The survey is also used to help regularly test the effectiveness of the CCGs’ internal communications and engagement channels.

88% of employees responded to the survey in 2018.

Page 53 of 64 Page 265 Questions asked in the staff survey 2017 2018 Improvement? Feel they have a clear vision on the future direction of CCGs and - 53% New question local health services Feel that they have the tools to do their job effectively 87% 86% -1% Feel that they have enough opportunities to contribute to the 75% 62% -13% decisions that affect them Feel that they know what is expected of them in their role - 90% New question Feel that their manager helps them understand how CCG 77% 72% -5% objectives relate to their role Feel that their immediate manager inspires them 74% 76% +2% Feel their manager cares about their wellbeing - 86% New question Feel they are given opportunities to develop and grow - 64% New question Feel satisfied by their work environment 80% 90% +10% Feel that their work is valued by their manager 90% 83% -7% Feel that their work is valued by their team colleagues 92% 86% -6% Feel that their work is valued by members of the organisation 71% 66% -5% Feel that their work is valued by external partners, stakeholders, 61% 59% -2% and patients

How are we doing?

What’s going well? Opportunities for improvement?

• Being kept informed • Understanding of strategy and direction • Wellbeing and culture • Integration of SMT with staff • Non-physical environment • Consistency • Supportive atmosphere • Equal opportunities for progression • Open door policy • Career development • Individual development • Meetings and emails (volume) • Positive challenge • Technology • Drive for high quality • Facilities and physical environment • Facilities and physical environment

EDS workforce survey

3 1 9 12 The majority of the workforce believes that the CCGs are ‘achieving’ in ensuring that all staff Undeveloped are provided with options to provide (1.69%) Developing feedback to the CCGs. (20.34%) Achieving (57.63%) Excelling 59% of staff and office holders (15.25%) 34 Don’t know combined responded. (5.08%)

Page 54 of 64 Page 266 Goal 4: Inclusive leadership - Organisational

4.1 Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their organisations.

This outcome focuses on the number of examples of strong sustained commitment the CCGs have provided to ensure that people from protected groups are considered equitably within the workforce and also when commissioning health and care services.

The CCGs have focused on the opportunities provided for staff to report their experiences compared to members of the overall workforce and if this information is available. The boxes below outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

We scored 'achieving' in Our INTERIM score is 2016 We scored 'achieving' in 2017 'achieving' in 2018

• CCG has GP director equality • Accountability and responsibility champions • How equality is embedded at Governing Body level • Activities • Patient Voice Committee assurance process • Example of CCG senior team • Equality, diversity and inclusion leading engagement for Our function • CCG constitution Health Our Care. • EDS workforce survey results • EIAs on Governing Body papers.

Accountability and responsibility

The CCGs have demonstrated our commitment to the equality, diversity and inclusion in a number of ways.

Governing Body accountability • Dr Sumantra Mukerji, Chair and Clinical Leader, Greater Preston CCG • Dr Gora Bangi, Chair and Clinical Leader, Chorley and South Ribble CCG

Clinical accountability • Dr Sandeep Prakash, GP Clinical Director – Greater Preston CCG • Dr Matt Orr / Dr Ann Robinson, GP Clinical Director – Chorley and South Ribble CCG

Lay member accountability • Debbie Corcoran, Lay member for patient and public involvement – Greater Preston CCG • Geoffrey O’Donoghue, Lay member for patient and public involvement – Chorley and South Ribble CCG

Page 55 of 64 Page 267 Executive accountability • Helen Curtis, Director of Quality and Performance- Greater Preston CCG and Chorley and South Ribble CCG

Activities

Governing Body

At every meeting, the Governing Body invites a patient to come and share their story about a health condition and the journey they have been on to meet their health and care needs. The topics of the stories are linked to CCG priorities or pieces of work that are taking place at that point in time. This ensures that the leadership team consider the depth of the impact that our commissioned services can have on the people who use them.

Patient Voice Committee

A patient assurance report is presented to the patient voice committee (PVC) on a bimonthly basis to provide assurance to the members that the CCGs are appropriately and effectively engaging and consulting with the local communities.

The chair from the operational patient advisory group (PAG) also attends the committee meeting to highlight any issues he feels the lay members need to know about or to ask any questions he needs a response from to feed back to the PAG.

Equality and diversity function

The CCGs are the only clinical commissioning group in Lancashire to employ an equality and diversity lead to manage this function for commissioned services. Support is provided by Midlands and Lancashire Commissioning Support Unit (MLCSU).

Equality and diversity activities

The majority of the activities reach across the internal and external stakeholders of the CCGs.

Equality impact Equality annual Equality annual Equality assessment Workforce Race Digital planning PAG assessment support and management reports strategies (EDS) Equality Standard and engagement assurance

Patient Voice OHOC planning Governing Body Annual General Equality strategic Training and LGBT Quality Committee and engagement reports Meetings meetings development Mark reports

Modern Day Disability Slavery Accessible Equality EDI North West Targeted Confident statements / Employer information assurance Forun membeship engagement suppport

Page 56 of 64 Page 268 EDS workforce survey

1 The majority of the workforce 9 10 believes that the CCGs are

4 Undeveloped ‘achieving’ in demonstrating our 1.(69%) commitment to promoting equality, Developed diversity and inclusion within and (16.95%) Achieving beyond our CCGs. (59.32%)

Excelling (6.78%) 59% of staff and office holders Don’t Know 35 (15.25%) combined responded.

4.2 Papers that come before the Board and other major committees identify equality-related impacts including risks, and say how these risks are managed.

This outcome focuses the number of papers that are presented to the board that take account of equality-related risks and their management.

The CCGs have a number of processes that ensure all equality related impacts and risks are considered and reduced or eliminated. The processes are regularly reviewed and improved as required. The boxes below outline the evidence shared in grading sessions, and the resulting scores for 2016, 2017 and 2018.

We scored 'achieving' in We scored 'achieving' in Our INTERIM score is 2016 2017 'achieving' in 2018 • Evidence from our Governing • our equality impact Body papers assessments on Governing • Governing Body papers Body and Committee meeting • CCG Improvement and papers • Process for the operaioonal plan Assessment Framework HFMA award for our operation • services with equality related • PAG panels for procurement, delivery planning impacts identified and managed safeguarding prior to board sign off • NHS Leadership Academy • LD Project development programmes and • Commissioning cycle and team specific training. engagement impact

Our Governing Body paper – front sheet

All papers that go to our Governing Bodies are required to have a front cover sheet. This consists of the tables below.

• Equality impacts checked as part of cover sheets on all Governing Body and Committee meeting papers

Page 57 of 64 Page 269 Our process for our operational plan

During 2017, the CCGs developed a process to develop schemes for our operational plan. This process includes the following steps:

• Form 0 is used to write up any ideas from any member of staff, and is required to be approved by the person’s line manager. The idea then goes into the pipeline.

• Form 1 is the next stage, which provides more clarity of the scheme. The author is required to undertake a number of impact assessments, including an equality impact assessment (EIA) screening to identify any negative impacts that may occur if this scheme was taken to the next stage.

If the schemes are viable, a business case is was then developed (Form 2) which includes a full equality impact assessment, where identified at Form 1 stage. If the scheme is not viable it is removed from the operational plan altogether.

In 2018, we have improved the process to ensure that the need for all full EIAs have been shared with the equality and diversity lead to enable a scheduled EIA to be undertaken with support from the patient advisory group.

EDS workforce survey

0 8 The majority of the workforce 18 believes that the CCGs are ‘achieving’ in demonstrating our commitment to promoting equality, Undeveloped (0%) diversity and inclusion within and Developed (13.56%) beyond our CCGs. Achieving

(33.9%)

20 Excelling 13 (22.03%) 59% of staff and office holders Don’t know (30.51%) combined responded.

Page 58 of 64 Page 270 4.3 Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination.

This outcome focuses the culture of the organisation and how well staff representing all protected groups fare, in relation to the wider workforce.

We scored 'achieving' in 2016 We scored 'achieving' in 2017 Our INTERIM score is 'achieving' in 2018 • Our equality strategy • OD strategy, coaching and meetings, equali-tea and mentoring culture and how we • WHat is cultural competence? encourage participation in NHS biscuits sessions, equality • NHS transformation mandatory training, and how Leadership Academy we carry out EIAs on business programmes. • Inclusive activities cases.

What is cultural competence?

Cultural competence is the ability to understand, communicate with and effectively interact with people across cultures. Cultural competence encompasses being aware of one's own world view, developing positive attitudes towards cultural differences, and gaining knowledge of different cultural practices and world views.

NHS transformation

There are a number of national changes being made across the NHS. This has required the CCGs to work in partnership across central Lancashire with our hospitals, community, primary and voluntary services to meet the needs of our local populations. Whilst there have been a number of cultural challenges within the system, we have united through the Our Health Our Care transformation programme to develop strategies to deliver an integrated partnership.

Advice and guidance

The CCGs provide on-going advice and guidance in-house to managers, via its dedicated equality and diversity lead, and also key HR functional leads.

In addition, the CCGs commission an outside HR service, where professionals can guide managers in relation to cultural competence and cultural issues as an when they arise, both in relation to CCG policies and legal frameworks.

Page 59 of 64 Page 271 On-going checks

Embedded into the CCGs’ talent and performance (review and appraisal) process are questions for managers to check on an on-going basis whether members of their team need any reasonable adjustments to be made, including in relation to cultural difference or practice.

Training and development

Managers and staff have opportunities to think about how their behaviours can impact on others via development sessions in teams and across the entire workforce, utilising themes such as coaching conversations, personal resilience and BELBIN team roles.

Supporting communities and listening to patients

The general culture of the CCGs is one of inclusivity.

As well as raising awareness amongst staff of patient stories, and different patient issues and needs, we also raised awareness about a number of national and local charities by asking all staff to participate in a wide range of activities and fundraising.

The charities that benefitted this year are:

• Comic relief • Derian House (terminally ill children) • Food Banks at Christmas • Guide dogs for the blind • Homeless hounds • McMillan coffee morning • Alzheimer’s Society • North West Air Ambulance • Save the Children • St Catherine’s Hospice

We commission a local learning disability organisation called Voice for All to manage the CCGs’ waste recycling services at its head offices.

EDS workforce survey

The majority of the workforce

5 9 believes that the CCGs are ‘achieving’ in demonstrating our 17 commitment to promoting equality,

Undeveloped diversity and inclusion within and (0%) Developing beyond our CCGs. (15.25%)

Achieving (47.46%) 59% of staff and office holders Excelling 28 (28.81%) combined responded. Don t know

(8.47%)

Page 60 of 64 Page 272

Contact details and alternative formats

For a copy of this document in an alternative format, including other languages, large print or audio, please contact us using the following telephone number:

Tel: 01772 214 232 [email protected] [email protected]

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অন�◌ান� ভাষ◌া, বড় ছ◌াপার হরফ বা অডি◌ও সহ, ডবকল্প কক◌ানন্◌া ফরম�◌ানে◌ এই ��র একেট প্রিডডলডপর জন� অন্◌ু �হ কনর ন্◌ীনে◌র ডববরণ বযবহার কনর আম্◌ানে◌র সনে◌ ক ◌াগ◌ান ◌াগ কর◌ু ন◌্ :

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Greater Preston CCG-কক ইন� ক�ন্ [email protected] Page 61 of 64 Page 273 Cantonese/香港中文

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Page 62 of 64 Page 274 Hindi/हिन्दी

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Page 63 of 64 Page 275 Punjabi/ ਪੰਜਾਬੀ

ਦੂਜੀਆਂ ਭਾਸ਼ਾਵਾਂ ,ਵੱਡੇ ਅੱਖਰਾਂ ਜਾਂ ਆਡੀਓ ਸਮੇਤ ,ਵਿਕਲਪਕ ਰੂਪਾਂਤਰ ਵਿੱਚ ਇਸ ਦਸਤਾਵੇਜ਼ ਦੀ ਕਾਪੀ ਲੈਣ ਲਈ , ਕਿਰਪਾ ਕਰਕੇ ਹੇਠਾਂ ਦਿੱਤੇ ਵੇਰਵੇ ਦੀ ਵਰਤੋ ਕਰਦੇ ਹੋਏ ਸਾਡੇ ਨਾਲ ਸੰਪਰਕ ਕਰੋ:

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Greater Preston CCG ਲਈ ਈਮੇਲ [email protected]

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Page 64 of 64 Page 276 Agenda Item 14

Governing Body Meeting

Date of meeting 24 January 2019 Title of paper NHS Greater Preston CCG Safeguarding Annual Report 2017/18 Presented by Mrs Helen Curtis, Director of Quality and Performance Author Mrs Lorraine Elliott, Designated Lead Nurse Safeguarding Adults and MCA Mrs Louise Burton, Designated Lead Nurse Safeguarding Children Clinical lead Dr Brigid Finlay, GP Director / Executive Lead for Safeguarding Confidential No

Purpose of the paper

This annual report reviews the work over 2017/18, providing assurance that the CCG has discharged its statutory responsibility to safeguard the welfare of children and adults across the health services it commissions.

Additionally, information is included about national changes and influences along with local developments and activity and how the challenges relating to safeguarding are being managed. The report also describes the priorities for the year ahead.

Executive summary

The CCG safeguarding annual report provides a summary of activities and developments that have taken place over the year. It demonstrates assurance regarding the CCGs statutory functions in relation to compliance with Section 11 of the Children Act (2014), the Mental Capacity Act (2005) and the Care Act (2014).

The report is later than usual this year due to a request from the Safeguarding Assurance Group members that the CCG Annual Report be submitted at the same time as the Lancashire Safeguarding Boards Annual Report. Although the Safeguarding Board’s report was published towards the end of September the next Safeguarding Assurance Group was held in December. It is recognised that this has caused delay in the Annual Report being presented to the CCG Governing Body. In the next reporting year the CCG Annual Report will be submitted before the end of quarter two regardless of whether the Lancashire Safeguarding Boards Report is published.

The report focuses on core business and service developments across the health system working in partnership, alongside reflecting on achievements and areas which require improvement. The report highlights the growing complexity of

CSR CCG Annual Report 2017/18 NHS Greater Preston CCG Governing Body meeting Page 277 24 January 2019 safeguarding and the continued proactive nature of the team to meet those demands. The CCG safeguarding team have strived to ensure that safeguarding is embedded across the health and social care system, which reflects and adapts to safeguarding developments from a local / regional and national perspective.

Key Developments

There have been a number of key developments across the safeguarding agenda over the reporting period, which includes the development of a sustainable Child Sexual Exploitation (CSE) model for health provision across Lancashire. CSE continues to remain a high profile over recent years and there is a national drive to strengthen accountability and improve joint working in all areas of exploitation to protect both children and adults.

The CCG have led on the development on the pan-Lancashire Female Genital Mutilation (FGM) work stream to develop a multiagency pathway to raise awareness, identification and response to FGM across Lancashire. Within the next reporting year the pathway will be adapted to support adults at risk of FGM.

The pan-Lancashire Sudden Unexpected Death in Childhood (SUDC) nurse-led service has been subject to a review commissioned by the Child Death Overview Panel in 2016. The review highlighted good practice in the response provided but gaps in provision during out of hours. To strengthen arrangements an option to extend the service to a seven day model has been agreed by the pan-Lancashire CCGs.

The CCG continues to engage with the Safeguarding Boards through the work of the Safeguarding Adult Review and Serious Case Review sub groups. This includes dissemination and embedding the learning from reviews and sharing good practice. The Welsh methodology for undertaking reviews adopted by Lancashire has been evaluated within the reporting period. Positive findings include: the reports being shorter in length, whilst not losing rigour and clarity and are significantly less resource intensive and cost less to commission.

The CCG have led on the development of a Mental Capacity Act (MCA) Learning and Development framework approved by the Safeguarding Board. The framework incorporates the findings from the pan-Lancashire MCA Research Project (2017) and sets out a suite of training packages, which supports the improvement of practice.

Deprivation of Liberty Safeguards (DoLS) continues to increase year on year, due to the lowered threshold since the Supreme Court Judgement (2014). There is an increasing number of DoLS, which have not been progressed and this is in the region of 5000 plus across Lancashire. Demand continues to exceed capacity and statutory timeframes are not being met. A prioritisation tool is in place to manage the risk, to ensure the highest risk / complex cases are processed expeditiously.

The CCG leads the Court of Protection Collaborative on behalf of the Lancashire CCGs. The aim is to strengthen communication between health and social care, ensuring involvement in court proceedings are as timely and effective as possible. The group have developed a standardised process for managing Court of Protection applications for domiciliary settings by developing a prioritisation tool, based on the Association of Directors of Adult Social Services guidelines. The tool will support the

CSR CCG Annual Report 2017/18 NHS Greater Preston CCG Governing Body meeting Page 278 24 January 2019 management of the increased volume of cases progressing through the Court of Protection.

Safeguarding Children Activity

Child Protection Plans

At 2017/18 year end Lancashire had 1,243 children subject to child protection plans; this equates to the rate of 50.4 per 10,000, a 11% decrease compared to the previous year: in Preston, there were 214 children subject to child protection plans equating to the rate of 69.0% per 10 000, a decrease of 11%.

There has been a gradual decline in the numbers of children subject to child protection plans since 2016. Currently, child protection plans in Preston remain high however are at a similar rate as in 2015; suggesting that the rates in Preston may be the average number for a city of its size and demographic.

In addition, Preston has a high referral rate with high levels of exploitation. Work is required to reduce the numbers of children who are subject to child protection intervention for extended periods of time.

Looked After Children

At 2017/18 year end Lancashire had responsibility for 1,968 Looked After Children; this equates to the rate of 79.7 per 10,000, a 6% increase compared to the previous year: in Preston, there were 298 Looked After Children equating to the rate of 96.0 per 10 00, an increase of 21%

The increasing numbers of Looked After Children are mirrored across Lancashire. It is understood that more children being placed on home placement agreements (place with parents) is a contributory factor. In addition to an increase in the number of 16 and 17 year olds coming into care following changes to the homeless agreement, this has since stabilised. There is significant work being undertaken in respect of children on the edge of care and increased scrutiny by senior managers prior to children becoming looked after.

Conclusion

Effective safeguarding practice is everyone’s responsibility and integral to maintaining high quality care and patient experience. Future consideration needs to be given to the delivery of statutory safeguarding functions as the Integrated Care Systems and Integrated Care Partnerships evolve. In addition to engaging with partners to implement the safeguarding partnership arrangements to ensure compliance with the revised Working Together to Safeguard Children (2018).

Key Priorities for 2018/9

Key priorities for 2018/19 include: working with partners to understand the numbers of children subject to child protection plans across the CCG; continue to support the SUDC nurse-led developments and transition, following the publication of the revised Child Death Review Guidance; to launch the GP Safeguarding Lead / Champion model; work with the Board to continue to review the backlog of DoLS and be ready

CSR CCG Annual Report 2017/18 NHS Greater Preston CCG Governing Body meeting Page 279 24 January 2019 to respond to the introduction of the Liberty Protection Safeguards, following the amendment to the MCA.

Recommendations

The Governing Body is asked to note and approve the Safeguarding Annual Report for 2017/18.

Links to CCG Strategic Objectives SO1 Improve quality through more effective, safer services, which deliver a ☒ better patient experience SO2 Commission care so that it is integrated and ensures an appropriate ☒ balance between in-hospital and out-of-hospital provision SO3 Be an integral part of a financially sustainable health economy ☐

SO4 Ensure patients are at the centre of the planning and management of ☒ their own care, and that their voices are heard SO5 Be a well-run clinical commissioning group and the system leader ☒

Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome Safeguarding Assurance Group 06.12.18 Approved

Quality and Performance Committee 09.01.19 Approved Were any conflicts of interest identified at previous meetings (mark X in the correct box below) Yes No X If conflicts of interest were identified what were these:

Implications Quality/patient experience Yes ☐ No ☒ N/A ☐ implications? (Potential) conflicts of interest? Yes ☐ No ☒ N/A ☐ Equality Impact Assessment? Yes ☐ No ☒ N/A ☐ Privacy Impact Assessment? Yes ☐ No ☒ N/A ☐ Are there any associated risks? Yes ☐ No ☒ N/A ☐ Are the risks on the CCG’s risk ☐ ☒ ☐ register? Yes No N/A If yes, please include risk description and reference number

Assurance

CSR CCG Annual Report 2017/18 NHS Greater Preston CCG Governing Body meeting Page 280 24 January 2019 N/A

CSR CCG Annual Report 2017/18 NHS Greater Preston CCG Governing Body meeting Page 281 24 January 2019

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Greater Preston Clinical Commissioning Group

Safeguarding Annual Report

April 2017 – March 2018 Page 283 Page

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Table of Contents Page Page Number Number Introduction 3 Part 2 - Developing and Strengthening Pathways and Services 18 Purpose of the Report 3 The Changing Landscape of Safeguarding 18 Mental Capacity Act Implementation and Deprivation of Liberty Key Achievements 4 21 Safeguards Deprivation of Liberty Safeguards 21 Part 1 - Delivery of the Statutory Safeguarding Functions 5 Court of Protection 22 Policy Development 6 The Court of Protection Collaborative 22 Supervision 6 Child Death Overview Panel 23 Learning and Development 6 SUDC – responding to child deaths 23 Promote improvements within the Safeguarding System 7 Safeguarding in Primary Care 23 External Scrutiny 7 Safeguarding Assurance of Commissioned Services 7 Part 3 – Influencing Partnerships 24 Learning Lessons from the review process 8 Lancashire and Cumbria Children’s Services Improvement Journey 24 Domestic Homicide Reviews 9 The Children and Social Work Act 2017 25 Safeguarding Children 9 Lancashire Safeguarding Children’s Board 10 Part 4 – Using Intelligence and Information to Inform Decisions 25 Voice of Children and Young People 10 Multi–Agency Safeguarding Hub 25 Safeguarding Children Activity 11 Looked After Children 11 Part 5 – Safeguarding Quality Improvement 26 Health of Looked After Children Across Central Lancashire 12 Regulated Care 26 Governance Arrangements for Looked After Children 13 Domiciliary Care Packages for individuals in receipt of CHC 27 Voice of Service Users 13 Safeguarding Adults 14 Conclusion 27 Lancashire Safeguarding Adult Board 14 Key Priorities for 2018 – 2019 28 Self-Neglect and Hoarding Framework 16 Report Contributors 29 Making Safeguarding Personal 17 Appendix 1 – structure chart 30 Views of Service Users 17

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Introduction

Purpose of the Report There is little doubt that the scope of safeguarding has widened; safeguarding for both adults and children has transformed in recent years with the introduction of new legislation creating new duties and responsibilities. In response partners are working together to keep children, young people and adults at risk safe from harm, through a collaborative approach and collectively responding to multi-agency challenges. The CCG safeguarding annual report provides a summary of activities and developments that have taken place over the year. It demonstrates assurance regarding the CCG’s statutory functions in relation to compliance with Section 11 of the Children Act (2014), the Mental Capacity Act (2005) and the Care Act (2014). The report outlines how the CCG has contributed to the partnership arrangements across the rapidly changing landscape and takes account of national changes, which influence local developments. The report will focus on key areas of core business: 1. Delivery of the statutory safeguarding functions 2. Developing and strengthening pathways and services 3. Influencing partnerships 4. Using intelligence and information to inform decisions 5. Safeguarding quality and improvement Core business involves coordinating and driving improvements across the health system and working in partnership alongside reflecting on achievements and areas that require improvement. This approach is central to any system of keeping people safe in order to: • Keep them free from harm, abuse or neglect • Protect their wellbeing and human rights • Protect their health The narrative and pictorial sections throughout this report provide an overview of how the CCG has delivered against the key areas of core business. The report will conclude by looking forward to the year ahead, identifying key priorities for 2018-2019. The Designated Professional / Nurse Network across Lancashire work closely together to promote a standardised approach, in respect to safeguarding and Mental Capacity Act (MCA), this includes sharing good practice and striving for service improvements where possible across Lancashire. The report highlights the growing complexity of safeguarding and the continued proactive nature of the team to meet the demands. There is acknowledgement that this is emotionally difficult work, set against increasing austerity within the multi-agency systems and the evolving new NHS structures. The safeguarding team will continue to provide the necessary leadership and safeguarding expertise to facilitate improved assurance of safeguarding arrangements.

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Key Achievements 2017/18

 Revised and agreed service specifications and performance targets for Looked After Children and Sudden Unexpected Death of a Child (SUDC)

 Review of the SUDC commission to extend the delivery to a seven day service. This was undertaken following a review of the service by the Child Death Overview Panel

 Develop a sustainable Child Sexual Exploitation model for health provision across central Lancashire

 Development of a multi-agency Female Genital Mutilation pathway agreed across pan-Lancashire

 Making Safeguarding Personal single agency audit tool completed by the CCGs across Lancashire

 Review of the Welsh model for children and adult learning reviews including strengthening arrangements for monitoring multi-agency actions plans and dissemination of learning

 Contribution to the development of a Lancashire Court of Protection prioritisation tool used by all of the CCGs, promoting a standardised approach

 Development and implementation of a Mental Capacity Act Learning and Development Framework

 Contribution to the Lancashire Safeguarding Adult Board multi-agency Safeguarding Concerns Guidance

 Representation at the Strategic Domestic Abuse Board and contribution to the associated work streams to provide strategic leadership across partnerships to co-ordinate the response to all age domestic abuse

 Strengthened the GP self-assessment audit process, including the development of evidence indicators

 Refresh of the GP rolling programme of training for Primary Care

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1. Delivery of the Statutory Safeguarding Functions

Accountability for safeguarding rests with the Chief Officer of the CCG in meeting statutory and non-statutory constitutional and governance requirements. The CCG safeguarding team incorporates the designated statutory safeguarding roles. To ensure that the CCG is fulfilling its statutory responsibilities for safeguarding, a quarterly activity report is tabled at the Safeguarding Assurance Group, which in turn reports to the Quality and Performance Committee (see appendix one).

The NHS England Accountability and Assurance Framework (2015) outlines the safeguarding roles, duties and responsibilities of all organisations commissioning NHS Health and Social Care. It reports on how health organisations will be held to account both locally and nationally in respect of their safeguarding arrangements; including how professional leadership and expertise will be developed and retained in the NHS.

The CCG has continued to demonstrate compliance against the Safeguarding Vulnerable People in in the NHS Accountability and Assurance Framework and Section 11 requirements. The self-assessment is subject to scrutiny by the Quality Assurance and Performance Improvement Sub Groups of the Lancashire Children and Adult Safeguarding Boards. Throughout 2017/18 the CCG has demonstrated compliance in most areas. An action plan has been developed regarding Level 2 safeguarding training for both children and adults to strengthen this area for improvement.

In accordance with the Framework, the CCG is required to demonstrate that they have appropriate systems in place for safeguarding, these include:

• Ensuring a clear line of accountability for • Ensuring that staff are competent to carry out their safeguarding is reflected in the CCG governance responsibilities for safeguarding through effective arrangements. This includes Designated Lead roles supervision and training for safeguarding and an approved nurse led service for responding to unexpected deaths in childhood • To ensure effective inter-agency working with Local Authorities, Police, Third Sector, Children and • Having in place clear policies setting out a Adult Safeguarding Boards and Health and commitment to safeguarding, including safe Wellbeing Boards recruitment practices and arrangements for dealing with allegations against people who work with • To work with partners to ensure effective systems children and adults and services are in place to enable agencies to respond to abuse and neglect of children, young • To fully support the safeguarding inspectorate people and adults teams to promote improvement across the system

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Policy Development Within the reporting period the CCG safeguarding policy has been reviewed to reflect changes in current legislation and guidance. The policy was strengthened following recommendations from the NHS England self-assessment against the Accountability and Assurance Framework. Shared sample policies to support safeguarding arrangements include domestic abuse for Primary Care and MCA implementation for the regulated care sector. These reflect national and local developments and provide an evidence base for practice. To support small providers a sample policy was developed and workshops held to assist in meeting the standards outlined within the Safeguarding Assurance Framework.

Supervision Supervision is fundamental to effective safeguarding practice across a range of settings and should therefore lead to better outcomes for children, young people and adults with care and support needs. Within the reporting period the designated lead nurses attended specialist safeguarding training facilitated by the NSPCC and NHS England. Subsequently a CCG supervision framework was developed and implementation is planned for 2018/19. This framework will provide a structure for safeguarding supervision to support the improvement of working practices.

Learning and Development The CCG has a duty to ensure that staff have access to appropriate safeguarding training and learning opportunities to recognise child and adult abuse and to take effective action. In addition, the CCG must ensure that staff are familiar with the legal requirements of the MCA and it’s implementation. The team provide supervision and support to the Named Nurses for safeguarding within provider organisations. All provider staff including Primary Care can access ad hoc supervision for case management and support. Over the last year the team have supported staff across all providers to manage a number of complex cases, bringing services together and where necessary applying escalation processes where there is professional dispute.

An adult safeguarding Intercollegiate document is due to published 2018/19 and will provide a framework for roles and competencies for healthcare staff. Although this will not have a significant impact on the CCG; a staged approach for implementation will be necessary for commissioned services.

The CCG safeguarding team have been involved in the coordination of training on behalf of the pan-Lancashire CCGs; supported by funding from NHS England. This included a carer’s event to raise awareness of the principles outlined within the MCA, two multi-agency learning events focussing on case law and court of protection and a Female Genital Mutilation (FGM) Conference. The CCG also provides a rolling programme of training to support learning and development within Primary Care.

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Promote Improvements within the Safeguarding System • A pan-Lancashire collaborative approach to the Safeguarding Assurance Framework has continued to be achieved. The safeguarding standards have been revised in line with legislation and guidance and these are reflected both in the CCG’s safeguarding policies and contractual processes • Launch and continued support of the safeguarding and MCA multi-agency domiciliary champions model • The team are active members of the Children and Adult’s Safeguarding Boards and Sub Groups • Membership of the regional Looked After Children, FGM and MCA working groups • Proactive work around the dissemination of learning and recommendations from learning reviews • CCG representation at Lancashire Improvement Board supporting Lancashire’s improvement journey following their OFSTED Inspection 2015

External Scrutiny In June 2016, following the CQC review of Health Services for Children Looked After and Safeguarding in Lancashire, a Lancashire wide action plan was developed. The established CQC Action Plan Steering Group continued to meet to monitor the plan, which was finalised in September 2017. The action plan will continue to be scrutinised via the local area inspection teams.

Safeguarding Assurance of Commissioned Services The safeguarding standards audit tool form part of the Safeguarding Assurance Framework and are integral within the annual contract for commissioned services. A full review of the safeguarding standards has been completed and revised in light of new legislation. The audit tool is used to support the monitoring of safeguarding arrangements alongside quality visits, audits and triangulation of findings from inspections and safeguarding enquiries. The examples below highlight how the safeguarding team have supported commissioned services towards strengthening their safeguarding arrangements. Safeguarding Arrangements Strengthened:

• Provided sample policies to support safeguarding arrangements Themes highlighted for improvement: • Delivered training in relation to MCA and Deprivation of Liberty • Safeguards (DoLS) Safeguarding policies and procedures • Implementation of the MCA • Provided educational opportunities and support through the GP rolling • Compliance with supervision requirements programme and Safeguarding Champions workshop to the regulated • care sector Lack of auditing of safeguarding • Strengthened arrangements across Lancashire for RADAR and Quality • Compliance with training requirements • Identifying and responding to domestic Performance and Improvement Planning (QPIP) so that concerns are abuse picked up early and partnership support is mobilised 289 Page • Proactive supportive visits to support providers in demonstrating

compliance

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Learning Lessons from the Review Process

A learning review is completed when a child / adult has died or been seriously harmed and abuse or neglect are suspected to have contributed, or there are concerns about the way in which agencies have worked together. This can take the form of a Serious Case Review (SCR), Safeguarding Adult Review (SAR), Practice Review and Multi-Agency Learning Review. The CCG continues to engage with the Lancashire Safeguarding Boards through the work of the SCR / SAR sub groups to disseminate and embed learning from reviews and share good practice. Lancashire has adopted the Welsh Model learning and review framework for undertaking reviews, which has been evaluated within the reporting period. The report was presented to the Boards and the findings indicated significant advantages of the Welsh Model compared to the Traditional Model, including clarity of purpose, resource, time and economic cost. The triangulated data suggests the Welsh reports are shorter in length whilst not losing rigour and clarity; are significantly less resource intensive and cost less to commission. The Lancashire Safeguarding Boards have also presented Lancashire’s interpretation of using the Welsh Model to the Scottish Parliament.

Serious Case Reviews Lancashire Safeguarding Children Board (LSCB) has been busy with a number of SCRs commissioned in the previous reporting year being published across Lancashire. In 2017/18, 11 referrals were made for SCR and four SCRs met the criteria for Review and were subsequently commissioned by the LSCB. There have been no SCRs commissioned relating to the Preston area within the reporting period. Safeguarding Adult Reviews Lancashire Safeguarding Adult Board (LSAB) has seen an increase in referrals to the sub group for a SAR with 12 referrals over the year and four SARs meeting the criteria and commissioned, one of those SARs is ongoing in the Preston area. Two Lancashire CCG Safeguarding Adult Reviews, Adult A and Adult D were published during the reporting year. The full reports and learning briefs are available on the LSAB website. Summary of Published Reviews Common themes amongst the learning from the published SCRs across Lancashire include:

• Professional curiosity: professionals need to exercise an appropriate level of professional curiosity during assessment – this is crucial to understanding family environment and dynamics • Engaging with Fathers: professionals need to recognise the importance of engaging with fathers and encourage fathers to talk about developing their relationship with their child. Fathers should be included in assessments and their presence/absence recorded • Concealed/denied pregnancy: professionals should always consider a psycho-social assessment, mental capacity assessment and referral to children's social care when a woman has concealed or denied a pregnancy

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Common themes identified from the learning regarding SARs include:

• Voice of the adult/family: when undertaking any assessment professionals should always seek to incorporate family member views (particularly if they are actively involved in the care of the service user) and, where appropriate, share with other agencies • Information sharing: this not only applies to other professionals involved with the service user, but also to the service user and their family members • Domestic Abuse: should be considered by professionals working with adults and older couples. This includes assessment of controlling and coercive behaviour which could be long standing within a relationship • Mental Capacity: professionals should always be mindful of completing a mental capacity assessment when working with individuals when there are concerns regarding mental wellbeing and confusion • Self-neglect and hoarding: professionals should identify self-neglect and/or hoarding at the earliest opportunity and consider if a co-ordinated multi-agency approach is required

Domestic Homicide Reviews Domestic Homicide Reviews (DHRs) were established on a statutory basis under section 9 of the Domestic Violence, Crime and Victims Act (2004). The DHR statutory guidance published December 2016 was amended to include NHS England and CCGs as statutory partners. The purpose is to contribute to a better understanding of the nature of domestic violence and abuse and to highlight good practice.

Within the reporting year there have been three DHRs and learning has resulted in the following developments:

• Development and dissemination of a sample GP domestic violence and abuse policy • Awareness raising via the GP rolling programme of training of male victims of domestic violence and abuse, including female perpetrators of domestic violence • Ensuring that the Care Act requirements regarding assessment of people with care and support needs are understood by agencies and are being implemented • Clinical guidance in relation to the management of self-harm and suicide is followed in Primary Care

Safeguarding Children The CCG as with all other NHS bodies has a statutory duty to ensure that it makes arrangements to safeguard and promote the welfare of children and young people that reflect the needs of the children they deal with. Safeguarding and promoting the welfare of children is defined as:

• Protecting children from maltreatment • Preventing impairment of children's health or development • Ensuring that children grow up in circumstances consistent with the provision of safe and effective care • Taking action to enable all children to have the best outcomes Page 291 Page

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Lancashire Safeguarding Children Board The CCG continues to works collaboratively to support the delivery of the LSCB priorities and statutory objectives, this is evident throughout the body of this report. Additional areas to note include:

• The Multi-Agency Risk Sensible Model Toolkit has been developed to support professionals when considering risk/need when undertaking a referral and work with a family • The LSCB have carried out a campaign in respect to cannabis, to increase awareness of the potential risks and impact on parenting • The CCG continues to participate in the LSCB’s themed multi-agency audit programme • A multi-agency conference has been held to support the implementation of learning from Reviews • A joint pan-Lancashire Communication and Engagement sub group has been established

Voice of Children and Young People In January 2018, a group of children and young people from across Lancashire came together to tell the Safeguarding Board about what "safeguarding" means to them. The group shared their experiences and what it means to be safe, and helped create a film to share their views. The children and young people involved were in care or leaving care, some were young carers or have a disability, and others have a parent in prison. The film can be viewed on the LSCB website. What is Safeguarding? - Lancashire Safeguarding Children Board

A ‘Mind of My Own’ (MOMO) is a user-friendly application that helps children express their views, wishes and feelings in a fun digital way, has been piloted in Lancashire during 2017 and is being used for a range of purposes. It is available to any children and young people involved with Children’s Social Care, including children subject to child protections plans and Looked After Children. It is currently licensed for lancashire.gov.uk email addresses and a contract has been extended to 2021. Work will continue to evidence the impact of MOMO in capturing the voice of children/young people in the year ahead. Page 292 Page

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Safeguarding Children Activity Table 1 % increase % increase Child Protection Plans Mar-17 Per 10,000 Mar-18 Per 10,000 since Mar-16 since Mar-17

Preston 239 77.4 0% 214 69.0 -10%

Chorley & South Ribble 190 41.6 -7% 179 38.9 -6%

West Lancashire 80 36.0 -27% 94 42.9 18%

Lancashire 1,394 56.8 -3% 1,243 50.4 -11%

The Lancashire rate is above the 2016/17 national rate, which has been the case since 2015/16. There has been a decline in the numbers of children subject to child protection plans since 2016. Currently, child protection plans in Preston remain high however are at a similar rate as in 2015; suggesting that the rates in Preston may be the average number for a city of its size and demographic. Work is required to reduce the numbers of children who are subject to child protection intervention for extended periods of time. A plan for 2018/19 will include Children Social Care and health partners undertaking an audit of cases where children have been subject to child protection plans for over twelve months.

Looked After Children As of March 2018, Lancashire County Council were looking after 1968 children in care, this equates to a rate of 79.5 per 10 000. This is a 5.6% increase in the number of Looked After Children compared to the previous year. In addition, there are almost 1,000 Looked After Children from other local authorities placed in Lancashire, residing in Private/Independent Children’s Homes or with foster carers; many of whom originate from neighbouring local authorities.

Across central Lancashire at March 2018, there were 916 Looked After Children, with 317 originating from out of area and 591 originating from within central Lancashire boundaries. The numbers of Looked After Children continue to rise, this is mirrored across Lancashire; it is understood that more children being placed at home on care orders is a contributory factor. Page 293 Page

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Table 2

% increase % increase Looked After Children Mar-17 Per 10,000 Mar-18 Per 10,000 since Mar-16 since Mar-17

Preston 264 85.5 18% 298 96.0 13%

Chorley & South Ribble 222 48.7 15% 264 57.4 19%

West Lancashire 105 47.2 21% 127 57.5 21%

Lancashire 1,864 75.9 10% 1,968 79.7 6%

Health of Looked After Children Across Central Lancashire CCG responsibilities to support Looked After Children are mandated through the Children’s Act 1989, 2004 and ‘Promoting the Health and Wellbeing of Looked After Children 2015, both of which set out a duty to comply with requests from the Local Authority in support of their statutory requirements for the completion and quality assurance of health assessments.

The CCG commissions the acute provider to complete Initial Health Assessment (IHA) and there are inbuilt arrangements with the 0-19 teams to under Review Health Assessments (RHAs), with the exception of those Looked After Children who are harder to reach. The quality and timeliness of health assessments is monitored by the CCG via quarterly and exception reporting by the community provider. RHAs are on the whole completed within the statutory timeframes; however compliance rates for IHAs remain low due to a series of co-dependant multi-agency challenges. Case tracking meetings are well established with Children’s Social Care partners to address any issues that prevent the timely completion of statutory health assessments. There will be a continued drive to improve the quality and performance of health assessments with a focus on partnership working arrangements.

Subsequent to Lancashire County Council’s disinvestment and agreement by central Lancashire CCGs to bridge the funding deficit; the Looked After Children Specialist Service specification has been reviewed to include additionalities around Looked After Children, who are not in main stream school or who have complex needs.

A looked after child benchmarking exercise developed by NHSE was completed by CCG at the end of 2016. Each CCG has recently been requested to review the self-assessment and feedback to the Looked After Children regional lead. A response has been provided from a Lancashire and South Cumbria perspective identifying good practice and key areas that require strengthening which include:

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• Strength and difficulties questionnaire’s not being used to inform health assessments to allow health to contribute in a meaningful way • Reporting on themes and trends regarding health needs and outcomes to influence commissioning and development through the joint strategic needs assessment • Tracking of Looked After Children in and out of area, particularly those in residential settings and specialist commissioned placements

The key areas identified are co-dependent on our partners in the Local Authority. It is anticipated that the strengthened governance arrangements outlined below will support improvements consistently across Lancashire and South Cumbria.

Governance Arrangements for Looked After Children The CCG receives quarterly performance data on Looked After Children from Lancashire Care Foundation Trust. These detailed reports include health performance, and children’s case studies highlighting positive experiences, learning and links to service improvements.

The establishment of the pan-Lancashire Looked After Children Professional Network group supports the delivery of statutory responsibilities in relation to LAC and the co-ordination and delivery of the North Regional Looked After Children work plan. The regional group supports the delivery of the National Looked After Children forum work plan and the pan-Lancashire Looked After Children Professional Network cascades information, shares good practice and feeds into the regional group and its workstreams.

The Looked After Children Recovery Action Plan Group was disbanded in 2017 and governance has been strengthened by the introduction of the Permanence and Corporate Parenting Board within Lancashire Children Services. The purpose of the Board is to improve the care experience for children and young people; from initial placement planning through to securing placement, permanency and leaving care. The designated nurses along with providers form part of a strong health membership to support the continuous drive to improve the quality and performance of health assessments and wider initiatives to ensure the holistic health needs of Looked After Children are met.

Voice of Service Users

In Lancashire, LINX, the Children in Care Council, along with the Care Leavers Forum offered their ideas about what is vital and what needs to happen quickly for Looked After Children. They have engaged in a number of activities to support and strengthen service delivery. PROUD is one of the biggest events of the year with young people being nominated for awards by a wide range of key workers and agencies. Approximately 60 young people and their guests attended PROUD in February to celebrate their wide ranging efforts and achievements. Their presence at the event reminded us of their resilience and continued dedication to being the best they can be.

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Safeguarding Adults The CCG is committed to promoting wellbeing in their safeguarding arrangements, by working together with individuals and partner agencies to establish what being safe means to them and to determine how that can be best achieved. In April 2015 the Care Act (2014) came into force which placed adult safeguarding onto a statutory footing. The Care Act (2014) defines an adult at risk as:

• has needs for care and support (whether or not the Local Authority is meeting any of those needs) • and is experiencing, or at risk of, abuse or neglect; and as a result of those needs is unable to protect her/himself against the abuse or neglect, or the risk of it

Lancashire Safeguarding Adult Board The CCG works closely with Lancashire Safeguarding Adults Boards (LSAB’s) in achieving their priorities set out in the 2016-18 business plans. Priorities were set based on the 15 Care Act responsibilities under 6 Key Safeguarding Principles: Empowerment; Prevention; Proportionality; Protection; Partnership; and Accountability, significant progress has been made:

• All sub groups of the Lancashire Board consider issues of diversity throughout work programmes and during development of policy and practice • In Lancashire the MCA Sub Group have developed a framework for learning, providing a suite of packages in order to support the implementation of MCA across the workforce • The existing Lancashire Section 11 process has been amended to enable the collection of information regarding all-age safeguarding. This provides the Board with assurance that arrangements are in place to safeguard adults effectively • In October 2017, the new online Lancashire Safeguarding Policies and Procedures manual were launched • Across the Board progress has been made in reviewing policies in relation to: People in Positions of Trust; Self- Neglect and Hoarding; Making Safeguarding Personal; and SARs

The CCG have worked collaboratively with the LSAB in the development of operational guidance for safeguarding concerns to support providers in identifying when safeguarding referrals should be made. The guidance aims to assist practitioners in making appropriate referrals and assist in the management of risk, by enabling agencies to rationalise decision making around the level of support and response required to the allegation of abuse. The guidance and its appendices have been successfully embedded across the health workforce during 2017/18 and a review of its first year has been undertaken via an online survey of practitioners. Overall, the findings indicated a positive response and highlighted that the resource is well regarded by partners. The guidance can be found here and should be used in conjunction with providers’ multi-agency procedures. Page 296 Page

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Safeguarding alerts received by Lancashire County Council (LCC) continue to increase year on year. In 2017/18, 11,341 adult cases were received by the Lancashire MASH, a 5.4% increase from the previous year of 10761. The associated increase may be as a result of service development initiatives, awareness raising across multi-agency partners and multiple referrals made by different agencies regarding the same concern for a service user.

Historically the focus on safeguarding alerting was based on the principle of ‘no alert is a bad alert’ however due to increasing demand and the complex nature of safeguarding referrals, it has been recognised that many safeguarding concerns will not meet the threshold for a statutory section 42 safeguarding enquiry and rather will follow an alternative care pathway. Following the implementation of the safeguarding referral guidance the number of referrals made into MASH have been identified as appropriate.

Interestingly the number of referrals made to the central Lancashire locality has seen a reduction in numbers within the reporting period. The reason for this is not clear at this time.

The charts below show the percentage of alerts received across Lancashire with the key themes:

Percentage of Alerts Across Lancashire: Main Themes of Alerts Across CCG Footprint:

• 44.2% from social care staff • Neglect and Acts of Omission • 27.1% from health staff • Physical Abuse • 10.1% classed as 'other' • Emotional/Psychological Abuse • 7.8% from family members • Financial Abuse

Table 3 – Total number of safeguarding adult alerts received by LCC

Apr-16 – Mar-17 Apr-17- Mar-18 Chorley and South Ribble 2376 2042 Preston 1651 1602 West Lancashire 942 826 Lancashire 11343 10884 Page 297 Page

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Table 4 - Total number of alerts received progressing to a safeguarding enquiry from the 1 April 2017 to 31 March 2018

Number of Safeguarding Alerts Progressing to a % of Alerts that Alerts received by LCC Safeguarding Enquiry Substantiated per District Chorley and South Ribble 2042 803 34 Preston 1602 636 31 West Lancashire 826 297 32 Lancashire 10884 4332 30

Self-Neglect and Hoarding Framework The Care Act statutory guidance has seen a number of amendments to those who self-neglect, including further clarification of enquiries under Section 42 of the Act. Ordinarily it is not appropriate for people who are failing to care for themselves to undergo a safeguarding enquiry due to Section 42 being aimed at individuals who are suffering from abuse or neglect from a third party. Self-neglect across Lancashire is managed with the support of Adult Social Care and can be challenging and complex due to the multi-faceted nature of individuals who self-neglect.

Self-neglect can be a result of a conscious decision to live life in a particular way that may result in having an impact on a person’s health, wellbeing or living conditions and may have a negative impact on other people's environments. Often in these circumstances people may be unwilling to acknowledge there might be a problem and/or be open to receiving support to improve their circumstances. There are various reasons why people self-neglect. Some people have insight into their behaviour, while others do not; some may be experiencing an underlying condition, such as dementia.

Themes from a local SAR identified that despite the Care Act including hoarding as a category of self-neglect under the heading of abuse and neglect, professionals working with individuals living with hoarding may not identify hoarding as a safeguarding concern and can often face strong resistance from the individuals involved. Professionals are not always confident of how to respond leading to inconsistent interventions. Therefore the LSAB recognised the need to develop a Lancashire Self-Neglect Framework to support agencies working with individuals who present risks to themselves and/or others. The purpose of the framework is to provide a process guide for all partner agencies on how to respond when concerns of self-neglect have been identified. The framework will apply when there are:

• Significant concerns by agencies about an individual's safety and/or/wellbeing as a result of self-neglect • Significant concerns about the safety and/or wellbeing of others (risk of serious harm, injury or death) • Existing agency involvement with appropriate multi agency working which has been tried and unable to resolve the issues. Page 298 Page

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Making Safeguarding Personal The implementation of the Care Act and the Making Safeguarding Personal (MSP) agenda has resulted in a change in approach to how safeguarding concerns are addressed which focus on the rights of adults to autonomy in decision making where they have the mental capacity to do so. The outcome is to engage with individuals about the outcomes they wish to achieve from a safeguarding intervention depending on their wishes and circumstances.

The LSAB has been encouraging the development of an MSP approach across all agencies. As part of these work streams the CCG has undertaken an audit to understand how effectively MSP was embedded in commissioned NHS services and the work required to further enhance service user voice in the safeguarding process. The resulting actions identified areas requiring strengthening, which were:

• Incorporating MSP within safeguarding mandatory training across the CCG & within Commissioning Support Unit • Strengthening the process of capturing service users experience following safeguarding procedures, which can enable and influence the CCG’s learning • Incorporating MSP into the Safeguarding Assurance Framework audit tool • Promoting the use of Advocacy services within commissioned services and Primary Care

An action plan has been developed against the above recommendations for all CCG’s across Lancashire and is being progressed and monitored through the LSAB Quality Assurance Sub-Group. Progress will be reported in 2018/19.

Views of Service Users The Lancashire Board engaged with a group of service users to develop an Easy Read Guide: 'What is safeguarding and how to report your concerns', which aims to help vulnerable adults understand what 'safeguarding' is; what 'abuse' is; the different types of abuse, and what to do if they are worried or concerned. This was developed in partnership with the Learning and Disability Partnership Board, and was published to the LSAB website in September 2017.

The Boards routinely consult with and seek the views of family members in relation to SAR’s to ensure their views are appropriately reflected. Family members are always considered during decision making around publication and any possible effect publishing may have on an individual.

Additional information on the work of the board, including board minutes, can be accessed here.

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2. Developing and Strengthening Pathways and Services The Changing Landscape of Safeguarding

Child Protection – Child Protection Information Sharing Project (CP-IS) is a national system (across England) that Information Sharing connects children’s social care IT systems with those used by NHS in unscheduled care settings. By linking the different IT systems, CP-IS is enabling staff to securely share information and work more closely and to provide earlier interventions for children who are considered vulnerable and at risk.

The CCG have supported CP-IS implementation by ensuring CP-IS application was included in contracting processes with Acute Provider services and have received assurances against progress. Plans are in place for Urgent Care settings to get their system accredited to enable CP- IS functionality, meanwhile interim arrangements are in place.

Domestic Abuse The CCG are represented on the pan Lancashire Domestic Abuse Strategic Board, providing a strategic health perspective in the development and future implementation of the pan-Lancashire Domestic Abuse Strategy, underpinned by an action plan to support the delivery.

Within the reporting period Lancashire Victim Services was commissioned to support victims of crime. The model brings together services for victims of hate crime, young victims, sexual abuse and domestic abuse as well victims of more general crime types and of repeat anti-social behaviour.

In March 2018 the government launched a consultation on domestic abuse, seeking new laws and stronger powers to protect and support survivors. The CCG participated in the consultations by representation at the event and contribution to the on line consultation seeking views on the measures to be included in the governments draft Domestic Abuse Bill.

It has been recognised that approaches to domestic abuse across the adult agenda need to be strengthened to support adults with care and support needs including dementia. A multi-agency policy is in development to improve arrangements for victims of domestic abuse, along with work streams to strengthen information sharing to primary care.

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Female Genital FGM refers to procedures that intentionally alter or cause injury to the female genital organs for Mutilation non-medical reasons. There have been significant legislative changes over recent years introducing a number of responsibilities for professionals, employers and organisations in respect to FGM.

The CCG has led on the pan-Lancashire FGM work stream to develop a multi-agency safeguarding pathway which was launched at a FGM multi-agency conference to raise awareness, identification and response to FGM across Lancashire.

Recent progress has been made locally with the first stage of implementing the FGM Information Sharing (FGM-IS) across maternity units in England. It is a national system that allows authorised healthcare professionals to systematically share information about a family history of FGM; the second phase will be to introduce the project alongside EMIS in Primary Care and 0-19 services.

Commissioning service standards for commissioning FGM care produced by NHS England have been recently introduced to improve care offered to girls who have undergone FGM. The guidance describes service standards expected to be commissioned for children under the age of 18.

Child Sexual The CCG commissions for early assessment and support to those at risk of child sexual Exploitation exploitation (CSE) to provide the best possible health outcomes for young people at significant risk of CSE within the local area.

Throughout 2017/18, following a referral into the local multi-agency CSE Team (Deter), 352 young people had health assessments undertaken. Common themes include: sexual health, substance misuse and emotional health and wellbeing, comprising of a wide range of issues including; self- harm, suicide attempts, eating disorders, depression, anxiety, stress and sleep. A co-ordinated response to these health needs is provided working closely in partnership with agencies.

CSE continues to remain a high profile and over recent years there has been a national drive to strengthen accountability and change the culture from one of denial to one of action, and improve joint working and information sharing in order to protect vulnerable children. More recently there is increasing recognition of the changing nature of exploitation of children with recent guidance for England from the Department for Education (2017) advocating that CSE should not be separated from other forms of child sexual abuse, trafficking, gendered violence or going missing.

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Modern Slavery & Modern slavery is an international crime involving a substantial number of source and transit Human Trafficking / countries. Organised crime groups systematically exploit large numbers of individuals by forcing County Lines and coercing them into a life of abuse and degradation.

The CCG is represented on the pan-Lancashire Anti-Slavery Partnership (PLASP) hosted by Lancashire Constabulary. PLASP are in the process of developing a localised action plan to create multi-agency pathways and training, working in partnership with both statutory and third sector agencies. Prevent Section 26 of the Counter Terrorism and Security Act 2015 places a duty on health services to have due regard to the need to prevent individuals from being drawn into terrorism. The challenge for services is to ensure that where there are signs that someone has been drawn into terrorism, health professionals are trained to recognise the signs and know how to access support.

Channel is a voluntary, confidential programme which provides support to people who are vulnerable to being drawn into terrorism. It operates across the country through Local Authority- chaired multi-agency panels and is not any form of criminal or civil sanction. The aim of Channel is to safeguard people from the harm which radicalisation can cause, before they come to harm themselves or become involved in criminal behaviour that harms others. Lancashire has participated in the ‘Dovetail’ pilot, which was successful in trialling a new method of delivery for the Channel programme, which saw Local Authorities taking the lead on the coordination of the key activities. Nine sites tested a variety of models and Blackburn with Darwen Borough Council was selected to host the pilot on behalf of the pan-Lancashire Local Authorities.

Within the reporting period NHS England reviewed the Prevent Training and Competencies Framework found here. The framework was developed in order to meet the Prevent Duty (2015) and to encourage a consistent approach to training and competency development regarding Prevent across the healthcare system. A training needs analysis was undertaken which identified staff members required to undertake Prevent basic awareness and Wrap 3 training as part of their role. The CCG achieved 90% compliance in basic awareness training and 100% compliance in Wrap 3.

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Mental Capacity Act Implementation and Deprivation of Liberty Safeguards The MCA 2005 is an important piece of legislation and one that will make a real difference to the lives of people who may lack mental capacity. It empowers people to make decisions for themselves wherever possible and protects people who lack capacity by providing a framework that places individuals at the heart of the decision-making process. It enables individuals to participate as much as possible in any decisions made on their behalf and ensure that these are made in their best interests. All agencies have a responsibility to ensure that the services they provide pay regard to the MCA and the principles outlined within the Act.

The CCG is committed to ensuring that best practice information is available for service users, and the public about the MCA and about the promotion of the rights of individuals who may lack capacity to consent to care and treatment. Service user views are incorporated into practice development initiatives where possible.

All health and social care staff have statutory responsibilities to adhere to when acting or making decisions on behalf of individuals who lack the capacity to make those decisions for themselves. The CCG safeguarding team led on the development and implementation of a MCA Learning and Development Framework approved by the LSAB. The framework incorporates the recommendations from the pan Lancashire MCA Research project (2017) and sets out a suite of training packages which supports the achievement of MCA across the Health and Social Care Economy and contributes to agency effectiveness over the coming years. The packages can be found here and are recommended as a best practice guide for agencies to use or to benchmark their own training arrangements with.

Deprivation of Liberty Safeguards The House of Lords Select Committee recommended in March 2014, that the current deprivation of liberty safeguards (DoLS) were ‘not fit for purpose’. The Law Commission was asked to review this recommendation in March 2017 and published a detailed report along with draft legislation. This will include a new system being introduced to replace the DoLS framework with the ‘Liberty Protection Safeguards’ and an amendment to the MCA. There will be implications for the CCG with additional responsibilities in the authorisation of DoLS for individuals funded by Continuing Health Care packages of care. In 2017-18 the Local Authority received 3425 DoLS authorisation’s applications across Lancashire these figures are unable to be broken down per locality. There an increasing number of DoLS applications that have not been processed. This number has increased year on year and although exact figures are not available within the reporting year; this is in the region of 5000 plus. Demand continues to exceed capacity and statutory timeframes are not being met however this position is replicated in some areas across the country. There remains a clear prioritisation process in place to ensure the highest risk/more complex cases are processed expeditiously. The Local Authority is seeking additional resource and the CCG is working collaboratively to manage presenting risks across the system and in maintaining patient safety.

The Policing and Crime Act (2017) amended the Coroners and Justice Act 2009, with the effect of relieving coroners of the duty to undertake an inquest into every death, where there was a DoLS authorisation. The change applied from; deaths where a DoLS is in place occurring on or after April 2017 were no longer subject to a mandatory investigation and inquest.

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Court of Protection The Court of Protection (COP) was set up under the MCA to deal with decision making for adults (and children in a few cases) who may lack capacity to make specific decisions for themselves. The COP deals with property and affairs and serious decisions affecting healthcare and personal welfare matters, including deprivation of liberty, and has the same authority as the High Court. Following the 'Cheshire West' Supreme Court judgment (2014) which set out an 'acid test ' for what constitutes a DoL, has brought thousands more people within scope of the COP. A COPDoL is an application to the court for people who are not safeguarded under the current DoLS legislation. The DoLS legislation safeguards people who are deprived of their liberty of whom reside in care homes or hospitals; however this legislation does not include people in domiciliary care settings and, in a person’s own home. CCG’s and local authorities are responsible to apply to the court for a COPDoL to seek authorisation to continue to support and care for the person, in their best interests, that results in a deprivation of their liberty.

The Court of Protection Collaborative The COP Collaborative Group was initiated in July 2017, originally to formalise the dialogue between health and social care to ensure involvement in court proceedings is as timely and effective as possible. The CCG safeguarding team represents all the Lancashire CCG’s together with colleagues with lead responsibilities for coordinating, overseeing, managing and/or making applications to the COP (or exceptionally the High Court) from the Local Authority and the Commissioning Support Unit. The COP Collaborative Group is concerned with adults (and in some cases children) who may lack capacity (or 'Gillick competency' in the case of children) to consent to serious health and welfare decisions, including the provision of care under circumstances that amount to a deprivation of their liberty. The purpose of the group is to exchange information about individual COP cases which involve both health and social care services, to facilitate timely intervention along with implementing best practice in relation to COP work and developing policies and procedures. The group have successfully achieved the priorities outlined within the previous annual report, by standardising the process for COP applications and in the development of a prioritisation tool based on ADASS guidelines to manage the increased volume of cases to progress through the COP. A priority for 2018/19 will be to implement a preventative process of managing CHC DoLS authorisations with the aim of progressing recommendations arising from DoLS authorisations and reducing section 21a challenges to the COP. Section 21a challenges can often result in an unsatisfactory patient experience and increase the potential of litigation to the CCG. Within the reporting period there have been challenges in practice regarding the GP requirement to confirm the diagnosis of ‘unsound mind’ in cases where a COPDoL is required within a domiciliary setting. A lack of confirmation of the diagnosis can result in care and treatment delays for patients within the Transforming Care pathways requiring discharge from hospital to a community placement. Transforming care is all about improving health and care services so that more people can live in the community, with the right support and close to home. Work is in progress in partnership with the Local Medical Committee to support understanding and legal responsibilities around the role in confirmation of ‘unsoundness of mind’.

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Child Death Overview Panel

The Child Death Review Panel (CDOP) became statutory in April 2008. The pan-Lancashire CDOP is a subgroup of the three Local Safeguarding Children Boards and has a statutory responsibility to review all the deaths of all children up to the age of 18 years. The team have maintained an active representation on CDOP business meeting to support the improvement of practice and prevention of future deaths.

From April 2016 there has been an increase in suicides across pan-Lancashire with 11 being reported to CDOP resulting in a further suicide thematic review being undertaken in collaboration with South Cumbria. There has been a continued decline in the number of deaths where unsafe sleeping arrangements are a feature. In May 2017, the Sudden Unexpected Death in Childhood (SUDC) prevention group hosted the ‘Make Every Second Count’ conference to support and increase the confidence of frontline practitioners when delivering safe sleep messages to parents. In addition, the ‘Safer Sleep Campaign’ continues to support professionals in providing consistent messages regarding safe sleep arrangements.

Sudden Unexpected Death in Childhood – Responding to Child Deaths Chorley South Ribble CCG leads on the collaborative commissioning arrangements for the pan-Lancashire SUDC) nurse-led service. The service provided by Lancashire Care Foundation Trust leads on the implementation and co-ordination of the rapid response processes following the unexpected death of a child. The number of unexpected child deaths in 2017/18 was 43, the lowest numbers reported for several years. Pan- Lancashire has experienced an average of around 53 annually, since the inception of the service in 2008, this has remained fairly consistent. During 2017/18 in central Lancashire there have been six deaths; a decrease in 11 from the previous year. Due to the unpredictable nature of child deaths, there is no current explanation for the decrease in numbers.

Service Development The findings of a review commissioned by CDOP in 2016, highlighted good practice in the response provided but gaps in provision during out-of-hours. To strengthen arrangements an option to extend the service to a seven day model was agreed by the eight CCGs across pan-Lancashire working in partnership with the provider. A steering group has been established to provide multi-agency co-ordination to support the new developments. It is expected that the seven day model will be operational by the end of 2018.

An event to acknowledge the 10 year anniversary of the SUDC nurse-led service and the launch of the seven day service is planned towards the end of the year.

Safeguarding in Primary Care The rolling programme of safeguarding training recommenced in June 2017. A new workshop style model has been developed focussing on key messages from learning reviews. The workshops have adopted an analytical approach in exploring risk factors and participants are encouraged

Page 305 Page to apply professional curiosity. Positive responses to both style and content were reported on evaluation. The sessions enable an opportunity to

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share information resources and tools to support practice, including case specific discussion. This supports a two way dialogue between the CCG and Primary Care.

The safeguarding team are working with the Primary Care team to roll out the Safeguarding Leads/Champion Model. The model supports safeguarding leads within Primary Care by strengthening safeguarding skills and knowledge. It will also promote standardisation of practice across Primary Care in line with other CCGs across Lancashire.

Additionally, the Named GP for Safeguarding supports the CCG to progress initiatives that include:

• Practice supervision visits following learning from reviews or complex cases • Production and dissemination various forms of communication • Including the role of GPs within the social workers induction handbook • Continued drive to improve communication surrounding child protection conference invites and reports • Updating policy and procedures

An online survey was conducted in response to the findings of the Lancashire Safeguarding Children / Adult Boards themed multi-agency audits outlined below:

• Child Sexual Exploitation • Domestic Abuse • Escalating concerns when there is professional disagreement

The CCG have completed the audits with Primary Care. Early themes indicate consistent issues around information sharing. It is recognised that this needs to be a two way process between social care and primary care services. It was evident that information sharing with GPs is often limited; however there were occasions where information was not always shared by GP practices. An emerging theme included a lack of professional curiosity around early child sexual exploitation indicators. Following analysis a report will be developed and recommendations made to support the strengthening of communication pathways.

3. Influencing Partnerships Lancashire and Cumbria Children’s Services Improvement Journey As part of the Lancashire County Council’s improvement journey Lancashire invited the Local Government Association to undertake a safeguarding children peer review. This provided an external and independent view of the progress being made to improve outcomes for children and young people. The review offered partner agencies an opportunity to feedback on how the multi-agency partnership worked together to safeguard and promote the welfare of children. Findings and areas for improvement are monitored by the Lancashire Improvement Board where the CCG is represented.

Page 306 Page A joint SEND inspection took place October 2017 by Ofsted, the CCG safeguarding team contributed to a Looked After Children focus group.

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Inspectors reviewed performance information and evidence of the local offer and joint commissioning identifying significant areas for improvement. The Local Authority and the CCG’s have submitted a written statement to Ofsted and improvement plans are in place.

Lancashire County Council is waiting the full Ofsted Inspection of Children's services. This will be a full four week inspection and will look at the breadth of Children's and interface with Health and Police around Social Care and vulnerable children. The CCG has been supporting the preparation and planning for the forthcoming Inspection.

The Children and Social Work Act 2017 The publication of the Wood report in 2016 brought about a fundamental review of the role and functions of Local Safeguarding Children Boards with widespread agreement that the current system needed to change to a new model to ensure “collective accountability” across the system. Proposals included a “stronger but more flexible statutory framework” that would give the three key partner agencies (Police, Health and Local Authorities) the “freedom to determine how they organise themselves” to work together to safeguard and promote the welfare of children in their local area. In addition, the review makes reference to a number of areas, including services for Looked After Children and proposed changes to the arrangements for SCRs and Child Death Reviews.

Following the report, the resulting Children and Social Work Act was granted royal assent in April 2017 to be enacted in April 2018. As a result of the Act and a period of consultation between October and December 2017, the government proposes to update and replace ‘Working Together to Safeguarding Children’ (2015). The CCGs have contributed to the consultation and will continue to work closely with partners and Safeguarding Boards to implement the new arrangements.

Looking ahead with the development of the Lancashire and Cumbria Integrated Care System the Designated Nurse network will be working collaboratively with NHS England and Lancashire and South Cumbria CCGs to review and align the safeguarding system arrangements into 2018/19.

4. Using Intelligence and Information to Inform Decisions Multi-Agency Safeguarding Hub The Multi-Agency Safeguarding Hub (MASH) across Lancashire and Cumbria is the single point of contact for all professionals to report safeguarding concerns; the team brings together agencies to share information in a timely manner to aid decision making when there are concerns. Implementation of MASH team in Lancashire has improved the sharing of information between agencies, helping to protect the most vulnerable children and adults from harm, neglect and abuse.

In Lancashire the LSCB led a multi-agency review during 2016 of the functioning of the Multi-Agency Safeguarding Hub (MASH) Working groups were established to support:

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• Partners working towards a fully integrated MASH • Improve demand management • Improve timeliness of communication • Redesign teams in MASH to support locality working • Development of single shared IT system • Management oversight and quality of practice

The CCG provide representation at the MASH Strategic Group and oversight of the action plan following the review of MASH arrangements. In recent Ofsted inspections/review visits the improvements have been recognised in the functioning of MASH teams supporting information sharing and timely decision making. A priority area moving forward is to strengthen adult arrangements within MASH.

5. Safeguarding Quality and Improvement Regulated Care RADAR and Quality The CCG’s are an active partner in the RADAR and Quality Performance Improvement Process (QPIP) offering safeguarding and MCA expertise, as well as access to community and primary care services for additional support. Over the reporting period there has been a reduction of care homes within the QPIP process across Lancashire, which may be due to the implementation of additional early intervention and a joint targeted approach by the CCGs and Local Authority. Over the year across the locality four care homes with nursing have made significant improvement following the QPIP.

Actions and Improvements Made: Themes Highlighted for Improvement: • Development of example templates to support Adult Safeguarding & MCA/DoLS Policies. • Poor leadership impacting on care delivery • Delivered additional training in relation to MCA & DoLS • Recruitment and retention pressures of registered nurses • Supported improved quality of supervision arrangements • Lack of access to robust training and supervision • Continued to provide educational opportunities and support • Poor quality record keeping /care and support planning through the Safeguarding Champions Workshop • Poor monitoring and recording • Strengthened arrangements across Lancashire for RADAR • Inconsistency in MCA implementation and compliance and QPiP processes, resulting in early intervention and • Medicines management partnership support mobilised • Supported the Safeguarding Board initiatives to improve quality of care e.g.; Leadership Training across the sector Page 308 Page

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Domiciliary Care Packages for Individuals in Receipt of CHC An area for further development includes safeguarding themes due to poor quality care due to a lack of contractual and quality assurance arrangements within domiciliary care packages. This is reported to be a Lancashire CCG wide problem. Currently there are no contracts in place for domiciliary healthcare providers and spot purchase arrangements are in place which can present with challenges due to the lack of quality contract monitoring arrangements, resulting in an increased safeguarding risk for adults and children in receipt of packages of care.

To strengthen multiagency partnership working and the sharing of soft intelligence a domiciliary Care RADAR model has been developed across Lancashire to identify areas of risk within the sector. Intelligence is reported predominantly by the Local Authority, due to there being no obligation for providers to submit quality data returns to the CSU, or to provide assurance to commissioners. There is recognition that a more robust pathway is required to improve quality assurance and contractual arrangements for the procurement and management of these services and will be an area of development within the Integrated Care System and Regulated Care task group.

Conclusion The report provides assurance to the Governing Body that the CCG is fully committed to ensuring it meets the statutory duties and responsibilities for safeguarding children, Looked After Children and adults at risk of harm, including MCA implementation. The report highlights the huge amount of work and developments in order to improve processes and builds on existing safeguarding systems and procedures. It demonstrates how the team works with external partners and across the health economy to ensure statutory safeguarding requirements are met.

Safeguarding work is instrumental to service development and develops at different paces; this is often dependent on how priorities evolve with developments being interlinked with national legislative or statutory guidance requirements. There will be a requirement to respond to the legislative changes to the Children and Social Work Act 2017 in the year ahead. Supporting the development of plans for future arrangements and how these are implemented across Lancashire and South Cumbria will pose some challenges. A move to equal partnership with the Local Authority and Constabulary will feel very different from safeguarding Boards who currently hold the statutory role.

The report highlights the growing complexity of safeguarding and the continued proactive nature of the team to meet the demands; set against increasing austerity within the multi-agency systems and the evolving new NHS structures. Future consideration needs to be given to the delivery of safeguarding statutory functions as the Integrated Care System and Integrated Care Partnerships evolve, and how the safeguarding arrangements are applied via the new commissioning framework.

The safeguarding team will continue to compassionately provide the necessary leadership and safeguarding expertise to promote the provision of an integrated and highly robust safeguarding service for all ages. Priority areas for implementation during 2018-2019 are outlined below.

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Key Priorities for 2018-2019

1. Delivery of Statutory Functions

• Continue to embed the principles of the MCA • Implementation of a robust process to monitor DoLS recommendations and reduce the risk of 21A challenges • Strengthen current arrangements regarding COPDOL applications and unsound mind • Continue to support a culture of learning through training and supervision, embedding lessons learnt • Work with partners to understand the numbers of children subject to a child protection plan across the CCG and develop plans to safely reduce numbers • Continue to work with the Adult Safeguarding Boards and Local Authority to support appropriate referrals/alerts to identify the reasons behind the large number of alerts not stepped up for further enquiries across Lancashire footprint • Work with partners to ensure robust information sharing processes for Looked After Children placed in and out of county and engage with initiatives to support increased compliance with timeliness of health assessments to improve the health outcomes for looked after children and care leavers • Implementation of the CCG supervision Framework • Launch and embed the Lancashire Self Neglect and Hoarding Framework

2. Developing and Strengthening Pathways & Services

• Continue to support the changing landscape of safeguarding protecting those who are vulnerable, missing, exploited and or trafficked • Improving awareness of the MCA across the regulated care sector • Embed the MSP principles across the CCG and partner agencies • Strengthen safeguarding practice & systems to ensure compliance with statutory Prevent Guidance and responsibilities • Embed the GP safeguarding lead / champion model across primary care • Implement the recommendations from the GP survey findings • Continue to support the SUDC nurse-led service developments and transition following the publication of the revised Child Death Review guidance • Support CP-IS implementation within the Integrated Urgent Care Service

3. Influencing Partnerships

• Continue to support Lancashire and South Cumbria’s improvement journey • Engage with partners to implement safeguarding partnership arrangements to ensure compliance with the revised ‘Working Together’ 2018 • Work with the Integrated Care Partnership Board and NHSE to align safeguarding arrangements to the new commissioning framework Page 310 Page

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4. Using Intelligence and Information to inform Decisions

• Continue to strengthen health input in to the MASH to support information sharing and timely decision making • Continue to improve quality and safeguarding initiatives across regulated care, through the safeguarding leads and safeguarding champions forum and RADAR/QPIP process

5. Safeguarding Quality and Improvement

• Continue to provide safeguarding/ MCA leadership expertise and consultation • Work collaboratively with partners across the regulated care sector in identification of early warning indicators and strengthening safeguarding arrangements to protect adults at risk

Report Contributors

Lorraine Elliott, Designated Lead Nurse Safeguarding Adults and Mental Capacity Act Louise Burton, Designated Lead Nurse Safeguarding Children and Looked After Children Kristy Atkinson, Deputy Designated Professional Safeguarding Adults Diane Kinsella, Deputy Designated Nurse Safeguarding Children Dr Linda Whitworth, Named GP for Safeguarding Lancashire Designated Nurse Network Page 311 Page

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APPENDIX 1 CCG Safeguarding Governance Framework

Governing Body Safeguarding NHSE Designated Executive Team Leads Regional Safeguarding Quality and Performance Committee Report by Exception

Assurance Meetings CSR CCG Safeguarding Assurance Group (quarterly)

Commissioning Provider Quality Assurance and System Multi-agency Safeguarding Meetings for Assurance Improvement for Leadership Partnership Contract Children and Meetings Regulated Care, Meetings Meetings Meetings Maternity Domiciliary and supported living (RADAR, QPIP)

Regional Safeguarding Meetings Lancashire Safeguarding Safeguarding Inspectorate MCA / DoLS, Prevent, FGM, CSE, Children and Adult Boards Meetings (Lancashire Ofsted CLA (including associated sub Improvements Boards, CQC groups) Safeguarding Review)

Page 312 Page Primary Care Safeguarding GP Leads Safeguarding Champions Care Home / Model Domiciliary Care Model

190103 GP Safeguarding Annual Report 2017 – 2018 v15 30 | P a g e

Agenda Item 15

Governing Body Meeting

Date of meeting 24 January 2019 Title of paper Audit Committee Update Presented by Mr Ian Cherry, Audit Committee Chair Author Mr Ian Cherry, Audit Committee Chair Clinical lead N/A Confidential No

Purpose of the paper The paper provides an update from the Audit Committee meeting held on 4 January 2019 and on any work undertaken by committee members outside of the meeting.

Executive summary The minutes of the meeting held on 2 November 2018 are attached for information. The key points from the meeting on 2 November were presented to the Governing Body on 29 November 2018.

The report on the meeting held on 4 January 2019 outlines the key decisions made, the assurances sought and any key risks that were identified. The Audit Committee would like to draw attention to the points highlighted in the report.

Recommendations The Governing Body is asked to note the report.

Links to CCG Strategic Objectives SO1 Improve quality through more efficient, safer services which deliver a ☐ better patient experience SO2 Commission care so that it is integrated and ensures an appropriate ☐ balance between in-hospital and out of hospital provision SO3 Be an integral part of a financially sustainable health economy ☐ SO4 Ensure patients are at the centre of the planning and management of ☐ their own care and their voices are heard SO5 Be seen as a well-run clinical commissioning group and the system ☒ leader

Audit Committee Update NHS Greater Preston CCG Governing Body Meeting 24 January 2019 Page 313 Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome

N/A

Were any conflicts of interest identified at previous meetings (mark X in the correct box below) Yes No X If conflicts of interest were identified what were these: N/A

Implications Quality/patient experience ☐ ☐ ☒ implications? Yes No N/A (Potential) conflicts of interest? Yes ☐ No ☒ N/A ☐ Equality Impact Assessment? Yes ☐ No ☒ N/A ☐ Privacy Impact Assessment? Yes ☐ No ☒ N/A ☐ Are there any associated risks? Yes ☐ No ☒ N/A ☐ Are the risks on the CCG’s risk Yes ☐ No ☐ N/A ☒ register? If yes, please include risk N/A description and reference number

Assurance This committee is an assurance committee. Additional assurances are provided through Internal Audit reviews, the Head of Internal Audit Opinion and External Audit Report and findings.

Audit Committee Update NHS Greater Preston CCG Governing Body Meeting 24 January 2019 Page 314 1.0 Introduction

1.1 The Governing Body papers include the approved minutes of the meeting held on 2 November 2018. The key points from the meeting on 2 November 2018 were reported on at the Governing Body meeting on 29 November 2018. This report covers the meeting held on 4 January 2019.

2.0 Decisions

2.1 The committee approved the process used to manage the Corporate Risk Register and recommends that the Governing Body approves the one addition to the register which relates to Referral to Treatment times. This recommendation is included in the GBAF and Corporate Risk Register within Governing Body papers.

3.0 Assurances

3.1 The committee received a ‘deep dive’ presentation by Mr Matt Gaunt on GBAF02 ‘Financial Sustainability’. Audit Committee members considered the different levels of financial sustainability within statutory financial frameworks and the current level of risk appetite for our CCGs. The committee discussed how we set about framing our partnership assurances in future as the next three to four years will look different, that there are potential issues with regard to future income as discussed by the Delegated Commissioning Committee (now the Primary Care Commissioning Committee), with long standing commitments using recurrent funding and that risks can only be mitigated by the CCG in areas where the owner has control. Hence the comment :-“unable to deliver system wide transformation as directed by the Integrated Care System (ICS) and Integrated Care Partnership (ICP)”. Comments made by the committee included: • With regard to measuring the impact of failure, whether in-year or in future years, the committee would normally expect to see zero based budgeting over a three year span. However this was not the method adopted by the CCG therefore impact tends to be over marginal areas of investment on an annual basis. • That we receive an indication of the use of non-recurrent funding to support recurrent programmes of work which could affect the risk rating going forward. • We tend to increase the risk rating with the difficulty of execution rather than the likelihood of occurrence and would expect the risk rating to be lower the closer towards the year end we were assessing likelihood. • That the CCG appetite to risk is currently low tolerance, high confidence. We take a balanced approach to risk, however at year-end we feel an increase in financial pressure and move to low tolerance, low confidence, which is reflective of our lead provider’s performance. • That assurances and gaps which occur through statutory routes for CCGs relate to reduced Consultant to Consultant activity and increased growth in A&E activity at Lancashire Teaching Hospitals. • There was concern that if nationally CCGs are required to provide additional financial resources to support hospitals which are in a deficit

Audit Committee Update NHS Greater Preston CCG Governing Body Meeting 24 January 2019 Page 315 position this would affect our financial controls, and that NHS England will ‘come down’ on CCGs not achieving financial sustainability. • That Primary Care and Continuing Health Care are two areas of risk which could be given more focus by the Governing Body. Primary Care programmes use 10% of CCG budget yet this should be more as we try to move patient care into the community. • That the risk profile does not seem to reflect patient outcome. Rather than trying to deliver our strategy we are trying to ‘balance our books’. • The Committee drew comparison between Lancashire Teaching Hospitals and Wrightington, Wigan and Leigh Hospital, which performs better in managing A&E. • There were strong levels of assurance around financial sustainability from external and internal auditors.

Overall the Audit Committee was satisfied with the way which the CCG manages financial sustainability and has confidence in the CCG achieving financial balance.

3.2 The Committee noted progress with regard to the Governing Body Assurance Framework (GBAF), which has been updated to reflect the changes made since last reported to the Governing Body. Good progress has been made across the risks included in the GBAF. The committee noted that the Quality and Performance Committee and Clinical Effectiveness Committee were assured that actions were being delivered by Lancashire Teaching Hospitals following recommendations from the Care Quality Commissioning report which concluded that the Trust “requires improvement”. The committee noted that assurance is dependent on delivery by the provider and that we should only reduce the risk when we see improvement. The Audit Committee could ask the Quality and Performance Committee to focus on areas which the Audit Committee requires assurance.

3.3 Grant Thornton provided an update on progress in delivering responsibilities as external auditors and reported that there were no issues.

3.4 KPMG colleagues provided an update on progress against the internal audit plan. Those reports which have yet to be finalised in time for year-end would be brought to the March 2019 Audit Committee meeting. As this would be too late for the committee to accept or influence assurance levels, at the meeting in private after the Audit Committee meeting it was agreed that the Audit Chairs would meet with KPMG colleagues to discuss the final reports. Audit Chairs would then consider whether an extra ordinary Audit Committee meeting would be convened before March to review final internal audit reports.

3.5 The committee undertook its annual review of the effectiveness of internal audit services. The outcome of a recent survey was that overall the results provided a satisfactory level of assurance to the committee. Where there were areas which respondents received low levels of assurance, KPMG colleagues would discuss with Corporate Governance Managers with a view to forming a strategy to address those areas. KPMG colleagues have been asked to promote more widely any additional benefits offered by KPMG including training events.

Audit Committee Update NHS Greater Preston CCG Governing Body Meeting 24 January 2019 Page 316 3.6 The Committee received the Emergency Preparedness Resilience and Response (EPRR) Annual Submission. The standards have undergone major revamp which it does every three years and includes new criterion not previously covered. The submission was based on the thresholds for the overall EPRR assurance rating sent by NHS England. Chorley and South Ribble and Greater Preston CCGs have both declared “substantially compliant”.

3.7 The Committee received the Information Governance (IG) update. The report summarised the work undertaken by the IG Team. The committee noted that as part of the new IG framework a newly developed Employee Privacy Notice is now available on the CCG’s website. The committee discussed the data flow mapping as referred to on page 166 of committee papers. There are several draft data flows which have been delayed. The IG Team is working with the Unscheduled Care Team, where the delays are to ensure these are complete.

3.8 The Committee noted that there was one amendment and one new entry on Procurement Decisions Register. The amendment related to the value of the GP Online Consultation Services contract. This was an administration error and has not had any financial impact on the CCG. The addition was for the Haven Community Crisis / Recovery Café contract award. There were no additional entries on the Hospitality, Sponsorship and Gifts Register, Tender Waivers Register or the Losses, Write-Offs and Special Payments Register.

4.0 Other Information

4.1 The Committee was introduced to Mrs Lynne Johnstone, Audit Manager, Grant Thornton, who replaces Mr Gareth Winstanley following his move to a new position for NHS Trusts.

5.0 Audit Committee Chair Update

5.1 The Audit Committee Chairs reported that other than the Our Health Our Care pre consultation meetings (which all had attended ) into Acute and Emergency Service redesign there have been few meetings to attend since the last Audit Committee meeting.

6.0 Private Meeting for Audit Committee Members

6.1 Committee members met privately directly after the Audit Committee meeting to discuss the outcomes and reflect on decisions made and what went well or not so well.

Mr Ian Cherry, Audit Committee Chair Greater Preston CCG January 2019

Audit Committee Update NHS Greater Preston CCG Governing Body Meeting 24 January 2019 Page 317

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Greater Preston CCG Audit Committee Minutes Friday, 2 November 2018, Bowman Room - Chorley House, Lancashire Business Park, Centurion Way, Leyland PR26 6TT at 9.30 am

Present Mr Ian Cherry, Audit Committee Chair Mrs Debbie Corcoran, Lay Member Patient and Public Involvement Mr Paul Richardson, Lay Member Governance

In Attendance Mr Paul Bell, Anti-Fraud Specialist, MIAA Mrs Linda Chivers, Audit Committee Chair, Chorley and South Ribble CCG (Chair) Ms Amanda Latham, Head of Internal Audit, KPMG Mrs Sarah Mattocks, Corporate Affairs and Governance Manager Mrs Jayne Mellor, Director of Transformation and Delivery (item 6 only) Mr Geoffrey O'Donoghue, Lay Member Patient and Public Involvement, Chorley and South Ribble CCG Mr Alan Stuttard, Lay Member Governance, Chorley and South Ribble CCG Mrs Anne Whittle, Corporate Business Manager (minutes)

1 Introduction Mrs Chivers welcomed everyone to the meeting, in particular Mr Paul Bell who was attending on behalf of Ms Jacqui Procter to represent anti-fraud. Introductions were made. Audit Committee members noted that there was no need for attendance from external auditors to every meeting. Mrs Chivers informed Audit Committee members that Mr Gareth Winstanley, Engagement Manager Grant Thornton was moving on to a new position for NHS Trusts and Ms Lynne Johnstone will replace Mr Winstanley. The Committee expressed thanks to Mr Winstanley for his contribution while he has been working with Chorley and South Ribble and Greater Preston CCGs.

2 Apologies for Absence Apologies for absence were received from Mr Matt Gaunt, Chief Finance Officer, Ms Harriet Fisher, Manager, KPMG and Ms Jacqui Procter, Anti-Fraud Specialist, Mersey Internal Audit Agency.

3 Declarations and Register of Interests The Register of Interests was presented for information. Mrs Chivers reminded committee members of their obligation to declare interests they have against the agenda which might produce a conflict. She asked if there were any new declarations in relation to the agenda. None were received, however it was noted that Mr Cherry’s declaration of interest was an early version that was out of date and also needed to include the role of conflicts of interest guardian. Mrs Mattocks would check and update the register of interests.

Page 319 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 2 November 2018

4 Minutes of Previous Meeting Both Audit Committees reviewed the minutes of the Audit Committee meeting held on 7 September 2018. These were accepted as a correct record, subject to the following amendment.

A spelling error “whether” under item 12 Managing Conflicts of Interest Policy to be corrected.

Resolved That the minutes from the meeting held on 7 September 2018 were accepted as a correct record, subject to the above correction.

5 Matters Arising Audit Committee members accepted those items which were identified as complete and updates where actions are not complete. The committee accepted the following additional update:

180522-03 External Audit Findings Report With regard to the delivery, funding figures and portion of our CCGs’ commitment to the Better Care Fund (BCF), Audit Committee members noted that the original question was about the mechanism for our CCG contribution to the BCF. Mrs Mellor provided an update that she has been asked to support some of this work and that a paper outlining an improved BCF would be presented by Peter Tinson, Chief Operating Officer, Fylde and Wyre CCG at the Collaborative Commissioning Board on 13 November. Mrs Mellor would ask Mr Gaunt to provide an update of the outcome from this report. The committee sought assurance that value for money is provided in respect of our CCGs’ BCF commitment.

Resolved That the Committee noted the updates provided and approved the closing of all actions assessed as complete.

6 GBAF Deep Dive Mrs Mellor presented an update on ‘GBAF04 – Service Transformation’ following a deep dive into this risk. She explained that the CCG has factored into current planning the expected outputs from the 10 year forward plan which is due to be released in early December. The risk definition has been updated last month to reflect that the risk can only be mitigated in areas where the owner has control “unable to deliver system wide transformation as directed by the Integrated Care System (ICS) and Integrated Care Partnership (ICP). CCG colleagues have been working with Andrew Bennett, Executive Director of Commissioning, ICS on what can be delivered at an economy level.

In reply to a question about how we can work on service transformation when we do not know the risks associated with wider ICS arrangements, Mrs Mellor explained that the risk has been reviewed for this reason. We have been talking about ICS system levels and the Lancashire footprint along with networks of GP practices and now considering wider community services including dental services.

Mrs Mellor described the work streams involved in this work which are Out of Hospital Care, Acute Modelling and Urgent Care Redesign Pathway. Mr Bennett

Page 320 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 2 November 2018 has appointed Ms Dawn Hawarth as Senior Programme Manager, Service Redesign Team, to progress the governance arrangements around this work.

Mrs Mellor advised that planning guidance is due and the CCGs will look at their strategic planning going forward as this is released. She gave feedback following her attendance to a conference led by Simon Stevens, Chief Executive NHS England and Steven Dalton, Chief Executive NHS improvement in London earlier this week, where it was confirmed that there will be a regional level for the north of England divided into two areas for North East and North West. The North West will include Lancashire, South Cumbria, Merseyside and Cheshire.

The next steps involve more out of hospital care where services need redesign to bring patient care closer to home. The only way for successful transformation is to co-produce plans with patients and citizens by engaging with members of the public more widely. Mrs Mellor referred to some learning around leadership and engagement from South Tyneside CCG. The Chief Officer of South Tyneside CCG advised at the conference that none of their achievements would be realised without full engagement with their partners.

Audit Committee members considered the challenges with partner organisations and recognised the need for our CCGs to consider how we can do more joint working and engagement with our partners. Mrs Mellor described the joint working that has been done in primary care resulting in 63 GP practices working collaboratively across 8 localities, with increased engagement with providers to improve outcomes and provide value for money.

The current position was that this was a low risk with transformation under way and wider primary care at scale delivering services across 8 networks. We are actively involved in ICS developments and the commissioning framework which links into local delivery. We also have oversight via the newly proposed ICP governance structure.

Assurance was sought with regard to the legal entity of taking up of contracts and setting up GP networks, for example assurances that those contractors have the right skills and that there are no conflicts of interest. A comment was received that this should come to Governing Body for approval as this will be of interest to patients when whole services are wrapped around them. Mrs Mellor gave an example of a local provider deciding to become a limited company with shareholders, but that this is not a CCG mandate.

Audit Committee members discussed the risks associated with how we commission services; there was potential for the CCGs to invite bids through the procurement process. Mrs Mellor felt that a joint informal development session of the Governing Body would be useful to explore this topic further. Mrs Mellor asked Audit Committee members to consider that we should not move fast and alone, but instead move far and together, with a vision that together we can successfully transform services.

The above comments around this risk would be added to the GBAF for the Governing Body to consider.

The committee considered that in driving the change there would need to be constructive engagement, providing analysis and targets for improvements and

Page 321 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 2 November 2018 clarity about decision making to avoid confusion for patients and provide assurance in relation to purpose and outcome.

Resolved That the Committee noted the update provided from the deep dive into GBAF04 Service Transformation.

7 External Audit Progress Report Mrs Mattocks presented an update report on progress from Grant Thornton on delivering their responsibilities as external auditors. The report included a summary of national issues and developments that may be relevant to CCGs and a number of challenge questions in respect of those emerging issues as a tool that the committee may wish to consider.

Audit Committee members noted the information contained within the report.

Resolved That the Committee noted the content of the report.

8 Annual Review of the Effectiveness of External Audit Mrs Mattocks presented a report which outlined the outcome of a recent survey which has been undertaken to support the review of the effectiveness of external audit services provided by Grant Thornton, as required in the Audit Committee’s Terms of Reference. Analysis of the survey results has been reviewed and summarised in the report.

Although the overall survey shows that the majority of respondents have a mostly high level of satisfaction with the external audit service, there was one very low score in relation to the external auditor’s communication / presentation of output. This will be fed back to Grant Thornton for their response. It was noted that the comments box at the end of the survey had not been completed by any members and for future surveys if a very low or very high score was given then a comments box should be mandated in order to act on this.

The committee was disappointed that there were two recipients who had not responded. Audit Chairs encouraged all members and CCG colleagues to take the time to complete future surveys as they are important for improving the functionality of the committee. Mrs Chivers added that members also have the opportunity to raise issues at the committees’ meeting in private with external auditors, and members and colleagues can always speak with Audit Chairs.

Grant Thornton colleagues would be asked to provide comments on the outcome of the survey at the next meeting.

Resolved That the Committee noted the content of the report. Grant Thornton colleagues would be asked to provide comments for the next meeting.

9 Internal Audit Progress Report Ms Latham presented a report on progress against the internal audit plan. One report on Cyber Security has been finalised with few recommendations which Ms Latham felt was promising. The remaining Quarter 3 reviews have been scoped.

Page 322 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 2 November 2018 Ms Latham gave an update following attendance to Integrated Care Partnership (ICP) related meetings. Observations in relation to governance arrangements were appended to the report and included areas where improvements could be made. Next steps will be to observe the same meetings again in December and January and look for evidence of progress made in those areas and provide a formal report back to the committee afterwards to take appropriate action.

Ms Latham added that there was a good level of engagement with contributions from everyone. The overriding challenge was that there were many good ideas but difficulty around decisions and summarising progress. She gave an example of a recurrent issue in relation to how we engage with citizens for the patient voice. Mr Gizzi had provided good feedback on ICP progress to CCG Governing Body meetings, and that this could be further improved by asking for Governing Body input on what they would like him to take back to the ICP. This will be included in the final audit report for action.

A list of previous internal audit actions from the former internal audit service provider last year would be followed up with Corporate Governance Manager.

Ms Harriet Fisher is currently focusing on Quarter 3 reviews, the scopes of which have been agreed. The Partnership Working report will come to the January 2019 Audit Committee meeting. Conflicts of Interest Review will take place in Quarter 4.

Audit Chairs asked that narrative on page 12 of the report is re-worded to reflect that Audit Chairs would discuss those areas where improvements could be made. Ms Latham would re-word the narrative.

Comments were received that the content of the report has improved. Ms Latham confirmed that KPMG now have Ms Harriet Fisher who has already met with key CCG colleagues. References in the report to ‘Risk and Assurance Committee’ should be amended to read ‘Audit Committee’.

Mrs Chivers asked Audit Committee members if they wished to extend the time of future meetings to allow more time to consider internal audit reviews whilst focusing on key points. It was accepted that it would be beneficial for future reports, which are normally circulated to Audit Chairs to be circulated to Audit Committee members when they are available and before the next Audit Committee meeting. In the meantime Ms Latham would continue to include summaries in progress reports. She advised that KPMG planning would start in November to allow a better spread of planning for next year.

Audit Committee members acknowledged the sector update which provided an update on developments in the health sector.

Resolved That the Committee noted the content of the Internal Audit Progress Report and the health sector update provided.

10 Information Governance (IG) Updates Mrs Mattocks presented an update report to the Audit Committee on progress with the Data Protection and Security Toolkit 2018-19. Audit Committee members were asked to review the IG Handbook which has been revised with some further

Page 323 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 2 November 2018 amendments since last approval in July 2018. The committee agreed that as the IG Handbook was not a policy there was no requirement to submit it to Governing Body for ratification and the committee’s approval was appropriate. Amendments following the review of the IG Handbook were included in the summary report.

Comments on the IG update report related to: Caldicott Log • The order of issues on the log was not in chronological order • The log should include full names and job titles. • More clarity required where ‘no response received’ and a specific date should be documented rather than ‘ASAP’ • Feedback should be provided to the committee on why there is a backlog

Data Protection Impact Assessments • These are being signed off out of sync, for example Senior Information and Risk Officer (SIRO) before Data Protection Officer (DPO), feedback should be provided on why this is the case

A concern was raised about not having a fall-back position for Governing Body members who are not able to attend the IG training session at the Governing Body Joint Informal Development Session on 13 December. Mrs Mattocks advised that we have January and February 2019 to address any members including staff whose IG training was outstanding in December. She would check whether online training would be available as a back-up.

Comments on the IG Handbook related to: • Reference to smartcards should be removed if staff do not use smartcards. Mrs Mattocks would check this with the IG team.

Mrs Mattocks would feedback the amendments and provide clarity where required.

Resolved That the Committee: • reviewed and provided comments on the IG update report; • reviewed and provided comments on the IG Handbook; and • approved the IG Handbook with no requirement for this to be ratified by the Governing Body.

11 Governing Body Assurance Framework and Corporate Risk Register Mrs Mattocks presented an update in respect of the Governing Body Assurance Framework (GBAF) and Corporate Risk Register (CRR). Each risk has been updated with progress against actions and any changes highlighted in red text. Audit Committee members were reminded of Mrs Mellor’s comment about ‘selling ourselves’ going forward by including all progress on the GBAF. Mrs Chivers reminded Audit Committee members that the remit of the committee is to look at the systems and processes in place, that they are being followed, and to provide scrutiny to ensure that processes are being carried out. This would be reflected in the executive summary on future cover sheets as Mrs Chivers explained that this needs to be different for Audit Committee than Governing Body as their roles are different.

Mrs Chivers asked Audit Committee members for comments on processes and

Page 324 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 2 November 2018 general risk management.

Comments received included: • That having no risks on the Corporate Risk Register was unusual; Mrs Mattocks referred to a recent Management Executive Team (MET) planning session where this was explored and she will be working with MET to produce risk assessments from this which would subsequently be reported to the committee. • That there was risk in having to use reserve monies to achieve financial balance, and therefore the scoring of GBAF 02 may need review. • Clarity was sought in relation to where actions have been completed, have these been added as additional controls and assurances. Mrs Mattocks would make this more explicit in future reports.

Assurance was sought in relation to where the Quality Risk Profile (QRP) toolkit is reported at the CCG. The committee also discussed that given the recent Care Quality Commission report published for Lancashire Teaching Hospitals which showed a rating as ‘needs improvement’ this needed to be factored into this GBAF 01, and subsequently the risk rating may need review.

Resolved That the Committee noted the progress being made on the GBAF for 2018/19, and that there currently are no risks on the Corporate Risk Register.

12 Key Updates from Quality and Performance and Clinical Effectiveness Committees Mrs Chivers explained to Audit Committee members that this agenda item was added to provide assurances that there are no risks from Quality and Performance and Clinical Effectiveness Committees that the Audit Committee should be made aware of. Mr Richardson provided an update from the last Quality and Performance Committee meeting which focused on LTH workforce issues and Quality Assurance visits. Mr Stuttard was in agreement that there was nothing specific which had arisen as a consequence of the meeting.

Mr Cherry was concerned that the CCG has not been formally notified of the outcome of CQC inspection at LTH and as a consequence the matter was not raised at QPC. Mr Stuttard explained that there was a potential timing issue as Mrs Curtis, Director Quality and Performance gave a verbal update at the last Quality and Performance Committee meeting, that the CQC inspection report was due and would contain that LTH still requires improvement but with some positive narrative. The report itself would come to a future Quality and Performance meeting.

Mr O’Donoghue confirmed that there were no areas of concern from the Clinical Effectiveness Committee, which currently focuses on Right Care, Medicines Management and clinical policies. There were some clinical policies being robustly developed jointly across Lancashire CCGs with praise received on how these are being done. Numbers of appeals have been reduced as a result of the ways which policies are being developed. The committee had received an update on National Institute of Clinical Excellence (NICE) guidance.

Mrs Chivers asked Audit Committee members how we gain assurances from Quality and Performance and Clinical Effectiveness Committees in future in terms

Page 325 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 2 November 2018 of seeking assurances around quality. It was agreed that feedback from those committees would be built into GBAF reports with leads from those committees providing assurances around quality which the Audit Committee seeks. Mr Cherry suggested that focus is on risk, adequate controls and adequate data.

Resolved That the Committee noted the update provided.

13 Register of Interests Update Mrs Mattocks presented the Registers of Interest report which provided an update on each of the three core registers for Governing Body members, GP Members and Employees. The paper outlined the current position and a proposal for the committee to agree how to manage those overdue declarations, particularly those GP members’ declarations of interest where there are several outstanding.

The committee was reminded that it recommended a zero tolerance approach in respect of outstanding declarations of interest for Governing Body members. The committee noted that there are currently 3 members outstanding for Chorley and South Ribble Membership Council and 9 members outstanding for Greater Preston Membership Council. There were currently 2 MLCSU embedded staff members also outstanding for their declarations of interest forms.

Audit Committee members considered whether the zero tolerance approach should be extended to include Membership Council. It was agreed that the CCG would write to those practices whose member representative’s declaration of interest remains outstanding, reminding them of their obligations. MLCSU staff will be followed up internally. Practices and MLCSU embedded staff will be given 14 days to return completed forms. Feedback would be requested from those practices whose GP member is not able to comply with this requirement. A draft letter would be shared with Audit Chairs for approval.

The executive summary sheet and agenda templates would be updated as suggested in the paper to support the declarations and management of conflicts raised at meetings.

Audit Committee members considered the approach of requesting the committee chairs to review the registers of interest against the agenda prior to each meeting. However it was agreed that this may take some of the responsibility away from individuals to make their own declarations of conflicts, and that a copy of all members’ declared interests is included in the papers for the statutory committees in order to establish any actual or potential conflicts of interest that may occur during the meeting.

Resolved That the Committee noted the content of the report. Mrs Mattocks would draft a letter to those GP members, and liaise internally with those MLCSU staff whose declarations of interest remain outstanding.

14 Corporate Registers Mrs Mattocks provided an update report on each of the CCG Corporate Registers. The committee:

- noted there have been 0 new entries on the Hospitality, Sponsorship

Page 326 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 2 November 2018 and Gifts Register

- noted there have been 0 new entries on the Tender Waivers Register

- noted there have been 0 new entries on the Procurement Decisions Register

- noted there have been 0 new entries on the Losses, Write Offs and Special Payments Register

Resolved That the Committee noted that no new entries had been made on the registers since the last meeting.

15 Anti-Fraud, Bribery and Corruption Policy and Anti-Fraud Update Mr Bell presented the Anti-Fraud, Bribery and Corruption Policy and Response Plan for approval. Changes to the policy were highlighted in the executive summary and on a track-changed document. The main changes related to a section on ‘Sanctions and Redress’ which has been added under section 4.20; and at Section 5.4 the policy stated that it would be reviewed on a biannual (twice a year). This has been amended to biennial (every two years) as it is an administrative error.

Audit Committee members provided the following comments:

• That the scope of the policy referred to on page 2 and section 1.3 also applies to office holders; • Section 3.30 ‘Head of Strategy and Corporate Services’ should be amended to ‘Director of Finance and Contracting’. • That there should be consistency with regard to Accountable Officer / Chief Officer.

The committee recommended the Anti-Fraud, Bribery and Corruption Policy and Response Plan to Governing Body for ratification, subject to the above amendments.

Anti-Fraud Update Mr Bell provided an update with regard to the work of Anti-Fraud Services.

The review of minor ailment services is progressing with testing and initial areas of improvement in respect of invoice payments. Ms Kerry Ann Wheat is waiting for the MLCSU pharmaceutical element and considering whether there is opportunity for override of the local pharmacy level. A more detailed update will be provided at the January 2019 meeting.

Feedback from Practice Managers shows that the CCGs are considering sharing fraud awareness sessions with GP practices. This work will be factored into next year’s Anti-Fraud Plan.

Two recent intelligence bulletins which have been circulated to staff include information around bank mandate fraud, in particular for health service trusts. Information alerts are circulated via Shared Business Services and CSUs as they

Page 327 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 2 November 2018 are also being targeted. A generic alert has been circulated relating to HMRC offering a rebate to staff. Examples of the above fraudulent activities will be factored into Anti-Fraud awareness sessions in November.

Mrs Chivers referred to the anti-fraud self-assessment toolkit and reminded Audit Committee members that the CCGs cannot achieve ‘green’ status where no fraud activity is recorded. Audit Chairs are considering how the CCGs can be more proactive in detecting fraud, possibly sharing some examples with staff to increase awareness. A confidential suggestion box may be considered. NHS Counter Fraud Authority has produced 4 short videos which Ms Procter has shared with the CCG Communications Team for general awareness.

The committee acknowledged that as there was some feedback received from the review of the effectiveness of anti-fraud services that the committee might be included in the decision around which proactive exercise to undertake at the CCGs. A pre-meeting took place between Mr Bell and Audit Chairs prior to the Audit Committee meeting to consider the next proactive exercise. It was suggested that as there are no major fraud issues across the CCGs a review of conflicts of interest would be useful.

The committee thanked Mr Bell for the Anti-Fraud update report.

Resolved That the Committee approved the Anti-Fraud ,Bribery and Corruption Policy, and noted the Anti-Fraud update.

16 Hospitality, Sponsorship and Gifts Policy Mrs Mattocks presented an updated Hospitality, Sponsorship and Gifts Policy for consultation and recommendation to the Governing Body for approval. Amendments were included in the executive summary sheet and related mainly to clarification points and updates according to national guidance.

Mrs Mattocks drew particular attention to section 5.4 and principles added for accepting commercial sponsorship from the pharmaceutical industry. A suggestion was received from the Medicines Management Team for the Audit Committee to consider this as the revised policy would allow the CCG to become more involved in joint working.

The committee was not comfortable with the suggestion that the Audit Committee approve all such proposals of requests from commercial sponsorship, as it would be their role to provide assurance against the process followed to approve these. It was instead suggested that requests for commercial sponsorship should be approved by the Management Executive Team, with the decisions scrutinised by the Audit Committee and recorded within the CCG’s Corporate Registers. Ms Latham advised that any delegated duty should be included in the Scheme of Delegation. Comments were received as follows:

• The policy should include sponsorship from all private companies, not just pharmaceutical. • Wording would be amended under section 3.4 with regard to the disciplinary procedure for office holders, to clarify that this contained within the constitution. • A typing correction would be made at section 4.3 ‘and’.

Page 328 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 2 November 2018 • The first bullet point under section 4.7 would be amended to reflect ‘a clear benefit to the CCG’. • Common examples would be included in the policy for what can and cannot be approved. • 5.12 – ‘Gifts’ needs its own section of the policy

The committee recommended the Hospitality, Sponsorship and Gifts Policy for approval by the Governing Body, subject to the above amendments.

Resolved That the Committee recommended the Hospitality, Sponsorship and Gifts Policy for approval by the Governing Body, subject to the above amendments.

17 Risk Management Strategy Mrs Mattocks presented an updated Risk Management Strategy for consultation and recommendation to Governing Body for approval. The amendments to the policy were outlined in the executive summary sheet. The key change related to the handling of risks. Mrs Mattocks explained that we now have High / Medium / Low categories assigned to the project risks and that this has now been included in the strategy. These categories are considered at the CCG weekly Friday operational (stand up) meetings. There was no material change in practice in the new strategy. The following comments and points of clarification were provided:

• Consistency was required for the name of the policy, which is ‘Risk Management Strategy’. • Section 7.3 to be re-worded to reflect that the delegated responsibility for risk management arrangements to the Audit Committee does not include delivery. • Typing errors to be corrected under section 7.7. • That all abbreviations should be written in full first. • That section 9.21 around risk identification should be expanded to include the 4 risk registers • GBAF = all risks to strategic objectives • CRR = all risks scoring 15 or above (excluding those on the GBAF) • Project Management = for all risks scoring of 9 or above or with an impact of 4 or above related to a CCG project • Operational risk register = any other areas of risk • Mrs Mattocks explained the layer of assurance needed where a risk is closed. It was suggested that the MET should take the decision to close a risk scored 15 or above, and that this should be reported to the Audit Committee. • References to SMT to be changed to MET.

A final and positive comment was received that improvements have been made in the area of risk management and with those related policies which have been submitted to Audit Committee for review.

Resolved That the Committee recommended the Risk Management Strategy to the Governing Body for approval, subject to the above amendments and clarification points.

Page 329 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 2 November 2018 18 Emergency Planning, Resilience and Response Policy Mrs Mattocks asked Audit Committee members to review the Emergency Planning, Resilience and Response (EPRR) Policy prior to submission to the Governing Body for ratification. The policy has been refreshed as part of an annual review and as per NHS England EPRR Framework and guidance. The changes made to the EPRR Policy were mainly clarification points driven by NHS England and were outlined in the executive summary. Audit Committee members provided the following comments:

• A bookmark error would be amended on the contents page • Paragraph 7.4 referred to contingency arrangements to cover increased activity within the local acute provider due to a major incident. A comment was received that other providers would also be involved if a major incident occurred, not just those acute providers. • It was also noted that the committee would expect to see some learning from the Manchester attack incidents and sought assurances with regard to testing of the policy. It was agreed that the CCG testing exercises plan would be submitted to a future Audit Committee to provide this assurance.

Resolved That the Committee recommended the Emergency Planning, Resilience and Response Policy to the Governing Body for approval ,subject to the above amendments.

19 Chairs Update Audit Committee Chairs provided an update on recent meetings attended.

Mr Cherry had met with Ms Latham in September to consider progress against the internal audit plan. He attended the opening of Dr Nair’s new surgery. He also attended the Integrated Care System Board meeting in October where he found no particular issues that needed to be escalated to the CCG, and Greater Preston Membership Council meeting in September.

Resolved That the Committee noted the update provided.

20 Any Other Business There was no further business to discuss.

21 Outcomes from the Meeting Audit Committee members took time after the meeting to consider the outcomes and reflect on the decisions made at the meeting and consider what went well and not so well.

Date of next meeting: Friday 4 January 2019, 9.30am in Board room 1, Chorley House

Signed as an accurate record ………..……………………. Date ……………………...

Page 330 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting 2 November 2018 Agenda Item 16

Governing Body Meeting

Date of meeting 24 January 2019 Title of paper Joint Quality and Performance Committee Update Presented by Mr Paul Richardson, Lay Member Author Mrs Helen Curtis, Head of Quality and Performance Clinical lead N/A Confidential No

Purpose of the paper

This report provides an update from the Quality and Performance Committee meeting held on 5 December, the January meeting was postponed until 9 January. The minutes of the November meeting are attached.

Executive summary

At the December meeting the Committee received presentations on the Care Quality Commission Report, Quality Risk Profile and Organisational Culture from Lancashire Teaching Hospitals Trust (LTHTr) and Organisation Culture Focus from Lancashire Care Foundation Trust (LCFT).

The overall rating for LTHTr remained as ‘requires improvement’ although 16 core domains improved to a ‘good’ rating from ‘requires improvement’ and four service lines (Maternity, Children and Young People, Surgery and Outpatients) moving from ‘requires improvement’ to good. The Trust acknowledged there would be a challenge over the next 12 months to improve Urgent and Emergency Services and Medicine. CQC recommendations are broken down in to ‘must do’ and ‘should do’, progress on these has already been reported. There was a reduction in the number of ‘must do’ and ‘should do’ in comparison to the 2016 inspection findings.

The Trusts Quality Improvement Plan includes a comprehensive CQC Inspection Accountability report and the Committee was informed that this was scrutinised at Executive and Non Executive Director level. The plan includes significant components in relation to communication and staffing and the streamlining of audits into the STAR Accreditation Framework. The presentation included findings from the recent completion of the Quality Risk Profile – a process that involves the CCGs, NHSE, NHSI and the CQC completing an evidence based assessment against a range of key indicators and risks. The Committee was of the opinion that the Trust had clear insight into the issues that needed to be addressed in order to move to good and that there was an appropriate action plan in place to address the

Joint Quality and Performance Committee Update NHS Greater Preston CCG Governing Body Meeting Page 331 24 January 2018

shortcomings. Evidence of delivery of that action plan and an improved CQC rating would be ultimately be required before the Committee could be fully assured.

With regard to organisational culture within the Trust, staff survey returns have improved each year from 2017 with 70 out of 94 areas improving their response rate. The Trust remains below national average in a number of areas but highlighted a number of initiatives to improve including the appointment of freedom to speak champions. The Committee was advised that the 24hours in LTH mini series has improved staff engagement and morale with an increase in staff recommending the Trust as a place to work and receive care.

The presentation from LCFT to the Committee confirmed the staff survey from the previous year was disappointing. Staff did not feel they received recognition for their work and were not supported from a team and management level. Staff reported that they felt the quality of care had slipped and they experienced bullying and staff shortages. The Committee were advised that a people plan has been developed which is being managed by the Organisational Development Team. Champions for Staff Health and Wellbeing along with a number of other initiatives have been put in to place and well promoted. Appraisals and PDRs were to be based around shared objectives with support and training being put in place for managers to enable them to be carried out in a timely manner.

Recommendations

The Governing Body is asked to note the content of the report.

Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome Quality and Performance 05/12/2018 A number of actions were

Joint Quality and Performance Committee Update NHS Greater Preston CCG Governing Body Meeting Page 332 24 January 2018

Committee agreed at the meeting in relation to the various agenda items. Were any conflicts of interest identified at previous meetings (mark X in the correct box below) Yes No x If conflicts of interest were identified what were these: Yes as identified in the declaration of interests submissions to the Committee.

Implications Quality/patient experience Yes ☒ No ☐ N/A ☐ implications? (Potential) conflicts of interest? Yes ☐ No ☒ N/A ☐ Equality Impact Assessment? Yes ☐ No ☒ N/A ☐ Privacy Impact Assessment? Yes ☐ No ☒ N/A ☐ Are there any associated risks? Yes ☐ No ☒ N/A ☐ Are the risks on the CCG’s risk Yes ☒ No ☐ N/A ☐ register? If yes, please include risk GBAF01 description and reference number

Assurance

Assurances will continue to be provided on delivery to the Quality and Performance Committee.

Joint Quality and Performance Committee Update NHS Greater Preston CCG Governing Body Meeting Page 333 24 January 2018

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Quality and Performance Committee Minutes Wednesday, 7 November 2018, Board Room 1 - Chorley House, Lancashire Business Park, Centurion Way, Leyland PR26 6TT at 10.30 am

Present Mrs Linda Chivers, Lay Member - NHS Chorley and South Ribble CCG Mrs Helen Curtis, Director of Quality and Performance - NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Dr Brigid Finlay, GP Director - NHS Greater Preston CCG Mr Matt Gaunt, Chief Finance Officer - NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mrs Tricia Hamilton, Governing Body Nurse - NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Dr Eamonn McKiernan, Secondary Care Doctor - NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mr Alan Stuttard, Lay Member - NHS Chorley and South Ribble CCG (Chair)

In Attendance Mrs Ruth Bond, PA, Quality and Performance Team - NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mr Andy McAllister, Performance Lead - NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mr Glenn Mather, Evidence and Effectiveness Lead – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Miss Stephanie Purcell, Quality and Performance Manager - NHS Midlands and Lancashire Commissioning Support Unit

1 Welcome and Apologies for Absence

Mr Stuttard welcomed the Committee Members and confirmed apologies from: Mr Ian Cherry, Lay Member – NHS Greater Preston CCG (attending ICS Board) Mr Sam James, Head of Performance – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mrs Jayne Mellor, Director of Planning and Delivery – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mr Paul Richardson, Lay Member – NHS Greater Preston CCG

2 Declarations of Interests

Minutes of Quality and Performance Committee 7 November 2018 Page 335

There were no conflicts of interest outside those noted in the routine submission. Mrs Curtis advised the Committee that her daughter was employed at Lancashire Teaching Hospitals Trust as a Specialty Business Manager. The Committee agreed another member of the Committee would present any items relevant to this conflict. Concerns were raised regarding the non-submission of declarations of interests to Committees.

Action: Mrs Curtis to raise the matter with Mr Gaunt

3 Minutes of Previous Meeting

Minutes of the previous meeting were accepted as a true record.

4 Matters Arising

20180307/5 LTHTr Ophthalmology business case – Mr Gaunt has written to Mr Havey but no response has been received. This has now been escalated to Mr Gizzi to raise with Ms Partington. No further progress reported on this issue.

Action: Mrs Curtis to contact Mrs Naylor at Lancashire Teaching Hospitals Trust to re- request.

5 Finance Report

It was reported the CCG was successful in securing a repayment of 75% of the 0.5% risk reserve and there will be an update in the next Quality and Performance Finance report.

The risks that are not reflected in the forecast position are a shortfall in QIPP delivery of £2.7m and further over performance of non-elective activity of £1m primarily at Lancashire Teaching Hospitals Trust. These risks are offset by uncommitted budgets and anticipated full year forecast underspends of £2.9m.

It is reported there will be a significant risk all CCG’s will be reporting an over spend by year end. Forecasts should reflect trend and winter period, normally at this stage there is a good understanding of financial placement. Discussions had taken place regarding the winter plan and the CCG is confident that this has been accounted for correctly.

6 Integrated Board Report

Figures in the report indicated a fall in percentage of service users waiting no more than 18 weeks from referral and also an increase inwaits over 52 weeks for incomplete pathways. A performance notice has been issued relating to 52 week breaches. There may be a planned reduction of elective surgery over the winter period, however NHSE are still to confirm this.

The cancer 62 day waits from urgent GP referral to first definitive treatment for cancer is compliant for both CCG’s although September may show a more challenged position.

Concerns were raised that Lancashire Teaching Hospitals Trust were unable to continue to improve and sustain the improvements.

Minutes of Quality and Performance Committee 7 November 2018 Page 336 1300 pathways have been removed from the waiting list in a short period of time. This was reportedly due to staff vacancies where there had been gaps in central and divisional validation teams, which have now been filled. Confirmation was given that weekly reporting figures were different to the month end figures as the weekly figures are raw data and un-validated. Assurance has been requested by the Committee that these pathways have reduced in an acceptable manner.

When comparing with other Trusts using, Lancashire Teaching Hospitals Trust is not the only trust experiencing issues with constitutional standards. Contract levers serve as traction with the Trust which allows better understanding of the consequences if targets are not achieved.

Discussion took place around the percentage and length of wait of patients who were outside the 62 day wait for cancer treatment and the level of harm as a consequence of failure to meet targets. It was advised that the longest wait was 104 days. Mrs Curtis confirmed that breach reports and reasons for breaches were reviewed and RCAs required.

7 GBAF

t was agreed that in light of Committee discussions about Lancashire Teaching Hospitals Trust the finance risk rating should be raised to 16 and the Operational Risk should be amended to above 15. It was suggested that assurances should include positives as well as negatives. If no action can be taken and a gap in assurance still remains ‘to escalate to NHSE’ should then be added.

8 Lancashire Teaching Hospitals Trust Quality Visit

The quality visit report for Lancashire Teaching Hospitals Trust focussed on Ward 23 (Respiratory), Ward 10 (Urology) and portering services at Royal Preston Hospital.

Ward 10 feedback included staff being happy and positive with strong ethos of teamwork between nursing and medical staff. Consultants were proactively providing 7 day consultant led ward rounds which supported discharges and patient flow over the weekend. At the time of the visit the ward was being refurbished which resulted in the temporary loss of 10 beds (2 bays) and a temporary call system, which was not working effectively. In order to address this staff undertook frequent safety huddles to review unwell patients.

The portering service welcomed the CCG accompanying them during their duties. Care and compassion were recognised from the porters towards patients. The porters reported issues on the consultation process for car parking and security staff which had been taking place over the past 12 months. Staff felt there was a lack of communication and update from the senior leadership team. This had resulted in a recruitment freeze equating to the service carrying sixteen vacancies. A lack of training around mortuary duties was highlighted as portering staff are required to provide support over the weekend.

Ward 23 was extremely busy, with high acuity of patients, the pressure and strain that the staff were under that day was palpable. A number of issues highlighted on the visit centred around the staffing challenge even though it was acknowledged the vacancies numbers had reduced from seventeen WTE to seven WTE. The high utilisation of agency and bank staff was highlighted as an issue over the weekends and night shifts. The ward staff had been involved in a number of improvement projects including the NHSE 100 day

Minutes of Quality and Performance Committee 7 November 2018 Page 337 wave four project and NIV? Clinical audit which has resulted in a robust action plan for SMART improvements. Two advance nurse practitioners had recently been recruited with the aim of admission avoidance and early discharge. It was identified that there were development opportunities for the band six staff around leadership. The visiting team raised concerns with Senior Management at the end of the visit in regards to medicines administration and MCA training. This resulted in immediate input from Pharmacy for medicines reconciliation and arrangements for MCA training to be carried out.

9 Care Home report

The report featured Nursing and Residential Homes on the Continuing Healthcare Framework and Independent Sector Mental Health providers across the two CCG’s. Detail included providers who were risk rated as moderate to high risk and the actions being taken in response to concerns raised. One home in the Preston area had been issued with a Notice of Proposal by CQC due to ongoing quality concerns. A representation to court has been made and an enhanced package of support has been put in to place with a further option of a Local Authority Manager to be placed in the home to oversee the effectiveness and implementation of measures.

Some care homes had reported that their residents had not yet received their flu vaccine, this has been escalated.

10 Serious Incidents

No new never events have been reported. A round table discussion is to take place with representatives from Lancashire Teaching Hospital Trust, NHSE, CQC and the CCG’s. It was reported that the top five incidents listed were similar across other CCG’s although the order varies. A number of incidents were closed through the Serious Incidents review panel.

11 Transforming Care

It was reported there had been four patients admitted to hospital, three for Greater Preston and one for Chorley and South Ribble and one patient for each CCG had stepped down from the secure service in Whalley Hospital.

There were a total of 20 patients across the two CCG’s 12 of which are ready for discharge but were awaiting suitable accommodation and/or support. The position of Lancashire as a whole is off trajectory for reasons including community infrastructure, beds, and timings of discharge. This had been reported to NHSE and although the CCGs had received some positive feedback NHSE are still monitoring. NHSE are requesting a refreshment of the trajectory discharge dates.

The Committee reviewed and approved the revised discharge dates.

The model of care for Learning Disabilities and Autism is being reviewed and a paper to be presented to the Commissioner Oversight Group in November which would see Lancashire and South Cumbria working together.

12 Any other business

The Committee’s terms of reference have been reviewed and compared with similar from

Minutes of Quality and Performance Committee 7 November 2018 Page 338 Oldham CCG. Consideration will be taken to include the Chief Officer along with the Chair for each CCG along with an extension of time and membership. A revised version will be circulated to both Chairs.

Lancashire Teaching Hospitals Trust have been invited to the thematic Committee meeting in December to present their CQC report. Quality Improvement Board profile to be circulated prior to the thematic meeting.

Action: Helen Curtis to circulate Quality Improvement Board profile.

Date of next meeting: Wednesday, 5 December 2018

Signed as an accurate record ………..……………………. Date ……………………...

Minutes of Quality and Performance Committee 7 November 2018 Page 339

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Page 340 Agenda Item 17

Governing Body Meeting

Date of meeting 24 January 2019 Title of paper Delegated Commissioning Committee Update Presented by Mr Paul Richardson, Lay Member Author Mrs Jill Truby, Committee Secretary Clinical lead Dr Hari Nair, GP Director Confidential No

Purpose of the paper This paper is intended to provide the Governing Body with a summary of key decisions made by the Delegated Commissioning Committee.

Executive summary The Delegated Commissioning Committee met in December 2018. The meetings were held in public. The minutes of that meeting have not yet been ratified.

The items considered at the meeting included:- • Terms of Reference • Out of Hospital Transformation update • Application to merge Gutteridge Medical Centre • Dr Wilson – request for additional rooms • Whittle surgery – protakabin/Chorley Medics building • Specification for atypical population • Prescribing Quality and Savings Scheme 2019

The ratified minutes of the meeting held on October 2018 are attached.

Recommendations The Governing Body/Committee is asked to receive the update.

Delegated Commissioning Committee Update NHS Greater Preston CCG Governing Body Meeting 29 November 2018 Page 341 SO4 Ensure patients are at the centre of the planning and management of ☐ their own care and their voices are heard SO5 Be seen as a well-run clinical commissioning group and the system ☒ leader

Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome

N/A

Were any conflicts of interest identified at previous meetings (mark X in the correct box below) Yes No

If conflicts of interest were identified what were these:

Assurance Delegated Commissioning Committee

Delegated Commissioning Committee NHS Greater Preston CCG Governing Body Meeting Page 342 24 January 2019

Greater Preston CCG Delegated Commissioning Committee Minutes Wednesday, 3 October 2018, Board Room 1 - Chorley House, Lancashire Business Park, Centurion Way, Leyland PR26 6TT at 2.30 pm

Present Mrs Tricia Hamilton, Governing Body Nurse Mr Matt Gaunt, Chief Finance and Contracting Officer Mr Paul Richardson, Lay Member Mrs Helen Curtis, Head of Quality and Performance Mr Ian Cherry, Lay Member Mr Denis Gizzi, Chief Officer

In Attendance Mr Alan Stuttard, Vice Chair, NHS Chorley and South RIbble CCG (meeting chairman) Dr Hari Nair, GP Director Mrs Jayne Mellor, Director of Planning and Delivery Dr Sumantra Mukerji, GP Director Mrs Linda Chivers, Lay Member Finance and Audit, NHS Chorley and South Ribble CCG Dr Gora Bangi, Chair of NHS Chorley and South Ribble CCG Mrs Donna Roberts, Head of Primary and Elective Care Mrs Sarah Danson, NHS England Mrs Jill Truby, Committee Secretary

Members of the Public There were 8 members of the public present

1 Welcome and Apologies for Absence As Chairman of the meeting, Mr Alan Stuttard welcomed everyone to the meeting in common of the Delegated Commissioning Committees of Chorley and South Ribble CCG and Greater Preston CCG.

Apologies for absence received from Dr Eamonn KcKiernan

Quorum The meeting was quorate.

2 Declarations of Interests Mr Stuttard reminded committee members of their obligations to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of the CCGs.

Declarations made by member of the Delegated Commissioning Committee are listed in

Minutes of Greater Preston CCG Delegated Commissioning Committee 3 October 2018 Page 343 the CCGs’ Register of Interests. The Register is available either via the secretary to the governing body or the CCGs websites at the following link: http://chorleysouthribbleccg.nhs.uk/about-chorleysouthribbleccg/who-we-are/our- governing-body/

Declarations declared by members of the Delegated Commissioning Committee are listed in the CCG’s Register of Interest presented.

Declarations of interest from today’s meeting pertinent to the agenda: • Paul Richardson declared that his wife worked at Edith Rigby It was agreed that this declaration was not deemed to have a potential impact on any decision making and therefore it was agreed that Mr Richardson could participate in full for this item.

Greater Preston Delegated Commissioning Committee resolved: • Declarations of Interests were noted

3 Minutes of Previous Meeting The minutes of the meeting held on 6 June 2018 were agreed as an accurate record.

4 Matters Arising There were no matters arising.

5 Terms of Reference Members received a paper detailing the changes which have been made to the Delegated Commissioning Committee Terms of Reference for the committee to approve them to be submitted to the Governing Body for ratification.

Mrs Sarah Mattocks presented the paper and explained that a review had been undertaken of the function of the Committee. This has resulted in the following amendments to the terms of reference: • Section 18 is a new section to clarify the responsibilities the committee is to take with regards to primary care proposals and strategy • Section 19 amended to reflect that the Committee will receive summaries of the CQC inspections completed in the area, along with assurance against action plans. • Section 23 reflects that the GP Director for primary care is now an invited attendee rather than a member • Section 31 has been updated to reflect the mechanism of the committee reporting its’ decisions to NHS England • Section 35 reflects an updated quorum from 5 to 4 members, to reflect that the GP Director is no longer a voting member • Sections 41 to 43 is a new section to clarify the oversight of investments that the committee must have (full understanding of the recurrent revenue consequence over the lifetime of the investment). • Section 44 reflects the requirements of the new NHS England internal audit framework for delegated CCGs

These amendments were agreed by the Committee.

The Committee was also asked to consider the following given feedback received from members: • Changing the meeting title to Primary Care Commissioning Committee

Minutes of Greater Preston CCG Delegated Commissioning Committee 3 October 2018 Page 344 Agreed

• Changing the GP Chair from membership to attendee Agreed • Review the quoracy of the meeting. The previous terms of reference stipulated that the GP Chair or the GP Director must attend to achieve quorum to ensure clinical representation on any decisions.

Now that the committee has approved to remove the GP Director and the GP Chair from the Membership, the statement in section 35 regarding ‘appropriate lay member/executive majority’ can now be removed. The following was then agreed to achieve quoracy:

• The Chief Officer, or the Chief Finance and Contracting Officer, or Director of Quality & Performance, and • Secondary Care Doctor or Governing Body Nurse

It was also agreed that the lay member for patient and public involvement would be an invited attendee.

Greater Preston Delegated Commissioning Committee resolved: • To approve the proposed changes to the Terms of References

6 Quarterly Contractual Changes Report Mrs Sarah Danson presented the paper which would provide the committee with a summary of the contractual changes that were effective during the previous quarter April 2018 – June 2018.

Greater Preston Delegated Commissioning Committee resolved: • To note the contractual changes.

7 Out of Hospital Transformation Mrs Donna Roberts presented the report and explained that in August 2017 the committee signed off the CCGs “Out of Hospital” strategy. This detailed the CCGs proposed direction of travel in regards to developing both sustainable general practice and out of hospital care.

The strategy was developed in collaboration with the membership practices of both CCGs and incorporated the national strategic direction and associated requirements known at that time. One of the key elements of the strategy was developing primary care at scale and integrated care on locality footprints.

Since 2017 the strategic direction of travel has matured and one of the key areas of focus is the continued development and maturity of primary care network (described in our strategy as integrated care teams). Further details on the specific requirements are expected to be included within the NHS 10 year plan due to be published in early November 2018.

The Delegated Commissioning Committee is asked to note the contents of the paper and to approve the proposed next steps as outlined in section 5: • The proposed £4 ICT investment as per the requirements of the Lancashire and South Cumbria STP and the GP five year forward view.

Mrs Roberts outlined exactly how the transformation investment of £4 was made up and

Minutes of Greater Preston CCG Delegated Commissioning Committee 3 October 2018 Page 345 the proposals as to how it was to be invested.

A general discussion ensued. Mrs Roberts was asked whether the CCG has any influence in the way practices invested this money. Mrs Roberts answered that it was entirely up to individual practices. However the CCG would monitor outcomes.

In response to a query from Dr Bangi on exactly what an ICT was, Mrs Roberts explained it was an Integrated Care Team working in geographically sensible localities serving populations of 30,000+ people to deliver services shaped around local needs and what works best for different patient groups. These teams are the practical, operational model of accountable care provision. The ICTs will comprise representatives from primary care, community nursing, acute care, specialist care, mental health, dentals, social care etc. to ensure full utilisation of all skills that exist within these professions.

Mrs Roberts reported that she was attending the Network of Practice Managers lead forum on the 10 October to discuss the ICT proforma in detail and that at this forum dates will be agreed for further workshops to progress this work.

Mrs Chivers raised concerns around potential risks. Was there a risk in delivering the ICT? Mrs Roberts responded that until the schemes were in place we were unable to confirm.

Mr Cherry enquired as to exactly who owns the limited company and has control of the contract and who the directors were. Mrs Roberts explained that they are developed by GPs as providers. The contracts remain with the individual practices. It was suggested that a standard term other that ICT was used. The proposal is to use neighbourhoods to represent the geographical footprint and networks.

Dr Dickinson questioned the completion of form 1 and indicated that this was too onerous for the practices to fill in. Mrs Roberts confirmed that this would be completed by CCG staff.

Mr Stuttard summarised the discussion. The principle of the scheme was fine however there were some issues regarding the mechanics to be resolved. Mrs Roberts reported that these would form part of the discussion at the meeting on 10 October.

Mrs Roberts reported that these would form part of the discussion at the meeting on 10 October.

In conclusion: • Principle agreed • Funding to be paid as per the proposal to GP collaboratives • Issues relating to mechanics to be resolved • Meeting on 10 October to discuss ICT proforma • Separate workshop to be held to discuss the £2 • CCG to complete form 1 • Name – standard name to be agreed

Update to be submitted to DCC in December, addressing points raised to assure the committee that all areas have been addressed.

Greater Preston Delegated Commissioning Committee: • Noted the contents of the report and approved the proposed £4 ICT investment as per the requirements of the Lancashire and South Cumbria

Minutes of Greater Preston CCG Delegated Commissioning Committee 3 October 2018 Page 346 STP and the GP five year forward view.

8 Edith Rigby specification Mrs Donna Roberts outlined the specification received for Edith Rigby approved premises.

In 2015/16 Greater Preston Clinical Commissioning Group reviewed all its PMS contracts. At the time the Delegated Commissioning Committee agreed to defer decision on the PMS funding in Park View Surgery’s contract until further information was available about the volume of special care and regularity of violent patients.

The PMS review panel held in November 2015 agreed that Park View Surgery offered a unique service over and above GMS to a particularly vulnerable patient group. It was acknowledged that the practice had built relationships with the probation hostel and police to enable effective partnership working and service delivery for this patient group. This could be replicated by another practice but would increase the risk of service disruption.

Greater Preston Delegated Commissioning Committee: • Approved the specification for Park View Surgery to recognise the additional work associated with an approved premises and consequently remove the PMS Premium from the contract.

9 Medicom premises relocation Mrs Sarah Danson asked the Committee to consider an application received from Medicom to relocate premises from The Health Centre, Flintoff Way, Deepdale, Preston to Issa Medical Centre, 73 Gregory Road, Preston.

This is an interim move until the primary care development at Garstang Road is completed.

Greater Preston Delegated Commissioning Committee: • Approved the application received from Medicom to relocate premises from The Health Centre, Deepdale, Preston to Issa Medical Centre, Gregory Road, Preston on an interim basis.

10 Any other business There was no further business.

Signed as an accurate record ………..……………………. Date ……………………...

Minutes of Greater Preston CCG Delegated Commissioning Committee 3 October 2018 Page 347

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Governing Body Meeting

Date of meeting 24 January 2019 Title of paper Clinical Effectiveness Committee Update Presented by Mr Geoffrey O’Donoghue, Lay Member Author Mrs Rebecca Potter, Quality and Performance Support Officer Clinical lead Dr Sandeep Prakash, GP Director Confidential No

Purpose of the paper This report provides an update from the Clinical Effectiveness Committee held on 10 October 2018 and 9 January 2019.

Executive summary Individual Funding Requests (IFR) Annual Report 2018/2019 Q2

A summary of the IFR application and decisions was provided to the Committee. IFRs are requests to fund drugs, treatments, procedures and interventions that fall outside of the current commissioning contracts or where there is no Commissioning Policy. A Funding request may also be submitted for a patient who does not meet the criteria within a specific Commissioning Policy for whom their Clinician feels they may be an exceptional case.

RightCare

The Committee received an update on progress made against the RightCare programme of work.

The CCG are still awaiting the refreshed ‘Where to Look’ and ‘Focus’ packs from NHS England. The CCG completed a full refresh of the evaluation plans and submitted them in September 2018 to NHSE. Following a meeting with Right Care Delivery support team the CCG were notified further work was required in order to link the schemes of work to the RightCare opportunities, this work was completed and submitted December 2018.

RightCare is now a regular agenda item for the Elective Care group so that the Getting it Right First Time (GIRFT) and RightCare agendas are prominent and aligned. The overall aim is to ensure the governance structure is maintained, so RightCare is embedded within the CCGs operational groups for focus on assurance.

Clinical Effectiveness Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting Page 349 24 January 2019 The CCG RightCare PMO process has been shared with other CCGs across the north of England as an example of best practice.

Evidence based interventions (EBI)

An update was provided to the Committee on NHSE Evidence Based Interventions.

Following on from the period of consultation and engagement on the proposed commissioning of 17 interventions, NHSE in November 2018 notified Clinical Commissioning Groups (CCGs) the guidance is now mandated, with the expectation that this will be in place by April 2019.

The implementation of this programme of work is being led by the Commissioning Policy Development Implementation Group (CPDIG) on behalf of the Lancashire & South Cumbria CCG’s.

The CCG had a number of NHSE policies already in place therefore only 3 policies need to be adopted from NHSE.

Clinical Policy update

An update was provided to the Committee on the work of the Commissioning Policy Development and Implementation Group (CPDIG).

Further policies have been ratified by the Joint Committee of CCGs (JCCCG) in November 2018:

Assisted Conception Spinal injections and Radiofrequency Denervation.

A 6 week patient engagement exercise has been completed for varicose veins, with a view that there was support for the provision of funding. However a decision has been made on the policy for reversal of sterilisation, that funding would not be supported for this procedure.

An update was provided on the Hernia Policy. The policy had been amended but there had been no change to commissioning intentions. A review of activity has taken place which demonstrated there had been a significant reduction in overall procedures with no significant increase in emergency procedures after the implementation of the Hernia policy in November 2017. No further concerns or complaints have been received from clinicians or patients. The CCG Evidence & Effectiveness team will continue to monitor this and provide updates to the Clinical Effectiveness Committee and CPDIG.

CQUIN Q2 reconciliation

The CCG monitors the achievements against the agreed contractual CQUIN schemes for Lancashire Care NHS Foundation Trust (LCFT), Lancashire Teaching

Clinical Effectiveness Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting Page 350 24 January 2019 Hospitals (LTH), Ramsay Health Care (RHC).

The Committee were presented with the Q2 CQUIN progress report for the providers. Levels of achievement for each of the providers are outlined below:

- LTH – 5 fully achieved, 2 partially achieved, 3 not achieved and 4 without reporting requirements for Q2. - LCFT – 8 fully achieved, 1 partially achieved and 3 without reporting requirements for Q2. - Ramsay – 2 fully achieved (out of 2)

For 19/20 NHSE have advised that CQUIN scheme would be reduced in value to 1.5% from 2.5% from 1st April 2019.

Medicine Management

There had been a national medicine safety alert regarding Sodium Valproate and the affects for women of child bearing age, this drug was now a contra indication for this section of the population. Work had been carried out with neurologists regarding which patients would need to be reviewed for a change in prescription. Prescription ordering direct was repeat prescription ordering service from a single area where patients would attend a central hub, employed with staff who had received extensive training.

Recommendations The Governing Body are asked to note the content of this report.

Links to CCG Strategic Objectives SO1 Improve quality through more efficient, safer services which deliver a ☒ better patient experience SO2 Commission care so that it is integrated and ensures an appropriate ☒ balance between in-hospital and out of hospital provision SO3 Be an integral part of a financially sustainable health economy ☒ SO4 Ensure patients are at the centre of the planning and management of ☒ their own care, and that their voices are heard SO5 Be a well-run clinical commissioning group and the system leader ☒

Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome

Clinical Effectiveness Committee 10 January 2018

Clinical Effectiveness Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting Page 351 24 January 2019 Were any conflicts of interest identified at previous meetings (mark X in the correct box below) Yes No X If conflicts of interest were identified what were these: N/A

Implications Quality/patient experience ☒ ☐ ☐ implications? Yes No N/A (Potential) conflicts of interest? Yes ☐ No ☒ N/A ☐ Equality Impact Assessment? Yes ☐ No ☒ N/A ☐ Privacy Impact Assessment? Yes ☐ No ☒ N/A ☐ Are there any associated risks? Yes ☐ No ☒ N/A ☐ Are the risks on the CCG’s risk Yes ☐ No ☐ N/A ☒ register? If yes, please include risk description and reference number

Assurance Assurance will continue to be provided to the Governing Body from the Clinical Effectiveness Group.

Clinical Effectiveness Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting Page 352 24 January 2019 Agenda Item 19

Lancashire Health and Wellbeing Board

Minutes of the Meeting held on Tuesday, 20th November, 2018 at 10.00 am in Committee Room 'C' (The Duke of Lancaster Room) - County Hall, Preston

Present:

Chair

County Councillor Shaun Turner, Lancashire County Council

Committee Members

County Councillor Graham Gooch, Lancashire County Council County Councillor Mrs Susie Charles, Lancashire County Council Dr Sakthi Karunanithi, Lancashire County Council Louise Taylor, Lancashire County Council John Readman, Lancashire County Council Councillor Bridget Hilton, Central District Council Councillor Barbara Ashworth, East Lancashire District Council Councillor Margaret France, Central HWBP Greg Mitten, Interim Chair of West Lancashire HWBP Adrian Leather, Third Sector Representative Tammy Bradley, Housing Providers David Russel, Lancashire Fire and Rescue Service Dr Tom Marland, Fylde and Wyre CCG Alex Walker, East Lancashire CCG Professor Max Marshall, Lancashire Care NHS Foundation Trust Denis Gizzi, Chorley and South Ribble CCG and Greater Preston CCG Sam Gorton, Lancashire County Council Julia Westway, Morecambe Bay CCG

Apologies

County Councillor Geoff Driver Lancashire County Council CBE Cllr Viv Willder Fylde Coast District Council Jacqui Thompson North Lancashire HWB Partnership Clare Platt Health Equity, Welfare & Partnerships

1. Welcome, introductions and apologies

The Chair welcomed all to the meeting.

Apologies were noted as above.

Page 353 Replacements were as follows:

Alex Walker for Mark Youlton, East Lancashire CCG Professor Max Marshall for Professor Heather Tierney-Moore, Lancashire Care NHS Foundation Trust Dr Tom Marland for Peter Tinson, Fylde and Wyre CCG Julia Westway for Dr Geoff Jolliffe, Morecambe Bay CCG

2. Disclosure of Pecuniary and Non-Pecuniary Interests

There were no disclosures of interest in relation to items appearing on the agenda.

3. Minutes of the Last Meeting held on 18 September 2019

Resolved: That the Board agreed the minutes of the last meeting.

4. Action Sheet and Forward Plan

Updates on actions from 18 September 2018 were received.

Mental Health and Wellbeing – Time to Change Hub – The application for a Time to Change Hub had been submitted and the outcome was due mid-December 2018.

All other actions had been added to the forward plan.

Since the circulation of the agenda papers, the forward plan had been revised.

Resolved: Sam Gorton to circulate a copy of the revised forward plan for comments to the Board.

If there were any other items for the forward plan, these should be sent to Sam Gorton, email [email protected] who would bring them to the Chair's attention for consideration.

5. Adult Services and Health and Wellbeing Update

Louise Taylor, Executive Director of Adult Services and Health and Wellbeing presented the attached PowerPoint.

The Care, Support and Wellbeing of Adults in Lancashire Vision, which was recently approved by Lancashire County Council's Cabinet, set out how the county council, together with its partners, would help people to live as independently and healthily as possible. The document recognised the need to keep pace with people's changing needs and expectations, whilst addressing the increasing demands upon public services at a time of significant financial pressure.

The Vision also signalled how services would be designed and delivered in the future, acknowledging that partners, the NHS in particular, had a key role to play in preventing and reducing long term physical and mental health conditions, and addressing the significant variations in health outcomes within the Lancashire population.

Page 354 The Housing with Care Strategy which was also approved by Lancashire County Council's Cabinet, outlined the county council's intentions in relation to the development of housing with care and support for older adults and younger adults with disabilities. It would be used to engage with a wider audience as part of a collaborative approach to developing a range of high quality housing with care and support schemes across Lancashire by 2025 for both older adults and younger adults with disabilities.

The Care, Support and Wellbeing of Adults in Lancashire, and the Housing with Care Strategy documents were attached to the agenda and are currently being consulted upon. The documents set out in context what we are doing for adults in Lancashire and what was planned going forward and also recognised that there was a lack of suitable modern housing to support adults with care and support needs across Lancashire, which meant that some people moved into residential care prematurely or some people received care and support in housing that was not ideal. It would also be used to engage with a wider audience as part of a collaborative approach developing housing with care and support across Lancashire.

Schemes that were working already were:

• Reablement • Home First • Telecare • Night time support/falls lifting service – starting to see a big difference with this service • Trusted Assessors – asking home care providers what it felt like to work alongside the county council, trialling providers to do reviews, which would release social workers to carry out other duties and avoid the individual telling their story more than once • Shared Lives would hopefully be extended • Passport to Independence where the reablement strategy had been highly effective alongside more efficient ways of working.

The presentation also emphasised what would be done differently and what needed to be done together – the system is health and care, an equal partnership.

Specific areas for collaboration were as follows and would be reported on at future Health and Wellbeing Board meetings:

• Market Position Statement • Better Care Fund • Fee Uplifts • Home response/falls lifting service • Extra Care Housing • Additional funding for winter pressures • Intermediate care • Workforce/apprenticeships

Colleagues around the table offered further support from Housing and Lancashire Fire and Rescue and would speak to Louise Taylor outside the meeting.

Page 355 The Board raised that there needed to be one common language which had to be repeated again and again so it became a common language ie people instead of patient, wellbeing instead of sickness.

Louise Taylor confirmed that the presentation would be shown to Integrated Care Partnerships across the County and would see if the presentation could be filmed and then made available on line.

The Board agreed that this area had to be owned by all partners and stakeholders across Lancashire and needed to do more to bring it together under one workstream and own it collectively.

Resolved: That the Health and Wellbeing Board received a presentation from Louise Taylor, the Executive Director for Adults and Health and Wellbeing, who outlined the key elements of each of the documents, highlighted the main issues and discussed the next steps.

6. Children's Services Update

Children and Young People's Emotional Wellbeing and Mental Health Transformation Programme

Dave Carr, Head of Service, Policy, Information and Commissioning and Gillian Simpson, NHS Midlands and Lancashire Commissioning Support Unit were welcomed to the meeting for another update on the Children and Young People's Emotional Wellbeing and Mental Health Transformation Programme.

This was the third year of delivery against the pan Lancashire Children and Young People's Emotional Wellbeing and Mental Health Transformation Programme which had resulted in the delivery of a number of key objectives which enabled children and young people to benefit from enhanced services and greater access to support. There had been significant engagement to inform the redesign of NHS funded Child and Adolescent Mental Health Services (CAMHS) and a core design developed for the future delivery of CAMHS services across the Lancashire and South Cumbria footprint. During the coming weeks, dialogue was expected to progress with NHS Providers and Clinical Commissioning Groups (CCGs) to agree a timeline for the further development of costed proposals, subsequent evaluation and implementation.

This report provided an update relating to the Lancashire Children and Young People's Emotional Wellbeing and Mental Health Transformation Programme including an overview of achievements during the past year and progress in the redesign of community Child and Adolescent Mental Health Services (CAMHS).

The last update to the Lancashire Health and Wellbeing Board, in January 2018, highlighted good progress in delivery against the 26 objectives in the pan Lancashire Transformation Programme. The work had continued during 2018.

Page 356 Key achievements included:

• Consulting with schools to inform the development of a Resilience Framework which would provide a common understanding of what was meant by resilience, the activities which could build resilience and provide opportunities to share good practice. • Continued funding for the Lancashire Sports Trust to support young people in building resilience. • Defining a "complementary offer" of non-clinical support to children, young people and their families. • Increasing access to Youth Mental Health First Aid (YMHFA) Training, delivered through the new network of Primary Mental Health Workers across Lancashire and complementing YMHFA training commissioned by the County Council. • Engagement with children, young people and stakeholders and the first stages of development of a new "Digital" offer for professionals, children, young people and their families. • Progressing the redesign of NHS funded CAMHS services. NHS CAMHS provider organisations had worked collaboratively with voluntary community and faith sector providers and with Clinical Commissioning Groups to co-produce a core model for CAMHS services across Lancashire and South Cumbria through a process of engagement and co-production with children, young people, families and wider stakeholders. Work was now progressing to establish the potential impact on funding and to agree timescales for the production of a final costed proposal, evaluation and potential implementation. • Securing interim community services to support “children with behaviours that challenge”, pending the CAMHS redesign. • Opening the Specialist In-patient Mother and Baby Unit in October 2018.

There were a number of challenges which create pressure in the system and acted as a catalyst for the transformation programme to propose to the need to increase the scale and pace of change.

These were:

National Access Target

At least 35% of children and young people with a diagnosable mental health condition to receive treatment from an NHS-funded community mental health service, or for those already hitting 35%, an additional 7% was required. This meant we still had 65% not in an NHS funded service.

Lancashire County Council re-invested £1.1m in early help. Whilst this was positive in terms of supporting children and young people with the aim of providing support earlier and hopefully preventing CYP needing to access CAMHS, it did leave a £1.1m gap in CAMHS funding. CCGs used Transformation funding to fill that gap but this was not sustainable and an ongoing solution was needed.

Page 357 Variations

There were significant variations in investment, in age range and in the services offered for Children and Young People with Emotional, Wellbeing and Mental Health across the Sustainable and Transformation Plan footprint.

Since the publication of the original Lancashire Transformation Plan in 2016, the programme had been clearly committed to redesigning, developing and commissioning services in line with the THRIVE model. THRIVE offered an opportunity to fundamentally change the way that services were conceptualised and delivered, moving away from the tiered approach to one that was integrated, person centred, goal focussed and evidence informed. THRIVE had been shown to reduce waiting times and improve experience of care. It was the nationally recognised model of choice and had been widely researched and evidence based and is central to the redesign.

The local performance for 2018/19 full year for the access target for Children and Young People Mental Health Services was broken down by each Clinical Commissioning Group area. All areas included within the Lancashire transformation plan area had achieved the target.

An issue was raised with regards performance on waiting times for CAMHS for each of the Clinical Commissioning Groups and requested a more in depth analysis on this. Gillian Simpson agreed to feed this information back at a future meeting when the Transformation Programme was due to return for an update.

As needs are higher than resources available, variation needs to be analysed and also access across the County too, as one are may need less resources than another area and the balancing of needs of the service needs looking into. The Board agreed that this should be raised through the Integrated Care System and feedback at a future meeting. It was also noted that for the following reports it would be useful to have sight of the impact of the other projects in the programme and what the outcomes are. An additional recommendation was also made.

Resolved: That the Health and Wellbeing:

i) Noted the report and accompanying presentation. ii) Request that Clinical Commissioning Groups through the Integrated Care System look further at the issues around how we collectively fund and deliver mental health provision for children and young people in a more equitable way and bring other elements with the next update.

Lancashire Special Educational Needs and Disabilities (SEND) Partnership – Update on the Implementation of the Written Statement of Action

Sian Rees, Improvement Partner SEND, Lancashire County Council updated the Board on the Lancashire local area SEND services which were inspected by Ofsted and the Care Quality Commission (CQC) in November 2017 to judge how effectively the special educational needs and disability (SEND) reforms had been implemented, as set out in the

Page 358 Children and Families Act 2014. The inspection identified two fundamental failings and twelve areas of significant concern. The partners in Lancashire were required to produce a written statement of action, setting out the immediate priorities for action; the progress on implementing these actions are monitored by the Department for Education (DfE) and NHS England (NHSE).

Since the last Health and Wellbeing Board update in September 2018, work had continued to progress the actions set out in the written statement of action and these are detailed in paragraphs 2.1 and 2.2 in the report. Since the agenda circulation, the draft strategy and provision have been revised and will be presented to the SEND Partnership Board on 26 November 2018. Once they have agreed the amendments, Sian will circulate to the Health and Wellbeing Board.

This is the third update to the Health and Wellbeing Board.

John Readman informed the Board that the Clinical Commissioning Groups involvement had been really strong and that Mark Youlton who represented them had brought strength to the SEND Partnership Board and the Integrated Care System (ICS) were discussing Mark's replacement when he leaves shortly. Edwina Grant will also be replacing John Readman, Interim Director of Children's Services when she commences at Lancashire County Council in December 2018 as the new Executive Director on the Health and Wellbeing Board as well as the SEND Partnership Board.

The Chair expressed its thanks to John and Mark as well as the SEND Team for their work on this.

Resolved: That the Health and Wellbeing Board i) Noted the progress of delivery on the written statement of action; ii) Received an update on progress at the January Board meeting iii) Noted the likely changes to the external monitoring process in 2019 as described in paragraph 4.

7. Urgent Business

An issue was raised with regards the continued rail disruption across Lancashire and citizens unable to make hospital/GP appointments, commute to and from work especially in rural areas which is now causing health problems due to the stress this is causing.

Resolved: That the Health and Wellbeing Board noted this issue and would discuss at a future meeting.

Page 359 8. Date of Next Meeting

The next scheduled meeting of the Board will be held at 10am on Tuesday, 29 January 2019 in Committee Room 'C' – Duke of Lancaster Room at County Hall, Preston.

L Sales Director of Corporate Services

County Hall Preston

Page 360 Lancashire Health and Wellbeing Board Forward Planner Date of Meeting Topic Summary Owner

January 2019 Children's Services Update To receive an update on: • Children's Services Ofsted Improvement plan Edwina Grant • Special Educational Needs and Disabilities (SEND Sian Rees Improvement Plan) January 2019 Motor Neurone Disease To request that the Council adopt the MND Charter. Julie Compton Association Charter January 2019 Better Care Fund Progress To receive an update and feedback on Better Care Fund BCF Steering Group (CP to raise spending proposals for 2019/20 onwards. with Tony Pounder) January 2019 Prevention and Population To receive update and provide ongoing support to this Dr Sakthi Karunanithi Health Plan and programme. Receive an update from the Director of Neighbourhood Working in Public Health and the Health Living Pharmacy Campaign. Page 1 the Integrated Care System March 2019 Lancashire Volunteer To receive an update and explore a social action network Ian Sewart Partnership for Lancashire. March 2019 Data Sharing To develop a data sharing agreement between Primary Dr Sakthi Karunanithi Care/Hospitals/Local Authorities for planning purposes. March 2019 Transforming Care – In To receive a further update in relation to life expectancy Rachel Snow-Miller

Patient Provision and health and wellbeing outcomes for people with Minute Item 4 learning and disabilities and their carers. March 2019 Lancashire Safeguarding Receive a report detailing proposals for future joint Louise Taylor Boards Annual Report working further to key issues identified in the Lancashire Edwina Grant 2017/18 Safeguarding Adults and Lancashire Safeguarding Children's Boards. March 2019 Residential and Nursing To receive a report on the capacity, quality and Lisa Slack Home Markets challenges. Louise Taylor March 2019 Digital Health Board To receive the strategy. Amanda Thornton Declan Hadley

Page 361 Page

Date of Meeting Topic Summary Owner

July 2019 Central Lancashire To provide an update on the future of acute services in Dr Gerry Skailes Integrated Care the Central Lancashire area detailing the case for Sarah James Partnership Development change, process and next steps. and Future of Acute Services TBC Review Morecambe Bay To receive an update about the Integrated Care TBC Plan: Improving Health, Partnership plan Care and Wellbeing TBC Review Fylde Coast Plan: To receive an update about the Integrated Care TBC Improving Health, Care Partnership plan and Wellbeing TBC Review West Lancashire To receive an update about the Integrated Care TBC Plan: Improving Health, Partnership Plan. Care and Wellbeing

Page 2

Page 362 Page

Care, Support and Wellbeing of Adults in Lancashire Presentation for Health and Wellbeing Board Page 3

Louise Taylor, Executive Director for Adult Services and Health and Wellbeing, Lancashire County Council Minute Item 5

November 2018

Page 363 Page

What is the picture we are painting?

• Keeping people safe, well and connected

• Keeping people independent and living at home, or close to

Page 4 home

• Keeping response, plans and expenditure reasonable and proportionate Page 364 Page

3 Context - High Level Budget Analysis

• The county council has to find £135m savings over the next 2 years to balance the books, general reserves will be depleted at that point; • If we cannot balance our books, unlike health, government will not fund the deficit; • LCC has already taken c£350m out of the base budget over the last 5 years; • Central government is aiming to phase out general revenue support grant from 2020/21; Page 5 • Our income in the future will be from specific grants, locally collected business rates, and income from charges; • Local authorities cannot generate ‘profits’ through charging; • Local authorities can only increase council tax each year by a certain amount, currently 1.99%, without a local referendum; • Local authorities have been able to increase council tax for adult social care by 2% pa over the last 3 years. In Lancashire this has generated an additional c£7m pa, this has nowhere near covered the ASC ‘gap’, which is c£90m pa. Page 365 Page

4 Context - High Level Budget Analysis • LCC Adult Social Care gross budget for 2018/19 is £555M, net budget £347M; • Adult Social Care currently makes up 41% of LCCs gross revenue budget, 45% of LCCs net revenue budget; • Adult Social Care has been targeted with between £49m and £61m additional savings. This is in addition to the £63m already taken out of the Adults budget between 2018/19-2021/22; Page 6 • The 2018/19 total County Council budget is supported by reserves totalling

£42m. £19m of this reserves is supporting Adult Social Care services in 18/19; • Public Health grant is reducing year on year, and is likely to be un-ringfenced within 2 years; • Extra £5.5m for adult social care to fund additional winter pressures, and some additional funding in the Chancellor’s budget; • Will not address the inherent funding gap. Health withdrawing funding on the back of these announcements will compound the pressure. Page 366 Page

5 Evidence shows • Heavy reliance on Bed Based Services for all population groups; • Comparatively high use of care homes in the NW and Lancashire (but much better than 5 years ago); • There is growth in the use of residential care beds, but a reduction in nursing beds, the reverse of what we need; • Large residential homes tend to score lower quality than smaller homes, and nursing homes tend to score lower quality than residential; • Near average use of direct payments – England average is 28%, we’re at 26%, but

Page 7 top local authority performers are nearer 45 to 50%; • High % of adults going on to receive long term support; • Low % referred to universal services – LCC at less than 10% whereas best authorities are at 70%; • High % spend on LD&A unit costs on the current model of supported living; • Very high % spend on MH residential care; • High numbers of people with MH receiving a funded service from LCC; • Lancashire’s population is ageing; • Population health in Lancashire is varied, and in some parts, amongst the worst in the UK, and declining; • Many health related conditions are avoidable or reversible. Page 367 Page

6 We know …. • Our information and advice offer is poor; • Community and neighbourhood working is relatively under developed; • More Older People and those with Physical Disabilities receive long-term services; • Mental Health customers are far more likely to receive a residential based service than other comparator councils; • Culture of risk aversion/ over dependency not enabling e.g. high spend on night time support, single and small tenancies for LD&A; Page 8 • Many customers still receive homecare rather than an offer which will help them

regain or support independence; • Admissions to care homes are too high and quality is still too variable despite recent improvements; • Our Extra Care remains small scale and patchy; • We do not systematically identify or get agreement to joint funding from Health and subsequently can struggle to collect any agreed Health funding; • We struggle to distinguish demand from need. Page 368 Page

Why do we, as a system, need to change? • As a system our current approach is putting undue pressure on all our staff, who are faced with increasing backlogs and increasing expectations from people wanting services; • The county council is funding some services that arguably should be paid for by health, and vice versa, our respective staff teams are wasting time and energy in arguing over funding; • As a system we are placing people into long term residential based accommodation, which would not be their first choice, but is often seen as the safest and most expedient option for hospital staff, who are themselves under pressure to make a speedy discharge; • Our staff can demonstrate that reablement is a safe alternative to long term residential Page 9 placement;

• We know that the packages/services we put in place are often inadvertently reducing and sometimes removing people’s ability to look after themselves and/or recover from a period of ill health; • As a system we can no longer afford to provide long term/high cost packages of care and support; • As a system we need to focus far more on prevention and wellbeing; • As a system we are not always listening enough to our skilled and knowledgeable providers, partners, developers, customers and staff; • Others are changing, we need to keep pace. Page 369 Page

What our staff are telling us • Jointly provided services would make so much more sense to staff and the public; • There are examples from other countries (Ireland, NZ), and other parts of the UK (Lincolnshire), where integrated systems work, so why can’t we make it work; • Members of the public do not care who provides care and support services, they do not want to be passed around our systems and repeat their story; • If our staff could jointly use the same systems, or at least share information, it would save time and frustration, and improve the customer experience; Page 10 • Our staff spend a lot of time arguing with each other over funding. This is divisive, wastes time, and the person needing care is stuck in the middle;

• Health professionals often recommend a residential based solution as the ‘safest’ option, without upfront discussion with social care staff. This can then be difficult to row back from, is likely to cost more, and be dis-abling for the person; • Some social care staff are afraid of being blamed if something ‘goes wrong’; • Hospital referrals for Reablement are not always appropriate eg end of life; • Co-location of teams and joint training would be greatly beneficial; • We have lost some of our local presence and knowledge. Page 370 Page

Building on what works • Reablement • Home First • Telecare Page 11 • Night time support / falls lifting service • Trusted Assessors • Shared Lives • Passport to Independence Page 371 Page

10 What we will do differently • Based on best available evidence and legitimate challenge from external colleagues eg John Jackson LGA, John Bolton’s ‘6 Steps to Managing Demand’; • Nothing radical – has been done elsewhere, however not all at once and at such scale; • Accelerate existing activities e.g. Remodelling, Direct Payments, Telecare; • Shift emphasis from bed based to community; Page 12 • Engage purposely with the NHS regarding joint funding and joint working

arrangements; • Review in house provision – strategic purpose, cost / benefits and other ownership and operating models; • New models of support in LD&A and Mental Health; • Additional external support from NW ADASS for Market Position Statement, and LGA for Housing with Care, and a Peer Review of the ‘Front Door’. Page 372 Page

What we must do together? • NHS England state that 30% of people in a hospital bed could receive more appropriate care in an alternative setting; • If we continue with the current model of care we jointly know: - we can’t afford it; - we can’t staff it; - it’s wrong anyway; Page 13 - it doesn’t always deliver the best outcomes.

• We need a profound system shift to: - improve prevention; - avoid referrals and admissions; - discharge earlier and more appropriately; - manage in primary and community care. • The system is health and care, an equal partnership. Page 373 Page

Specific areas for collaboration? - Market Position Statement - BCF - Fee uplifts Page 14 - Home response / falls lifting service - Extra Care Housing - Additional funding for winter pressures - Intermediate Care - Workforce / apprenticeships Page 374 Page

3 key things to agree? • Can we work together as a system to agree our approach to:

1) market management – what needs stimulation/development, what we might want to change /diversify eg housing with care and support to reduce reliance on residential admissions and keep people at home;

Page 15 2) funding issues – what can we jointly fund, what can fund via pooled budgets, what should be health funded, what should be LA funded;

3) prevention – what can we do better together in our neighbourhoods, are we clear on the joint impact of disinvestment in preventative services, have we got the focus right, do we focus too much on acute pressure/discharge issues/providing services after the event, should we focus more on reducing and preventing admission/improving our community services. Page 375 Page

Does this make sense? Is any of this a surprise to you? Have we got any of this wrong? Page 16

Thank You Page 376 Page