Chorley and South Ribble CCG Governing Body - Part 1

25 September 2019 at 2.30 pm Victoria Room, Farrington Lodge Hotel, Stanifield Lane, Farington, Lancashire, Preston PR25 4QR

Item Agenda Item Objectives/ Presented By Time No Desired Outcomes 1 Welcome and Apologies for Dr G Bangi 2.30 pm Absence Verbal

2 Declarations and Register of To provide Dr G Bangi 2.32 pm Interests (Pages 5 - 14) assurance Assurance

3 Minutes of Previous Meeting For group approval Dr G Bangi 2.35 pm (Pages 15 - 34) Approval

4 Matters Arising (Pages 35 - To update the Dr G Bangi 2.40 pm 36) group Discussion

Standing Items 5 Chair's Update To update the Dr G Bangi 2.45 pm group Verbal Board Assurance 6 Governing Body Assurance To provide Mr M Gaunt 2.55 pm Framework and Corporate assurance Assurance Risk Register (Pages 37 - 104)

Strategy 7 Integrated Care System (ICS) To update the Mr D Gizzi 3.05 pm Update (Pages 105 - 136) group Discussion

8 Integrated Care Partnership To update the Mr D Gizzi 3.15 pm (ICP) Update (Pages 137 - group Discussion 192)

9 Our Health Our Care (OHOC) To update the Mr D Gizzi 3.25 pm Programme Update (Pages group Discussion 193 - 200)

Operational Delivery 10 Integrated Board Report To update the Mrs H Curtis 3.45 pm

Agenda Chorley and South Ribble CCG Governing Body - Part 1 Meeting MEETING HELD IN PUBLIC

(Pages 201 - 306) group Mr M Gaunt Mrs J Mellor Discussion 11 Financial Performance Report To update the Mr M Gaunt 3.50 pm (Pages 307 - 326) group Discussion

Governance and Quality 12 Healthier Lancashire and To update the Mr M Gaunt 4.05 pm South Cumbria Joint group Approval Committee of CCGs Terms of Reference (Pages 327 - 362)

13 Governance Update (Pages For group approval Mr M Gaunt 4.15 pm 363 - 372) Approval

14 Organisational Development To update the Mrs H Curtis 4.25 pm Update (Pages 373 - 390) group Discussion

15 Assurance Engagement of the For group approval Mrs L Chivers 4.35 pm Mental Health Investment Approval Standard 2018/19 TO FOLLOW

16 Policies for Approval (Pages For group approval Mrs L Chivers 4.40 pm 391 - 436) Mr P Richardson Approval Committee Updates and Minutes 17 Audit Committee Update To provide Mrs L Chivers 4.45 pm (Pages 437 - 452) assurance Approval

18 Joint Quality and Performance To provide Mr P Richardson Committee Update (Pages 453 assurance Approval - 466)

19 Primary Care Commissioning To provide Mr P Richardson Committee Update (Pages 467 assurance Discussion - 474)

20 Remuneration Committee Mr P Richardson Update (Pages 475 - 478) Assurance

21 Clinical Effectiveness To provide Mr G Committee Update (Pages 479 assurance O'Donoghue - 510) Assurance

22 Patient Voice Committee To provide Mr G Update (Pages 511 - 524) assurance O'Donoghue Assurance 23 Lancashire Health and For information Mr D Gizzi Wellbeing Board Minutes Information

Agenda Chorley and South Ribble CCG Governing Body - Part 1 Meeting 25 September 2019 MEETING HELD IN PUBLIC

(Pages 525 - 534)

Questions from the Public 24 Questions from the Public For discussion Dr G Bangi 4.50 pm Verbal Any Other Business 25 GBAF Risk Review For Discussion Dr G Bangi / 5.00 pm Mr M Gaunt Verbal 26 Any Other Business For discussion Dr G Bangi 5.05 pm Verbal Date, Time and Venue of next meeting: Wednesday, 27 November 2019, 1.30 pm, Boardrooms, Chorley House, Lancashire Business Park, Centurion Way, Leyland, PR26 6TT

Agenda Chorley and South Ribble CCG Governing Body - Part 1 Meeting 25 September 2019

This page is intentionally left blank Agenda Item 2

Governing Body Meeting – Part 1

Date of meeting 25 September 2019 Title of paper Declarations and Register of Interests Presented by Dr Gora Bangi, Chair Author Mrs Sarah Mattocks - Corporate Affairs and Governance Manager 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, in addition to updates given after this date 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 Chorley and South Ribble CCG Governing Body Meeting Page 5 25 September 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 Governing Body 24 July 2019 Governing Body on 24 July 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 ☐ ☒ ☐ register? Yes No N/A 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 Chorley and South Ribble CCG Governing Body Meeting Page 6 25 September 2019

NHS Chorley and South Ribble 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 Mrs 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 Mrs 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 NFPI - Second daughter is a Psychiatrist researching and practicing in Cambridge - 7 Page Declarations and Register of Interests

NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019

Name Role Declaration Date Mitigating Actions 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 NFProI - Lancashire Joint Police Audit & 12.06.2019 Interest to be managed as and when Richardson Member for Governance, Ethics Committee - Updated conflict arises NHS Greater Preston NFPI - Son is employed by NHS Blackpool CCG & NHS Chorley & Teaching Hospitals Trust - Current South Ribble CCG NFPI - Daughter employed by Public Health England - from 2013 Vacant post GP Director, NHS Personal Chorley and South TBC Ribble CCG TBC Dr Lindsey GP Director, NHS NFPI - Sister in law works for LCFT as 12.12.2018 No direct involvement in commissioning Dickinson Chorley and South Team Manager for Mental Health - from contracts from LCFT Ribble CCG Dec 2018 Interest noted, will be reviewed in line with FI - GP Partner in The Chorley Surgery - agenda items at committee meetings and from 2016 procurement involvement. Where a FI - Shareholder in the Primary Care Prime conflict emerges the individual will be Vendor company - from Nov 2018 excluded from decision. FI – GP working for The Chorley Surgery providing primary medical care services for residents of NHS Chorley and South Ribble/Greater Preston CCG Mr Denis Gizzi Chief Accountable FI - The Electric Church Recording Studio 14.08.2019 Interest noted, will be reviewed in line with Officer, Chorley & South FI - Smart Sight Coaching - Current Updated agenda items at committee meetings and Ribble & Greater Preston FI - Procorre Consulting - Current procurement involvement. Where a

8 Page Declarations and Register of Interests

NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019

Name Role Declaration Date Mitigating Actions CCG’s NFII - Dr Alan Nye is a long-time conflict emerges the individual will be acquaintance from my time in Oldham - excluded from decision making Current NFII - My partner is owner and MD for C&I Consulting - Current Dr Gora Bangi Chair, NHS Chorley and FI - GP Principal - Leyland Surgery and the 20.03.2019 Interest noted, will be reviewed in line with South Ribble CCG Surgery Chorley - Current agenda items at committee meetings and FI - Director of BAS group limited - Current procurement involvement. Where a FI - Son employee of BAS Group Ltd conflict emerges the individual will be FI - Leyland Surgery - Member of Leyland excluded from decision making Network - Current FI - The Surgery Chorley - Member of Chorley Central Network - Current FI - Lancashire Care NHS Foundation Trust - is a Tenant - Current NF ProI- NHS Clinical Commissioners Board Member - Current II - Wife is a nurse at Lancashire Teaching Hospitals Trust - Current II - Son is an Accountant at Deloitte UK - Current Mrs Linda Chivers Lay Member, Chair of FI - Non-executive Director Bridgewater 18.12.2018 Interest noted, will be reviewed in line with Audit, NHS Chorley & Community Healthcare Foundation Trust agenda items at committee meetings and South Ribble CCG (Audit Chair) - 01.06.2018 procurement involvement. Where a NF ProI - Chorley and South Ribble CCG conflict emerges the individual will be Conflicts of Interest Guardian - Current excluded from decision making. if deemed appropriate member would also be excluded from any discussion prior to a decision.

9 Page Declarations and Register of Interests

NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019

Name Role Declaration Date Mitigating Actions Mr Matt Gaunt Chief Finance & No Interest Declared 11.12.2018 No risk to decision making as no potential Contracting conflicts identified Officer,Deputy Accountable Officer, Chorley & South Ribble & Greater Preston CCG’s Dr Satyendra GP-Director Chorley & FI - GP Provider 21.12.2018 Interest noted, will be reviewed in line with Singh South Ribble CCG FI - GP Principal agenda items at committee meetings and NF ProI - LMC Member procurement involvement. Where a NF ProI - Member of Chorley- East conflict emerges the individual will be collaborative excluded from decision making NF ProI - Member of Central Lancashire GP Provider Group FI – GP working for Clayton Brook Surgery providing primary medical care services for residents of NHS Chorley and South Ribble/Greater Preston CCG Mr Geoffrey Lay Member - NF PI - Co-opted Governor at Parklands 21.12.2018 Interest noted, will be reviewed in line with O'Donoghue Public,Patient Academy, Chorley - 17.12.2018 to Present agenda items at committee meetings and Engagement NF PI - Secretary to Chorley Sheds, procurement involvement. Where a Chorley South Ribble community group set up to alleviate conflict emerges the individual will be CCG isolation and improve individuals mental excluded from decision making. if deemed health and wellbeing - August 2018 to appropriate member would also be Present excluded from any discussion prior to a decision. Sue Stevenson Chief Operating Officer No Interest Declared 14.11.2018 for Healthwatch Lancashire

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Declarations and Register of Interests NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019

Name Role Declaration Date Mitigating Actions Seeking Observer Status on the CCG Vancant post - Public Health Consultant, Public Health NHS Chorley and South Consultant Ribble CCG and NHS Greater Preston CCG Dr John Cairns GP Director, Chorley & NFProI - GP Partner at Library House 09.01.2019 Interest noted, will be reviewed in line with South Ribble CCG Surgery - Current agenda items at committee meetings and NFProI - Councillor West Lancs Council - procurement involvement. Where a Current conflict emerges the individual will be excluded from decision making Dr Ann Robinson GP Director, NHS FI - GP partner at Withnell Health Centre - 21.01.2019 Interest noted, will be reviewed in line with Chorley and South Current agenda items at committee meetings and Ribble CCG FI - GP practice, Withnell Health Centre, procurement involvement. Where a offer extended access appointments as conflict emerges the individual will be part of the Chorley East Collaboration - excluded from decision making Current NFPI - Husband is a Secondary Care Consultant in diabetes and endocrinology and Chair of the Division of Medicine at Salford Royal - Current NFPI - Husband has private diabetes clinic at Beaumont Hospital - Current NFPI - Husband is the secondary care doctor for Ormskirk CCG - Current FI – GP working for Withnell Health Centre providing primary medical care services for residents of NHS Chorley and South Ribble/Greater Preston CCG

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Declarations and Register of Interests NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019

Name Role Declaration Date Mitigating Actions Mrs Jayne Mellor Director of No Interest Declared 14.02.2019 No risk to decision making as no potential Transformation and conflicts identified Delivery Dr A.Reid LMC Representative, Personal 25.02.2019 Interest noted, will be reviewed in line with NHS Chorley and South FI - £1000 bond shareholder in Chorley agenda items at committee meetings and Ribble CCG Medics Ltd procurement involvement. Where a NFPROI - GP Appraiser for NHS England conflict emerges the individual will be NFPROI - Vice Chair of the Central excluded from decision making. Lancashire Local Medical Committee (LMC)

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Declarations and Register of Interests NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019

Declarations of Interest Flowchart

Annual 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 Annually 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 aware to the Governing Body of interest Y N your declaration of Y N Register of Secretary Pro-Forma 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 Could YOU (or a close relation, partner or friend) financially benefit? updated: Interest • Membership Council Are YOU (or a close relation, partner or friend) a partner / member / Indirect Pecuniary • Governing Body shareholder in an organisation that would financially benefit? Interest • Statutory Committees and Sub Committees Do YOU (or a close relation, partner or friend) hold a non-remunerative or Non-Pecuniary not for profit interest in an organisation that would benefit? Interest • Employees 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 Chief Finance and Review by Chief Finance and The Chair of the meeting will determine if there is a conflict of interest and the course of action to Contracting Officer and Lay Contracting Officer and Lay take (YOU should advise of the arrangements already agreed for managing the conflict) Member for Finance, audit Member for Finance, Audit and Conflicts of Interest to and Conflicts of Interest to determine arrangements for determine arrangements for managing conflicts 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 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

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Governing Body Meeting – Minutes

Wednesday 24 July 2019 The Garden Room, St Catherine’s Hospice, Lostock Lane, Lostock Hall, PR5 5UX

Present Dr Gora Bangi, Chair Dr John Cairns, GP Director Mrs Linda Chivers, Lay Member for Finance and Audit Mrs Helen Curtis, Director of Quality and Performance Mr Matt Gaunt, Chief Finance Officer Mr Denis Gizzi, Chief Officer Mrs Tricia Hamilton, Governing Body Nurse Mr Geoffrey O’Donoghue, Lay Member for Patient and Public Involvement Mr Paul Richardson, Vice Chair and Lay Member for Governance Dr Ann Robinson, GP Director Dr Satyendra Singh, GP Director

In attendance Ms Hollie Johnson, Governing Body Secretary (Minutes) Mrs Jayne Mellor, Director of Planning and Delivery Mrs Sue Stevenson, Healthwatch Representative Mrs Jessica Tomlinson, Local Medical Committee Representative In attendance Mrs Jewells Davidson, Patient Story to present

Members of the Mrs Madeleine Bird, Senior Communications Officer, CCG public Mr Paul Falconer, Lancashire Evening Post Ms Glenis Tansey, Engagement and Patient Experience Lead, CCG

CSRGB Welcome and Apologies for Absence /190724-1 Dr Bangi welcomed everyone to the meeting. Introductions were made for the purpose of members of the public.

Apologies were received from Dr Lindsey Dickinson, GP Director and Dr Eamonn McKiernan, Secondary Care Doctor.

CSRGB Patient Story /190724-2 Mrs Curtis introduced Mrs Jewells Davidson to the Governing Body. Mrs Davidson attended the meeting to share her experience of the Fibromyalgia Self-Management Programme.

The Fibromyalgia Self-Management Programme is run within the Community Pain Team, but is a true integrated offer for Moving Well enabling patients to be referred in from other areas of the service. The programme focuses on improving quality of life for patients with

Minutes of Previous Meeting NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 15

Fibromyalgia, aiding them with self-management techniques so that they leave the group feeling supported in the long term management of their condition. It is a 5 week programme delivered by experienced healthcare professionals from different backgrounds, including occupational therapy, psychology, specialist nursing and physiotherapy. It is run from two community venues in Chorley and Preston. The focus of the programme is on improving the quality of life of patient whilst living with Fibromyalgia.

The Governing Body heard Mrs Davidson’s journey with Fibromyalgia over the last 20 years, in particular her referral into the programme. Mrs Davidson described how the group that she attended discussed numerous self-management techniques to support patients to return to an active and fulfilling life. The concepts discussed included pain education, goal setting, pacing, sleep, hygiene, activity levels, coping with the emotional aspects of living with a long term condition and flare up planning. She detailed the benefits she had found from the practical exercises and relaxation and meditation sessions.

Mrs Davidson explained for Mrs Chivers that she felt that more could be done to educate employers on Fibromyalgia to assist employees with the condition and adjust to their needs in the workplace.

Mrs Hamilton questioned whether Mrs Davidson felt that the meetings were held frequently enough, and were convenient in terms of time and locality. Mrs Davidson felt that the convenience of the meetings suited her and other patients that she had spoken to. She did feel that meetings at the weekends would be helpful for others, as the evening ones could be difficult to attend.

Mrs Stevenson questioned what more could have been done to get a diagnosis for Mrs Davidson sooner. Mrs Davidson felt that there was not enough information available surrounding Fibromyalgia. She described how she had undertaken her own research and requested that her GP referred her to a rheumatologist for a diagnosis.

Mrs Stevenson made reference to to the self-management that Mrs Davidson had detailed which she undertook and questioned how others with the condition could be encouraged to follow the same. Mrs Davidson felt that more could be done to promote the programme to clinicians and to patients, as the advice and help it provided supported patients in all areas of self-management.

Dr Bangi emphasised the level the impact that was had from a patient story, as evidenced by Mrs Davidson’s presentation. On behalf of the Governing Body, he thanked Mrs Davidson for attending the meeting to share her story.

CSRGB Declarations and Register of Interests

Minutes of Previous Meeting NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 16

/190724-3 Dr Bangi 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 Chorley and South Ribble CCG.

GP’s declared their interests as primary care providers.

As Mr Richardson would be conflicted for part of agenda item 14; Governance Update, he would leave the meeting as appropriate. Mrs Chivers outlined that his insight prior to the Governing Body discussions would be useful.

Mrs Chivers noted that Mr Gizzi’s declaration required the update surrounding his friendship with Mrs Jackie Proctor, MIAA as Mrs Proctor no longer worked there.

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

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

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

CSRGB Minutes of Previous Meeting /190724-4 The minutes from the meeting held on 24 May 2019 were presented for approval.

The date of the meeting would be amended.

Resolved That the Governing Body accepted the minutes of the meeting held on 24 May 2019 as a correct record, subject to the required amendments.

CSRGB Matters Arising /190724-5 Governing Body members noted the actions completed on the matters arising sheet provided. The following updates were provided for the outstanding matters arising:-

CSRGB/180523-15 Terms of reference for the Quality and Performance Committee were on the agenda to be ratified as part of the Annual Committee Terms of Reference Review.

CSRGB/190327-7 An update surrounding the development of the Integrated Care Partnership (ICP) Risk Register was presented to the Audit Committee in July 2019. The Governing Body would be kept appraised of the

Minutes of Previous Meeting NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 17

register as part of the Governing Body Assurance Framework.

CSRGB/190522-10 Mrs Jayne Mellor had been appointed as the Chair of the Clinical Oversight Group (COG).

Resolved That the Governing Body noted the updates provided.

CSRGB Chair’s Update /190724-6 Dr Bangi welcomed Governing Body members to the meeting and provided an update on recent activities.

Lancashire and South Cumbria Integrated Care System (ICS) Dr Bangi informed the Governing Body of his attendance at a workshop that was held for colleagues across Lancashire and South Cumbria. The workshop allowed members to share their perspectives on how they saw the system developing over the next 12-24 months. Dr Bangi felt that the session was useful and underlined the strong relationships that are in place across the area.

Integrated Care Partnership Dr Bangi outlined that he was able to feed into the workshop organised by the ICS the progress being made in central Lancashire on the development of Integrated Care Partnership (ICP).

NHS Confederation Conference Dr Bangi provided an update following his attendance at the annual NHS Confederation Conference in Manchester with colleagues from the CCGs’ executive team. It had been a useful event and there was a clear message for CCGs and Trusts to continue to progress with current guidance. There was recognition of the challenges faced by all but a reiteration that services needed to be transformed for the better, and to deliver the recently published long-term plan.

Further, Dr Bangi outlined that there was a clear recognition from Mr Simon Stevens of the national workforce challenge, with reference to the Interim People Plan recently published. Mr Stevens emphasised the need for looking after the current NHS workforce better, which is something that the Governing Body have stressed previously when hearing about the organisational development work of the CCGs.

Governing Body members discussed the way in which Chorley and South Ribble CCG could do more to promote the work that is undertaken. Mrs Mellor made reference to to conversations that had been had around whether Dr Bangi could present the same at the NHS Clinical Commissioners National Event later in the year.

Chorley Youth Zone

Minutes of Previous Meeting NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 18

Dr Bangi made reference to his attendance at the Chorley Youth Zone facilitate. He detailed that it is a brilliant facility and it was clear to see how much it was of a benefit young people in the area. Going forward, the CCG would look at how it can better utilise such a ffacility for engagement in order that the CCG learns more about young people and how they access health services.

CCGs merger Both Chorley and South Ribble CCG and Greater Preston CCG Governing Bodies have been considering a number of options in order to reduce running costs as required by NHS England. The two CCGs already work very closely together with a shared executive team, shared committees and a shared workforce. One of the proposed options for helping to reduce the CCGs’ running costs was a formal merger, which could generate some savings but not all to reach the 20% requirement.

The constitution of both CCGs requires that the membership of each is consulted upon any such changes and, therefore, the nominated membership representatives were asked to vote upon a proposed merger during June 2019. The result of the vote was that neither of the CCGs’ memberships voted to merge.

The CCGs will now continue to explore other options which could contribute towards a reduction in running costs as required. At this stage there are no formally agreed options. All staff will be kept informed and consulted as options are considered.

Improvement Assessment Frameworks CCG Annual Assessment 2018/19 NHS England has a statutory duty to undertake an assessment of CCGs on an annual basis. This has been done via the Improvement and Assessment Framework (IAF), with the overall assessment derived from CCGs’ performance against a range of indicators, including an assessment of CCGs’ leadership and financial management.

Performance against the indicators is placed in one of four categories; outstanding, good, requires improvement, or inadequate. Chorley and South Ribble CCG was rated as good.

CCG IAF Patient and Community Engagement Indicator 2018/19 The Patient and Community Engagement Indicator evidences the CCG’s implementation of the statutory guidance in respect of patient and public participation in commissioning of health and care and therefore their compliance with the ‘14Z2’ statutory duty.

The scoring categories for the indicator are: outstanding, good, requires improvement, or inadequate. Dr Bangi was pleased to confirm that Chorley and South Ribble CCG was rated as good, with only one

Minutes of Previous Meeting NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 19

point away from being rated as outstanding.

Dr Bangi thanked the Governing Body, the executive team, and all staff at the CCG for their hard work, dedication and commitment to the CCG, its communities and patients.

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

CSRGB Governing Body Assurance Framework /190724-7 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.

Mr Gaunt drew the Governing Body to changes that had been made to the GBAF that were highlighted in red for their review and approval.

The Governing Body were informed that the following risks had been updated and added to the Corporate Risk Register:

The Governance Team collated feedback from the development session to present the first draft of GBAF 2019/20 for approval.

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

• There is a risk that the CCG has restricted control over Continuing Health Care (CHC) patients in receipt of domiciliary healthcare as the contract framework for these patients is managed by Lancashire County Council. If there are issues which impact on safety and quality with these services the CCG may not be fully aware due to not having a direct contract in place for these patients who receive care via spot purchase.

• There is a risk that the CCG is not in a position to meet NHS England’s requirement to be able to offer Personal Health Budgets to all New Homecare packages from 1 April 2019.

Mrs Chivers detailed the gaps in controls in GBAF01. She reminded the Governing Body of their responsibilities to own the risks on the GBAF, and questioned whether it was felt that the risk score should be higher than 3. Governing Body members agreed. Mrs Curtis suggested that the Quality and Performance Committee would review GBAF01 in more detail at its next meeting.

Minutes of Previous Meeting NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 20

Dr Bangi made reference to to how the GBAF had developed over time as an iterative document.

Mrs Chivers referred to ORR01 Referral To Treatment, 02 ‘Agree effective measures with Lancashire Teaching Hospitals NHS Foundation Trust (LTHTR) in order to instil oversight and scrutiny of efficiency of elective services’, and questioned the route of escalation for the same. Mrs Curtis confirmed that escalation was being reviewed as the CCGs worked in integration with partners of the ICP. A review of how performance would be reported at the ICP Board was also being undertaken.

Resolved That the Governing Body approved the changes made to the GBAF and the Corporate Risk Register.

CSRGB Integrated Care System Update /190724-8 Mr Gizzi presented an update on the Integrated Care System (ICS). The update provided details of the development of a shared vision for delivering the NHS Long Term Plan in Lancashire and South Cumbria, the process being undertaken to develop a five year strategy for all partners and commissioning development and the process of priority work streams across Lancashire and South Cumbria.

Mr Gizzi drew the Governing Body members’ attention to the following priorities for the next five years, as identified by the ICS;

1. Maximise the benefits of our work in neighbourhoods 2. Deliver an integrated health and social care workforce for the future with the capacity and capability to provide sustainable care and support for our local communities 3. Strengthen the resilience and mental health of people and communities 4. Establish a group model for all hospital services in Lancashire and South Cumbria 5. Reinvigorate strategic partnerships across the public sector 6. Establish a public sector enterprise and innovation alliance with our ICS partners, including academic partners and Local Enterprise Partnerships to deliver inwards investment and support job creation 7. Bring the entire health and social care system back into financial balance 8. Consolidate commissioning so that our arrangements for planning and prioritising our resources improve our population’s health and the outcomes of health and social care

Mrs Chivers outlined that it was imperative to ensure meaningful engagement with the care home sector as part of the ICS. Mr Gizzi felt

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that it was an area that needed strengthening in the ICS, and detailed how the representative from the care home sector brought valuable insight at the ICP Board. Mrs Curtis added that work to set up a collaborative at an ICS level was being led by the CCG’s Chief Nurse, Mrs Jane Brennan.

Resolved The Governing Body noted the ICS Update provided.

CSRGB Integrated Care Partnership Update /190724-9 Mr Gizzi presented an update on the Integrated Care Partnership (ICP) across the following areas:

• ICP Board business in May and June • ICP Mobilisation - Board and Leadership Development • Working as part of the wider ICS • Big Six Strategic Framework – Platform Specific Updates • Looking ahead to July and August

Mr Gizzi drew attention to the looking ahead section of the update, in particular the strategy update for the ICP. He detailed how the ICP Board had reviewed the strategy and its last meeting.

Governing Body members heard the discussions that had taken place around how and when integrating management and workforce would occur. Mr Gizzi felt that that piece of work, which the CCG was leading on, would begin to mitigate any feelings of concern had by the staff at CCG.

Mrs Chivers questioned what difference had been made to patients as part of central Lancashire working as an ICP. Mr Gizzi outlined the need to ensure that arrangements are organised correctly to ensure that a difference was made to patients. He provided an example of where an improvement had been seen within urgent care. The next phase would be to apply the operating model used within urgent care to other areas for transformation. Mrs Mellor detailed how a value stream analysis had been undertaken around newly commissioned services where tangible improvements had been seen. The same would be circulated to the Governing Body for their information.

Resolved The Governing Body noted the ICP Update provided.

CSRGB Our Health Our Care Update /190724-10 Mr Gizzi presented an update on the work of the Our Health Our Care (OHOC) Programme. Following approval of the Case for Change and the Model of Care, the update provided a summary of the programme’s progress in delivering the options modelling stage.

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Following completion of Stage A: agreeing the approach and methodology and Stage B: exploring alternatives to major service change (from the long list of options), the programme was at Stage C: Shortlisting options. The ten options as shortlisted were assessed at the informal Governing Body development session on 10 July 2019. The programme continued its wok to review detailed modelling outcomes on up to the six options listed in the update.

Mr Gizzi informed the Governing Body that clinical scrutiny of the options would be widened. Governing Body members agreed that the broadening of clinical scrutiny superseded the update in the paper that only six options had been agreed. There was potential to broaden the same as clinical scrutiny could revisit earlier options from the long list.

Mrs Chivers expressed her concerns around the timescales in place, and emphasised the need to ensure sufficient time to robustly consider all data provided. She questioned whether thought had been given to areas outside the locality, and provided an example of how patients in Chorley could find Royal Albert Edward Infirmary in Wigan more accessible than Royal Preston Hospital. Mr Gizzi agreed that consideration of the implications on other areas needed to take place.

Ms Hamilton emphasised the need to ensure that the broader clinical scrutiny had a multi-disciplinary approach, including professionals from across the healthcare sector.

Dr Bangi agreed with the need for a broader clinical group to provide scrutiny and wider assurance that the options have been worked up rigorously and robustly. He stated that this was the single most complex reform in the locality to date, and emphasised the need to ensure that meaningful reform was in fact meaningful. Mr Richardson agreed.

Dr Cairns detailed statistics from Lancashire County Council surrounding population growth in Chorley and South Ribble. Dr Bangi agreed with Dr Cairns that it was important to be cognisant of all variables, such as population growth.

Resolved The Governing Body noted the Our Health Our Care programme provided.

CSRGB Better Care Fund Planning 2019/20 /190724-11 Mrs Mellor presented an update on the Better Care Fund (BCF) Planning 2019/20. The BCF policy framework that was published in April 2019 had been followed by planning guidance this week. The CCG are required to submit the Lancashire BCF Plan by 27 September 2019.

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BCF reporting will incorporate the previous processes for BCF and the winter pressures grant, aiming to remove duplication in collection and reducing the reporting burden overall. BCF will continue to provide a mechanism for personalised integrated approaches to health and care that support people to remain independent at home or to return to the independence after an episode in hospital.

The continuation of the national conditions and requirements of the BCF provides opportunities for health and care partners to build on their plans from 2017 and to focus on joint working and integration further. This includes work collaboratively to bring together funding streams to maximise the impact on outcomes for communities and sustaining vital community provision.

Mrs Mellor outlined that in summary, all Health and Wellbeing Boards in England must agree for the use of pooled fund to support integration.

The Governing Body heard that this would be the first year that the winter pressures money was included within the BCF to encourage proactive joint planning ahead of winter. Central Lancashire had now established the 2019/20 winter planning group that would oversee planning, expenditure and delivery of this year’s winter plan which would be ready for the A&E Delivery Board meeting in September 2019.

To deliver against the integration ask within the planning guidance a review and reshaping exercise of the BCF governance had been completed, that resulted in the creation of an Advancing Integration Board. Mrs Mellor confirmed that to date, the work of the Advancing Integration Board had been the oversight of intermediate care review undertaken by Carnell Farrar, a significant investment of BCF monies would be in intermediary care and recognising that there is potential for this to be better used, especially in shifting away from supporting hospital discharge to avoiding admission. Recommendations from the review would guide how Lancashire County Council and CCGs would work together to provide the testing of integration at an ICP level.

The Advancing Integration Board had led a senior leader’s workshop and a number of development sessions to advance integration models building on the growing willingness across organisations. Mrs Mellor confirmed that discussions had commenced with regard to potential changes to s75 arrangements and the move towards the continuation of a single s75 but incorporating ICP schedules to the agreement for local delivery and accountability to deliver ICP level integration.

Mrs Chivers welcomed the support of the Advancing Integration Board, in particular the aim to bring the three stands together. She sought assurance that the board would not only consider schemes put forward in terms of allocating funding, but also as a mechanism of

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disinvestment by other partners. Mrs Mellor detailed that she was keen to ensure that disinvestments, reinvestments or recommissioning were taken through the ICP, and not BCF.

Mrs Mellor detailed how both she and Mr Gaunt were aware of the cost pressure within the BCF decision, in order to mitigate the gap.

Resolved That the Governing Body noted the Better Care Fund Planning 2019/20 update.

CSRGB Integrated Board Report /190724-12 Mrs Curtis presented the Integrated Board Report (IBR). The IBR remains focused on reporting performance information across key national healthcare standards that the 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 are highlighted where the CGs 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 standard 2. CCG performance shows a deteriorating position but remains above national standards

System level information is available via Aristotle which has been developed by the Commissioning Support Unit (CSU). Governing Body members were referred to the Aristotle ICP Board dashboard view attached for information that reflected the level of reporting to be monitored at an ICS level. A comparison of performance was provided across a Central Lancashire footprint at both commissioner and provider level.

Mrs Curtis informed the Governing Body that a deep-dive had been undertaken for A&E which would be presented to the Quality and Performance Committee in August.

Mrs Curtis drew Governing Body members’ attention to updates in the executive summary, the IBP and performance metrics.

The Governing Body agreed with Dr Bangi’s concerns and disappointment at Stroke performance in the IBR. Dr Bangi questioned how Chorley District Hospital and Royal Preston Hospital differed significantly. Mrs Curtis detailed the business plan that LTHTR had submitted with regard to workforce within the trust, which was aimed at making improvements. She made reference to to the comprehensive review on stroke that was received by the Governing Body previously that had focused on the whole pathway, and reminded members of the

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SNAP data that was outcome focused.

Mrs Curtis confirmed for Dr Singh that 999 responders did not downgrade calls from GP practices. She detailed her attendance at the ambulance controlled centre, at which time she had posed that question and had been assured that the priority was a patient breathing. Ms Tomlinson detailed how the same concerns had been raised by the Local Medical Committee (LMC) across Lancashire. The LMC were due to meet with North West Ambulance Service (NWAS) to discuss the same.

Mr Gizzi reminded the Governing Body that the transformation of stroke services was being managed at a Lancashire and South Cumbria level.

The Governing Body discussed their concerns around ring fenced beds, NWAS response, the impact had on patients alongside the performance targets reported.

Mr Gaunt outlined the need for a better understanding of the risks for consideration as to whether it should be an area reflected on the Corporate Risk Register.

Governing Body members discussed the contract performance notice in place. Mrs Chivers noted that the IBR stated the contract performance notice was manged informally and sought assurance that all providers are treated equally. Mr Gaunt detailed the monitoring process of contract notices was under review with a view of the ICP Board holding providers to account. He confirmed that the contract notices for stroke with LTHTR had expired, and continued to be monitored by the CCG with the same level of focus until the new way of working was implemented.

Resolved That the Governing Body noted the Integrated Board Report, the improvement actions in place and the proposal to cover A&E services in more detail within the July 2019 report.

CSRGB Financial Performance Report /190724-13 Dr Bangi left the meeting.

Mr Gaunt presented the Financial Performance Report update. The joint report set out the combined financial position for NHS Chorley and South Ribble and NHS Greater Preston CCGs as at 30 June 2019. The report includes the summary financial position, summary I&E, productivity and efficiently (QIPP) and net risks.

The CCGs are forecasting to achieve the planned full-year breakeven position. The year to date position highlights minor variances to plan

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for acute, mental health and community services which are mitigated by utilisation of reserves.

The plan approved by the Governing Body in May 2019 included an assessment of risk and potential mitigations, resulting in a net risk position of £3.7m. As at month 2 the net risk position increased to £4.5m as a result of additional risk associated with mental health and learning disabilities packages of care forecast cost. The net risk position as at the end of month 3 remains at £4.5m.

Resolved That the Governing Body approved the Financial Budget for 2019/20.

CSRGB Governance Update /190724-14 Dr Bangi returned to the meeting.

Mr Gaunt presented an update on Governance. The Governing Body were made aware that 14 out of the 22 member practices that took part in the vote for a merger of Chorley and South Ribble CCG and Greater Preston CCG disagreed. As a result, the Governing Body was asked to consider the following:

• The formation of a joint committee of Governing Bodies • Consider whether to make the role of Vice Chair for NHS Chorley and South Ribble CCG a fixed joint appointment with NHS Greater Preston CCG, or initiate a recruitment process • Continue with a GP Director vacancy, or whether to hold an election for two GP Directors

Mr Gaunt detailed how a Joint Committee could receive items such as the Integrated Board Report, financial updates, and the CCG’s Integrated Business Plan that were currently taken to individual Governing Body meetings. Meeting jointly would increase effectiveness in meeting production and attendance.

Mr Richardson and Mrs Chivers detailed how this worked for other CCG Committees, such as the Audit Committee. Mrs Chivers felt that a joint committee would allow for richer debate with the views of GP Governing Body members.

Governing Body members discussed the decision to progress the election process for two GP Director roles to the Governing Body.

It was agreed that the CCG should go ahead with an election for the vacancy. Mr O’Donoghue noted that in terms of Membership on the OHOC joint committee, it could be detrimental to the process to continue with a vacancy. Mrs Hamilton agreed, she emphasised the need to ensure that clinical contribution to the CCG was not reduced. Mrs Chivers reminded the Governing Body that the constitution

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outlined membership of the Governing Body as five GP Directors.

Mr Gaunt drew attention to the timescale around the process to elect to the Chair of the CCG. Electoral Reform Services (ERS) would deal with the process throughout on behalf of the CCG.

Mr Gaunt detailed the recommendation to make the role of Vice Chair a fixed appointment as outlined in the update. As requested, Mr Richardson provided his reflections to date on acting as Vice Chair for both CCGs in the interim period.

Mr Richardson left the meeting.

Governing Body members discussed the benefits to date of Mr Richardson carrying out the role as Vice Chair for both CCGs, and agreed that the role of Vice Chair should be made a fixed joint appointment for both CCGs.

Mr Richardson returned to the meeting. Dr Bangi informed him of the decision made.

Resolved That the Governing Body approved

• The formation of a joint committee of Governing Bodies • To make the role of Vice Chair for NHS Chorley and South Ribble CCG a fixed joint appointment with NHS Greater Preston CCG • To hold an election for two GP Directors

CSRGB Annual Committee Terms of Reference Review /190724-15 Mr Gaunt presented the annual committee terms of reference review. As part of the review of the CCG’s constitution, all committee terms of reference have been reviewed and updated where necessary. Membership Council and Governing Body meetings do not have terms of reference as they are covered in the constitution.

Following approval by the respective committees, changes to the following terms of reference were presented to the Governing Body for ratification:

• Remuneration Committee • Patient Voice Committee • Audit Committee • Quality and Performance Committee

The Clinical Effectiveness Committee was due to receive its terms of reference for approval at its meeting on 3 July 2019. As that meeting was cancelled, the terms of reference will be brought to be the

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Governing Body in September 2019 to be ratified, after the committee’s next meeting.

The terms of reference for the Primary Care Commissioning Committee and the Our Health Our Care Joint Committee would be presented to the Governing Body in November 2019, in line with the due date for review.

Mr Gaunt drew the Governing Body to the changes made to each of the terms of reference as outlined in the update provided.

In light of the approval of the fixed joint appointment with Greater Preston CCG of the Vice Chair, Governing Body members discussed the need to amend the Quality and Performance Committee terms of reference as the Vice Chair of that Committee should be the Governing Body Nurse and/or Secondary Care Doctor. The quorum for the meeting would be reduced to five members, in light of the same.

Resolved That the Governing Body ratified the following terms of reference:

• Remuneration Committee • Patient Voice Committee • Audit Committee

• Quality and Performance Committee, subject to the required changes discussed above.

CSRGB Policies for Approval /190724-16 Mrs Chivers presented the Risk Management Strategy for approval of the Governing Body, following a review of the same by the Audit Committee.

Mrs Chivers drew Governing Body members’ attention to the update that outlined which sections of the Risk Management Strategy had been updated.

The Information Governance Handbook was also reviewed by the Audit Committee, following which an amendment was made to the change in the name of the Data Protection Officer that is now provided by the Commissioning Support Unit Information Governance Team.

Resolved That the Governing Body approved the Risk Management Strategy, and the change to the name of the Data Protection Officer in the Information Governance Handbook.

CSRGB Audit Committee Update and Minutes /190724-17 Mrs Chivers presented an update report on the work undertaken by the

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Audit Committee at the meeting held on 28 June 2019. The minutes from the meetings held on 3 and 21 May 2019 were presented for information.

The Audit Committee was made aware of contradictions in reporting on the level of opioid prescribing to the CCG’s Governing Body and assurance given. As a result of potential financial and reputational risks for the CCG, it was agreed that it would be added to the Corporate Risk Register. The Audit Committee requested that the Clinical Effectiveness Committee and the Quality and Performance Committee review the same at the respective meetings.

Mrs Chivers referred to the previous update given to the Governing Body around the Single Tender Waiver process. The Audit Committee had received assurance that the process was appropriate and that it had been strengthened by the use of a trigger system when contracts are due to expire.

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

CSRGB Joint Quality and Performance Committee Update and Minutes /190724-18 Mr Richardson presented an update report of the Quality and Performance Committee at its meetings held on 5 June and 10 July 2019. The minutes from the meetings held on 8 May and 12 June 2019 were presented for information.

Mr Richardson informed the Governing Body that the committee had received a joint presentation focusing on Medication Reviews from Lancashire Teaching Hospitals NHS Foundation Trust and Lancashire Care Foundation NHS Trust at its thematic meeting in June. Further, an update was received surrounding the safety issues in the Emergency Department at Royal Preston Hospital, that the Governing Body had been informed of at the previous meeting.

Resolved That the Governing Body noted the update report provided.

CSRGB Primary Care Commissioning Committee Update /190724-19 Mr Richardson presented an update report on the Primary Care Commissioning Committee at its meeting held on 5 June 2019. The minutes from the meeting held on 3 April and 15 May 2019 were presented for information.

Items considered by the committee at its meeting in April included:

• Network DES Registration confirmation • Quarterly contractual of changes

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• Summary of the changes to the Policy Guidance Manual 2019/20 • Proposal to develop a Lancashire and South Cumbria wide approach to practice relocations • Template business case for practice merger applications • Whittle Surgery – proposed continued use of current portakabin premises and associated notional rent • Vice Chair arrangements

Resolved That the Governing Body noted the update report provided.

CSRGB Patient Voice Committee Update and Minutes /190724-20 Mr O’Donoghue presented an update report on the activities of the Patient Voice Committee at its meeting held on 3 July 2019. The minutes from the meeting held on 1 May 2019 were presented for information.

The Patient Voice Committee Annual Effectiveness Report 2019/20 was also presented for information.

Items considered by the committee at the meeting included:

• Equality Delivery System 2019/20 • Patient and Public Involvement Assurance Report • Station Surgery • Committee Annual Effectiveness Report 2019/20 • Our Health Our Care (OHOC) • Deep-dive - Primary Care Networks

Resolved That the Governing Body noted the update report provided.

CSRGB Lancashire Health and Wellbeing Board Minutes /190724-21 The Lancashire Health and Wellbeing Board minutes from 19 March 2019 were presented for information.

Mr Gizzi informed the Governing Body that he had been re-elected as Vice Chair of the Lancashire Health and Wellbeing Board at its meeting held on 23 July 2019.

Resolved That the Governing Body noted Lancashire Health and Wellbeing Board Minutes.

CSRGB Integrated Care Partnership Primary Care Strategy /190724-22 The Integrated Care System (ICS) Primary Care Strategy was presented for information. The strategy had been developed in line with 2019/20 Operational and Contractual Planning Guidance, and Minutes of Previous Meeting NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 31

demonstrated how the priorities in key national documents, including the long term plan and GP Contract Reform etc. will be delivered locally.

In developing the strategy, a system wide task and finish group was established representing all CCGs and local representative committees, such as the LMC and Local Professional Network chairs for Dental, Eye Health and Pharmacy services.

The strategy acknowledges and recognises the pressures faced in primary care, but also highlights the improvements that are already underway due to the coordinated work being progressed by the Lancashire and South Cumbria Integrated Care System.

Resolved That the Governing Body noted the ICS Primary Care Strategy

CSRGB Questions from the public /190724-23 There were no questions from members of the public.

CSRGB Risk Review /190724-24 Governing Body members discussed whether any changes were required to the risks on the GBAF as a result of the discussions had throughout the meeting.

As discussed in CSRGB/190724-7, it was agreed that the Quality and Performance Committee would review the risk scoring of GBAF01.

CSRGB Any other business /190724-25 There was no further business to discuss.

Date, Time and Venue of next meeting: Wednesday 25 September 2019 at 1.30 pm Victoria Room, Farrington Lodge Hotel, Stanifield Lane, Farrington, Lancashire, Preston, PR25 4QR

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

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NHS Chorley and South Ribble CCG Governing Body - Matters Arising

Code Title Lead Status Due Date Comments CSRGB/190724-7 GBAF Director of Quality and September GBAF01 was presented to the Quailty and The Quailty and Performance Committee Performance 2019 Performance Committee and reviewed by members would review GBAF01 at its meeting in at its meeting on 11 September 2019. September 2019.

Item Agenda

Page

Matters Arising NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019

This page is intentionally left blank Agenda Item 6

Governing Body Meeting

Date of meeting 25 September 2019 Title of paper Governing Body Assurance Framework and Corporate Risk Register Presented by Mr Matt Gaunt, Chief Finance and Contracting 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). The risk scoring matrix has also been included at the start of this paper for reference.

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.

In response to movement updates from the executive team and feedback from the last Governing Body, Audit Committee and Quality and Performance Committee, the following changes have been made and are highlighted in red text:

GBAF01 - Quality, Safe and Effective Services - Actions A2 and A7 have been closed as CQC re-inspections have taken place at LTH and LCFT during June. Actions A3 and A10 will monitor these gaps going forward. The headline findings from the LCFT inspection have been included at A10 and we await the outcome of the LTH inspection. - The gap in control regarding opioid prescribing has been kept open and progress updated. - All open actions have been updated.

GBAF02 – Financial Sustainability - The gap regarding QIPP has been expanded to reflect the joint system apprpoach and action A4 has been updated in this regard. - The two open actions have been updated with progress.

GBAF 03 – Well Led - Action A2 is closed as ICS reporting is now in place to the Governing Body.

Governing Body Assurance Framework Update and Corporate Risk Register NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 37 - Action A3 is closed as the Governing Body have agreed to run an election for all vacant GP posts. Action A4 has been opened to account for this. - Action A5 has been added to capture the requirement to produce a 5 year ICP plan to inform the ICS.

GBAF-04 – Integrated Care Partnership (ICP) delivery and accountability - A new gap in assurance has been added regarding the development of a 24 month plan around the future commisioning functions. - A new control has been added regarding the Director of Transformation and Delivery leading the planning and implmentation of the ICPs 5 year strategy. - The action around compliance with SEND legisltaion has been updated to reflect that this is a high risk and therefore will be added separately on the Corporate Risk Register.

Corporate Risk Register (CRR): There are three ongoing risks on the corporate risk register as follows (changes to these risks since the last meeting are highlighted in red text in the appended report):

- 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.

- There is a risk that the CCG has restricted control over Continuing Health Care (CHC) patients in receipt of domiciliary healthcare as the contract framework for these patients is managed by Lancashire County Council. If there are issues which impact on safety and quality with these services the CCG may not be fully aware due to not having a direct contract in place for these patients who receive this care via spot purchase.

- There is a risk that the CCG is not in a position to meet NHSEngland’s requirement to be able to offer Personal Health Budgets to all New Homecare packages from 1st April 2019.

The full risk assessments for the three open corporate risks are 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 changes made to the CRR

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 ☒

Governing Body Assurance Framework Update and Corporate Risk Register NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 38 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

NA

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 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 Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 39

This page is intentionally left blank Appendix B : Risk Matrix

Quantitative Measure of Risk – Consequence Score

Consequence score (severity levels) and examples of descriptors

1 2 3 4 5 Domains Negligible Minor Moderate Major Catastrophic Impact on the safety of Minimal injury Minor injury or Moderate injury Major injury leading Incident leading to patients, staff or public requiring illness, requiring requiring to long-term death (physical/psychological no/minimal minor intervention professional incapacity/disability harm) intervention or intervention Multiple permanent treatment. Requiring time off Requiring time off injuries or work for >3 days Requiring time off work for >14 days irreversible health No time off work work for 4-14 days effects Increase in length Increase in length of of hospital stay by Increase in length hospital stay by >15 An event which 1-3 days of hospital stay by days impacts on a large 4-15 days number of patients Mismanagement of RIDDOR/agency patient care with reportable incident long-term effects

An event which impacts on a small number of patients

Quality/complaints/audit Peripheral Overall treatment Treatment or Non-compliance Totally element of or service service has with national unacceptable level treatment or suboptimal significantly standards with or quality of service reduced significant risk to treatment/service suboptimal Formal complaint effectiveness patients if (stage 1) unresolved Gross failure of Informal Formal complaint patient safety if complaint/inquiry Local resolution (stage 2) complaint Multiple complaints/ findings not acted independent review on Single failure to Local resolution meet internal (with potential to go Low performance Inquest/ombudsman standards to independent rating inquiry review) Minor implications Critical report Gross failure to for patient safety if Repeated failure to meet national unresolved meet internal standards standards Reduced performance rating Major patient safety if unresolved implications if findings are not acted on Human resources/ Short-term low Low staffing level Late delivery of key Uncertain delivery Non-delivery of key organisational staffing level that that reduces the objective/ service of key objective/service development/staffing/ temporarily service quality due to lack of staff objective/service due to lack of staff competence reduces service due to lack of staff quality (< 1 day) Unsafe staffing Ongoing unsafe level or Unsafe staffing level staffing levels or competence (>1 or competence (>5 competence day) days) Loss of several key Low staff morale Loss of key staff staff

Poor staff Very low staff No staff attending attendance for morale mandatory training mandatory/key /key training on an training No staff attending ongoing basis mandatory/ key training

CCG Risk Scoring Matrix NHS Chorley and South Ribble CCG Governing Body meeting 25 September 2019 Page 41 Statutory duty/ No or minimal Breech of statutory Single breech in Enforcement action Multiple breeches in inspections impact or breech legislation statutory duty statutory duty of guidance/ Multiple breeches in statutory duty Reduced Challenging statutory duty Prosecution performance rating external if unresolved recommendations/ Improvement Complete systems improvement notice notices change required

Low performance Zero performance rating rating

Critical report Severely critical report Adverse publicity/ Rumours Local media Local media National media National media reputation coverage – coverage – coverage with <3 coverage with >3 Potential for short-term long-term reduction days service well days service well public concern reduction in public in public confidence below reasonable below reasonable confidence public expectation public expectation. MP concerned Elements of public (questions in the expectation not House) being met Total loss of public confidence Business objectives/ Insignificant cost <5 per cent over 5–10 per cent over Non-compliance Incident leading >25 projects increase/ project budget project budget with national 10–25 per cent over schedule per cent over project budget slippage Schedule slippage Schedule slippage project budget Schedule slippage Schedule slippage Key objectives not Key objectives not met met Finance including Small loss Risk Loss of 0.1–0.25 Loss of 0.25–0.5 Uncertain delivery Non-delivery of key claims of claim remote per cent of budget per cent of budget of key objective/ Loss of objective/Loss of >1 per cent of Claim less than Claim(s) between 0.5–1.0 per cent of budget £10,000 £10,000 and budget £100,000 Failure to meet Claim(s) between specification/ £100,000 and £1 slippage million Loss of contract / Purchasers failing payment by results to pay on time Claim(s) >£1 million Service/business Loss/interruption Loss/interruption Loss/interruption of Loss/interruption of Permanent loss of interruption of >1 hour of >8 hours >1 day >1 week service or facility Environmental impact Minimal or no Minor impact on Moderate impact on Major impact on Catastrophic impact impact on the environment environment environment on environment environment

Qualitative measure of risk – Likelihood score

Likelihood score 1 2 3 4 5 Descriptor Rare Unlikely Possible Likely Almost certain Frequency This will probably Do not expect it to Might happen or Will probably Will undoubtedly How often might never happen/recur happen/recur but it recur occasionally happen/recur but it happen/recur,possi it/does it happen is possible it may do is not a persisting bly frequently so issue

CCG Risk Scoring Matrix NHS Chorley and South Ribble CCG Governing Body meeting 25 September 2019 Page 42

Quantification of the Risk – Risk score

Likelihood

Consequence 1 2 3 4 5 Rare Unlikely Possible Likely Almost certain 5 Catastrophic 5 10 15 20 25 4 Major 4 8 12 16 20 3 Moderate 3 6 9 12 15 2 Minor 2 4 6 8 10 1 Negligible 1 2 3 4 5

CCG Risk Scoring Matrix NHS Chorley and South Ribble CCG Governing Body meeting 25 September 2019 Page 43

This page is intentionally left blank GBAF-01 - Quality, Safe and Effective Risk owner Next review date Current status Current trend Services Helen Curtis 01.10.2019

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

High Tolerance Low Confidence = Do not expend significant effort developing mitigations

Low Tolerance Low Confidence = Earliest possible

actions required to prevent risk rising

High Tolerance High Confidence = Take a balanced

approach to how we expend effort developing

mitigations Low Tolerance High Confidence = Always take all available actions to mitigate risk

Page Page GBAF01

NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019

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

3 3 9 3 3 9 3 2 6

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 are in line with the place which has been to be established to implement 17.10.18 with a continued regulations published by approved by Governing Body system wide reporting and rating of 'requires Department of Health & Social encompassing schemes which monitoring and support improvement'. Improvement Care will deliver better patient delivery of constitutional action plan needs to be experience, meet constitutional standards across the patch. delivered. targets and financial trajectories Action to address: A1 Action to address: A3 Care Quality Commission Integrated Performance and The outputs from the Our (CQC) inspection reports for all Improvement Group in place to Health Our Care sustaibaility providers have provided monitor Integrated Board workstreams are not yet assurance on what is and is Report and organise onward determined not working well. Also reporting to Quality and establishment of an Performance Committee and Action to address: A4 Improvement Board following Governing Body

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latest inspection of Lancashire Teaching Hospitals (LTH) to monitor progress against CQC action plans. Patient experience data as Enhanced PMO function Primary care networks in early measured by friends and following successful stages of development family test informs what is and recruitment to Senior is not working well from patient Programme Manager role to Action to address: A5 perspective. ensure robust management of Integrated Business Plan Trend analysis from complaints Development of internal RTT and 52 week trajectory provides assurance on quality escalation process to raise may not be delivered to Quality and Performance awareness of performance Committee issues to ensure early actions Action to address: A6 are identified Annual review of compliance Serious Incident Review Group LCFT CQC report published against the safeguarding to assess for improvements 23.05.2018 with a rating of assurance framework to when serious incidents have ‘requires improvement’. ensure compliance taken place. Serious incidents Improvement action plan are not closed down until the needs to be delivered. CCG receives confirmation from the Provider that all Action to address: A8 actions within action plan have been completed. Where themes are identified thematic reviews take place at the Quality and Performance Committee Health Watch local intelligence The CCG sends its cardiac reports which are publically patients to Blackpool Victoria available provide external Hospital. A CQC report assurance on key quality published in May 2019 gave a

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measures rating of ‘requires improvement’ for this organisation.

Action to address: A9 Safeguarding Toolkit in place A report has identified that for all providers provides there may be a risk to the CCG assurance on a range of with regards to opioid safeguarding quality prescribing standards. Action to address: A10 Right Care packs give Quality and Performance NTW review of Mental Health benchmarking information Committee monitor outcomes Services identified issues with across the full clinical pathway and performance measures local emergency services. from referral to mortality, against the NHS Outcomes therefore providing more Framework and standards to Action to address: A11 outcome based information, as drive improvement, Provider opposed to just performance dashboards, CQUINS which based data are also built into contracts for Providers, effectiveness, advancing quality, mortality rates, schemes within the Integrated Business Plan and benchmarking All Acute providers, GP Provider recovery plans in It has been reported that the practices and Care Homes place where constitutional number of reported Never have been Care Quality targets are not being met to Events at Lancashire Teaching Commission (CQC) assessed ensure a plan towards delivery Hospitals is greater than Inspection reports have average. provided assurance on what is and is not working well Action to address: A12

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LTH quality risk profile Primary Care Quality Contract completed which has provided in place to ensure key quality a baseline assessment against measures are monitored and Quality and Safety standards delivered Results of NHS England’s A&E Delivery Board Sub Improvement and Assessment Group in place to review Framework gave an overall outputs of Value Stream CCG rating of ‘good’ Analaysis workstreams and associated risks, which are reported to A&E Delivery Board Health economy wide collaborative in relation to harm free care, i.e. falls, React to Red, Care Homes to identify themes and implement prevention methods. Health economy wide C Difficile review panel to identify themes and implement prevention methods. Quality Surveillance Group will identify themes and implement prevention methods. Contract performance notices allow CCG to hold providers to account Quality & Performance Committee members gained updates both in terms of progress and plan to move LTH towards a CQC rating of

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'good'

Our Health Our Care workstreams report updates to the Governing Body at each meeting to ensure that progress can be reviewed

Action plan

Action Due date Assigned to Latest update Status

A1. Through the delivery 01.07.2019 Helen Curtis / Lisa 14.08.2019 Open – current gap in of the shadow Roberts Conversations are still assurance Integrated Care ongoing as to the Partnership (ICP) agree metrics that will be arrangements for adopted at an ICP holding account for Board level to monitor delivery of constitutional system performance targets and to ensure that these are reflective of the partnership as a whole i.e. wider than purely ‘health’ metrics. An update on this will be presented to the ICP Board in October.

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19.06.2019 The ICP Board received a paper outlining a proposed approach to Integrated System Performance Management, presented by Director of Quality & Performance on 23.05.19. The paper detailed the current metrics, including constitutional targets reported on through Aristotle, though limitations were noted in the lack of social care and mental health data currently reported on. Conversations are ongoing with ICS colleagues regarding the addition of further metrics to develop an Aristotle report more reflective of the health and care system as a whole.

The ICP Board approved the recruitment of an ICP Performance Lead, with

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the ICP Senior Leadership Team providing the review/approval route for the job description.

A2. Closely monitor LTH 31.08.2019 Helen Curtis 09.08.2019: Action Closed – merged with recovery plan and closed, plan has been action A3 escalate any concerns continually monitored with delivery until CQC re-ispection has taken place in June. All further actions will be monitored via A3.

14.06.2019: Due date extended from 31.03.2019 to 31.08.2019 to allow for continuing progress of action plan. CQC are currenlty undertaking an unanouced visit at LTH.

A3. Await CQC re- 31.12.2019 Helen Curtis 09.08.2019: Un- Open – current gap in assessment of LTH to annouced visits control gain assurance that the completed and initial recovery action plan has findings shared with addressed all concerns quality team, await outcome of well led inspection to develop

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action plan further.

14.06.2019: action plan continues to progress. CQC are currenlty undertaking an unanouced visit at LTH.

10.05.2019 action plan continues to progress, no date yet confirmed for re-inspection. A4. Governing Body and 30.09.2019 Gora Bangi / Sumantra 09.08.2019: Still Open – current gap in Our Health Our Care Mukerji / Denis Gizzi awaiting senate as per control Joint Committee to dates below. An OHOC review the progress of Development session the workstreams will take place on 14th August 2019 and a Joint Committee on 28th August 2019.

10.05.2019 Clincial senate will meet 16th and 17th September prior to PCBC submission A5. Progress 31.03.2020 Jayne Mellor 09.08.2019 Nine Open – current gap in establishment and networks now agreed, control devlopment of primary work in progress to care networks develop these.

10.05.2019 Networks

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currently being established A6. Manage RTT 30.09.2019 Helen Curtis 09.08.2019 Action Open – current gap in performance itself is complete as control this is ongoing. Action to remain open for monitoring until risk reduces. A Terms Of Reference have been agreed for an ICP wide elective care board chaired by CCG Chief Officer.

14.06. 2019: A separate risk is on the Corporate Risk Register to manage the risks to the CCG regarding RTT and this will be reported to each Governing Body meeting until the risk rating reduces. A full action plan is in place on this risk assessment to mitigate the risk. Action to remain open on the GBAF until the corporate risk rating reduces to <15.

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A7. Lancashire and 31.08.2019 Helen Curtis 09.08.2019: Action Closed – merged with South Cumbria closed, plan has been A8 Oversight Group to continually monitored oversee LCFT CQC until CQC re-ispection action plan has taken place in June. All further actions will be monitored via A8.

14.06.2019: Monitoring of action plan continues.

A8. Await CQC re- 31.12.2019 Helen Curtis 11.09.2019: A letter Open – Current gap in assessment of LCFT to has been received control gain assurance that the with headline findings recovery action plan has from LCFT advising addressed all concerns that the overall rating remains at ‘requires improvement’ with a deterioration to ‘inadequate’ across a number of domains in mental health services. 09.08.2019: Un- annouced visits completed and initial findings shared with quality team, await outcome of inspection to develop action plan

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further.

14.06.2019 action plan continues to progress, no date yet confirmed for re-inspection, although as CQC inspections are taking place in the area it is anticipated that this will be soon. A9. Quality Surveillance 30.09.2019 Helen Curtis 09.08.19: Action Open – current gap in Group (QSG) to monitor complete as control the required CQC monitoring is ongoing. improvements, and Next QSG 29.8.2019, review how the outputs an update will be from this can be provided to QPC. reported into the Quality & Performance 12.07.2019 QSG Committee (QPC) already reviewing the CQC findings. CCG looking into how this can be reported into QPC. Also looking to establish an ICS Quality Board which could capture evidence and report back into individual CCGs. A10. A separate risk to 30.09.2019 Helen Curtis 11.09.2019 Re-audit of Open – current gap in be assessed regarding opioid prescribing will control opioid prescribing to take place in November, after which this gap in

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deduce the level of risk control will be re- for the CCG considered for its level of risk.

09.08.2019 An audit has been conducted twice over the last 2 years. The medicines team are due to re-audit again in the autumn. The audits have shown that there is some prescribing within the CCGs of opioid doses in excess of those recommended by best practice guidelines.

The team have fed back the results to the respective GPs and over the last 2 years provided in practice training. In addition a training session has been delivered at the last PETS session with the MSK consultant and online training is to be made available for locums. A11. LCFT oversight 30.09.2019 Helen Curtis 09.08.2019: Await Open – current gap in group is monitoring the confirmation control outputs from this review regarding how LCFT and the CCG Chief improvements will be Nurse attends. The managed following

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urgent care pathway CQC findings has been the primary focus of the current 12.07.19 CQC CQC inspections. Await assessment is currently outputs from CQC underway inspections to determine further actions A12. The QSG oversees 31.10.2019 Helen Curtis 09.08.2019: Findings Open – current gap in the investigation reports from the CQC control from Serious Incidents. inspection may also A focussed QSG has inform this. taken place regarding Never Events and it was 12.07.19 Await outcome agreed that a of Improvement Board triangulated report submission. would be submitted to the next Central Lancashire Improvement Board Progress 10.05.2019: New GBAF for 2019-20 following feedback from Governing Body Development Session 08.05.2019. 14.06.2019: Risk reviewed. Gaps in controls updated to separate the RTT and CQC risks at LTH; also an additional gap in control has been added regarding LCFT CQC risk. Action plan has also been updated with 3 new actions added (A6, A7 & A8). 12/07/2019: Risk reviewed and updated following Audit Committee and QPC. Additional gaps have been added regarding; - the CQC rating of ‘requires improvement’ being allocated to Blackpool Victoria Hospital whereby the CCG referscardiac patients - A report has identified that there may be a risk to the CCG with regards to opioid prescribing - NTW review of Mental Health Services identified issues with local emergency services - It has been reported that the number of reported Never Events at Lancashire Teaching Hospitals is greater than average New actions have been added in this regard (A9-A12). 09.08.2019: Risk reviewed, a gap in control has been closed regarding opioid prescribing as this is being managed and is not a risk independently. Actions A2 and A7 have been closed as CQC re-inspections have taken place at LTH and LCFT

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during June, we await the outcome of these. All open actions have been updated. 11.09.2019: Risk reviewed following discussion at audit committee regarding a gap in control regarding opioid prescribing being closed. This has been re-opened as a gap and current actions being taken are documented under A10.

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This page is intentionally left blank GBAF-02 - Financial Sustainability Risk owner Next review date Current status Current trend Matt Gaunt 01.10.2019

Risk description Failure to achieve year on year financial sustainability within statutory financial frameworks Risk appetite High Tolerance Low Confidence = Do not expend significant effort developing mitigations

Low Tolerance Low Confidence = Earliest possible actions required to prevent risk rising

High Tolerance High Confidence = Take a balanced approach to how we expend effort developing mitigations Low Tolerance High Confidence = Always take all available actions to mitigate risk

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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 2 8 4 2 8 4 1 4

Existing assurance Existing controls Gaps in assurance Gaps in controls

Grant Thornton have confirmed Clear Governance QIPP for the 19/20 financial year through the Value for Money and decision for the CCG is £14 million, with conclusion that the CCG has proper making process, is identified QIPP of £9.4 million, arrangements to secure economy, in place with clear and unidentified QIPP of £4.6 efficiency and effectiveness. financial million, inclusive of £4.5 million delegations to savings to support Lancashire ensure regulation of Teaching Hospitals (LTH). financial matters. NHSE have directed the CCGs and LTH that QIPP should be managed as a system, and therefore going forward this will be reported as a £20 million gap reflective of the partnership.

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NHS England have assured the CCG The Primary Care as 'green' for financial arrangements Commissioning through the CCG improvement and Committee has a assessment framework (CCG IAF). role to sign off Primary Care investment proposals and strategy to ensure such proposals are future proof and support financial sustainability. Head of Internal Audit Opinion is Financial forecasts ‘significant assurance with minor are prepared improvement opportunitites’. This is quarterly and based on the overall adequacy and included within effectiveness of the organisation’s regular reported framework of governance, risk updates to the CCG management and control’. Governing Body to ensure Board oversight and early warning of financial position. In addition a monthly review of financial risks and opportunities supplements the quarterly forecasting review to ensure early identification of threats to delivery and associated

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mitigating actions.

The CCG has a well established programme management process to ensure that financial improvement and transformation schemes are properly resourced and managers and clinicians involved in their delivery are held to account to ensure the CCG meets its QIPP target. This has been strengthened through the recruitment of clinical advisors to supplement GP Director capacity. The financial position is reported bi-monthly to the Governing Body, and every month to the Quality and Performance Committee to Page Page

GBAF 02 NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019

ensure Committee and Board oversight and early warning of financial position. ICP finance workshop taken place to agree ways to link all providers into the ICP finance plan which has improved visibility of susatinability issues Process in place as part of operational plan to ensure no financial over estimates (A2) Planning process ensures that cost saving schemes that require a contractual mechanism to support delivery is built into planning process (A3) Action plan

Action Due date Assigned to Latest update Status

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GBAF 02 NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019

A1. Monitor Lancashire 31.03.2020 Matt Gaunt 14.08.2019 The ICP Open – current gap in Tecahing Hospitals against failed to meet the control agreed mitigation action plan control total for the following the allocation of £4.5 first quarter, however million the ICP expects to meet its control total in quarter 2 and thus will trigger payment of the first 2 quarters of the CCG support package.

14.06.2019 Action plan continues to be monitored. A new action (A4) has also been added to support this.

10.05.2019: The Governing Body have agreed to allocate the £4.5 million, the mitigation action plan has been agreed. This will now be monitored and reported. A2. Review process for 31.03.2019 Matt Gaunt 10.05.2019 operational Closed – now a control financial estimates of scheme plan approved at Part 2 mechanism delivery to ensure no over Governing Body March estimates going forward 2019 A3. Review planning process 31.03.2019 Matt Gaunt 10.05.2019 operational Closed – now a control to ensure that cost saving plan approved at Part 2 mechanism schemes that require a Governing Body March contractual mechanism to 2019

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support delivery is built into planning process. A4. The CCG and LTH 31.12.2019 Matt Gaunt 23.08.2019 driving cost Open – current gap in executive teams with their reduction whilst control clinical leaders, to develop maintaining quality will service improvements now be reported jointly designed to improve quality between the system while driving cost reduction. with a current gap of £20 million. The CCGs and LTH are required to submit a plan to NHSE by 13th Sep regarding how this will be mitigated.

14.06.2019 Chief Finance & Contracting Officer and Commisioning Delivery Manager presented opportunities for LTH service changes at their Medical Leadership Development Day on 13.06.19. LTH executives commited to releasing senior clinicians to joint working groups with the CCG to develop service change options

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Progress

10.05.2019: New GBAF for 2019-20 following feedback from Governing Body Development Session 08.05.2019. 14.06.2019: Risk reviewed. Control around Head of Internal Audit Opinion has been updated to reflect the 2018/19 opinion given by the CCGs internal auditors. The gap in control regarding QIPP has been updated to reflect the value of the full gap. The risk rating was considered in light of the QIPP gap, however has remained the same with no increase in likelihood as despite the risks associated plans are in place to mitigate these which are progressing, and options for identifying savings have not been exhausted. An additional action has been added in this regard. 14.08.2019: Risk updated. The gap regarding QIPP has been expanded to reflect the joint system approach and action A4 has been updated in this regard. The two open actions have been updated with progress.

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GBAF-03 – Well Led Risk owner Next review date Current status Current trend Denis Gizzi 01.10.2019 Risk description Failure to take a lead role in the Central Lancashire health system due to difference in objectives across the Integrated Care System, insufficient capacity and capability or misdirected resources Risk appetite High Tolerance Low Confidence = Do not expend significant effort developing mitigations

Low Tolerance Low Confidence = Earliest possible actions required to prevent risk rising

High Tolerance High Confidence = Take a balanced approach to how we expend effort developing mitigations Low Tolerance High Confidence = Always take all available actions to mitigate risk

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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 3 12 4 2 8

Existing assurance Existing controls Gaps in assurance Gaps in controls

NHS England have assured the The CCG has The CCG staff are not clear how The Integared Care System has CCG as 'good' through the CCG initiated the their role and objectives are aligned different objectives to just the improvement and assessment creation of an with the ICP agenda, and their Central Lancashire CCGs framework (CCG IAF), with Integrated Care particular skill sets are used to best quality of leadership rated as Partnership and the effect. Action to address: A5 'green'. ICP Board has agreed terms of Action to address: A1 Reduced clinical input at the reference , Quality & Performance Committee governance due to GP Director vacancies process and started to agree priorities. Action to address: A4 This evidences that the CCG is progressing system wide transformation

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which is vital to lead the organistion into a sustainable health economy. Assurance has been identified The CCG with strong staff engagement, leadership team with the annual staff survey has well defined evidencing that 87% feel they objectives and the are equipped to do their job resources in place effectively. The possitive to deliver them. feedback from the staff survery Clinical leadership provides assurance that has been leadership is strong as the staff strengthened morale is relatively high. through the recruitment of GP advisors. CCG assessment framework All committee terms moved from 'requires of reference have improvement' to 'good' in several been reviewed to areas ensure all are fit for purpose and able to deliver CCG business which will enable the organisation to evidence that it is well led. Mandatory training package is in place for all staff and monitored to ensure complted. This enables staff

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to have adequate knowledge to deliver on core elements of their roles. Declarations of interest are maintained annualy, it has been agreed that any Governing Body member who has failed to provide an update will be barred from participating in committee meetings. This is to ensure that all CCG business is done within statutory guidance and all CCG decisions are made with high probity. The ICS commissioning framework has been agreed and clarifies the interdependency between ICS, Locality and

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neighbourhood. This provides the CCG with a structure to develop system wide transformation to ensure a sustaible health economy. Regular joint Governing Body Development Sessions taking place to ensure that Governing Body members are engaged with the OHOC programme and contributing to its’ outputs. Staff engagement via development day and monthly team brief updates to maintain high staff morale and ellviate uncertainty where possible during a time of transformational change Updated Primary Care Commissioning

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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 OHOC Joint Committee established to facilitate a jointly lead sustainable secondary care programme that is aligned to the Lancashire and South Cumbria Integrated Care System acute reconfiguration programme. OHOC risk register in place to mitigate the risks identified to the delivery of the OHOC programme Mechanisms are in place to keep the Governing Body updated on

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outputs from the ICS (A2) Action plan

Action Due date Assigned to Latest update Status

A1. Scope staff 01.12.2019 Denis Gizzi 09.08.2019: The outputs Open – current gap in engagement materials from the direct reports assurance from local organisations session have been to implement a 'job1/job2' shared with all staff. approach This will include a weekly staff update on the IBP meeting and a bi-monthly update on Governing Body meetings. The refreshed IBP meeting launched 09.09.2019 which will integrate the CCG and ICP schemes within the IBP to make clearer the ‘job1/job2’ apporach.

10.07.2019: a direct reports session took place off site on 05.07.2019 to give staff the opportunity to discuss better ways of working and how each

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team can support each other with an action plan developed with key outputs.

12.06.2019: staff feedback has been presented via Team Brief updates along with culture of care beromoter feedback. Staff survey is currently open for responses which will add to this feedback. Each directorate will then produce a response for how this feedback will be utilised.

06.02.2019: Ongoing – awaiting outcome of staff away day 13.02.2019, feedback is currently being collated via survey monkey A2. Scope how the CCG 01.12.2019 Denis Gizzi 09.08.2019: The CCG Closed – now a control can further enable the has supported a review mechanism Integrated Care System of the Terms Of to report into the CCG to Reference for the enable the objectives to JCCCGs.The become more alligned Governing Body has agreed that any specific updates from

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JCCCG would go in the chair’s updates as appropriate.

12.06.2019: The ICP Board development session in August will support this. In addition the primary care strategy as approved by the ICS Board will be included in the Governing Body papers in July, and this such reporting of ICS movements will continue to be reported to the CCG Governing Bodies via the standing agenda item.

10.05.2019 in progress A3. Develop a plan to 31.07.2019 Matt Gaunt 09.08.2019 Plan Closed – now forms review Governing Body reviewed by Governing action A4 vacancies Body. Agreed to run an election for all GP Board vacancies.

10.07.2019 a plan has been developed and shared with MET 04/07/2019. The Governing Body will be provided with an

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elections update at the July meetings for consideration on next steps. A4. Recruit to all 30.09.2019 Matt Gaunt 09.08.2019 Election Open – current gap in Governing Body process in progress for control Vacancies all vacancies with ERS. However the elections will still leave the Chorley and Southn Ribble Governing Body with a vacancy issue. This will be considered at the September Governing Body meeting. A5. Await ICP 5 year 31.12.2019 Denis Gizzi 09.08.2019 ICP plan is Open – current gap in plan which will then being drafted with control inform the ICS 5 year partners plan Progress

10.05.2019: New GBAF for 2019-20 following feedback from Governing Body Development Session 08.05.2019. 12.06.2019: Risk reviewed and actions updated. Additional gap in control has been added regarding gaps in GP director vacancies. 10/07/2019: Risk updated to reflect progression of a plan regarding Governing Body vacancies for consideration at the Governing Body meetings in July. 09.08.2019: Risk reviewed. Action A2 is closed as ICS reporting is now in place to the Governing Body. Action A3 is closed as the Governing Body have agreed to run an election for all vacant GP posts, action A4 has been opened to account for this. Action A5 has been added to capture the requirement to produce a 5 year ICP plan to inform the ICS. 11.09.2019: Further update made to action A4 following Audit Committee discussions, to illustrate that despite the progression of elections for Chorley and South Ribble CCG there will still be a vacancy issue. This will be considered at the September Governing Body meeting.

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This page is intentionally left blank GBAF-04 – Integrated Care Partnership (ICP) Risk owner Next review date Current status Current trend delivery and accountability Jayne Mellor 01.10.2019

Risk description Due to system leadership failures within ICP, ICS, NHS, the CCGs may fail to meet statutory responsibilities Risk appetite High Tolerance Low Confidence = Do not expend significant effort developing mitigations

Low Tolerance Low Confidence = Earliest possible actions required to prevent risk rising

High Tolerance High Confidence = Take a balanced approach to how we expend effort developing mitigations Low Tolerance High Confidence = Always take all available actions to mitigate risk

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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

5 2 10 5 2 10 5 1 5

Existing assurance Existing controls Gaps in assurance Gaps in controls

Link with the Integrated Board Milestones and key processes Lack of defined commissioning Compliance with Special Report (IBR) is now in place have been set for the ICP to responsibilities between ICS Educational Needs and which triangulates enable us to produce plans and ICP Disabilities (SEND) legislation information relating to plan, which have been supported by needs to be assessed performance and finance to all partners (Out of Hospital Action to address: A1 give overall picture of delivery and Urgent and Emergency Action to address: A3 of integrated business plan Care) and are therefore which is a key contributor to appropriate for delivery across system transformation the patch. ICP Programme Board in place ICS agreed via accountable to support delivery. ToR officers group to draft a agreed with appropriate detailed narrative of a 24 representation from partners month plan around the including Primary Care to future commisioning ensure system wide functions supported by a

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representation and oversight. timeline road map

Action to address: A4

Engagement events taking place regarding acute sustainability and new models of care to ensure all transformational plans have incorporated all partners in order for plans to be fit for purpose in line with the transformational methodology approved by the ICP. OHOC Joint Committee established to facilitate a jointly lead sustainable secondary care programme that is aligned to the Lancashire and South Cumbria Integrated Care System acute reconfiguration programme. Governance structure and scheme of delegation approved for Lancashire and South Cumbria Change Programme to facilitate decision making to progress the programme. Integrated Business Plan in place detailing a series of schemes local delivery which

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will contribute to CCG QIPP target. Plan has been approved by Governing Body to ensure senior oversight of plan. Work stream leads in place for each scheme on all plans to facilitate delivery and all schemes are contractually tied with providers. Senior membership at Joint Committee of CCGs and on the Lancashire and South Cumbria Programme Board to ensure decisions are made and that business is progressed. The CCG has initiated the creation of an Integrated Care Partnership and the ICP Board has agreed terms of reference, governance process and started to agree priorities. This evidences that the CCG is progressing system wide transformation. Out of Hospital Strategy agreed and in place to support transformation in primary care, to ensure a balanced focus across sectors. A&E Delivery Board in place to oversee system stability. Associated sub group is in

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place with Programme Management Office support to review outputs of Value Stream Analaysis workstreams and associated risks, which are reported to A&E Delivery Board. ICP representation on all ICS Commissioning Development Work streams to ensure that Central Lancashire transformation developments are in line with Lancashire and South Cumbria. Performance measures with targets for improvement for all schemes on all plans to monitor delivery. Commissioning programme support in place to work and support ICS Director of Commissioning - to define process for agreeing commissioning framework at ICS/ICP level. Head of Primary Care and Head of Urgent Care now linked into ICS commissioning framework, which will help to alleviate the lack of defined commissioning responsibilities between ICS and ICP.

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Scheduled engagement events have now been completed to ensure system wide contribution to transformation. Primary Care transformation is progressing with all practices now signed up to 7 day access and the establishment of integrated care teams. Wellbeing and Health in Integrated Neighbourhoods (WHIN) Board in place to oversee this strategic platform of the ICP with a detailed driver diagram and associated action plan approved. Published 10 year plan to enable the CCG to form long term transformation plans. Out of hospital and Acute reconfiguration programme groups established which will report to a Joint Clinical Oversight Group (COG) to oversee acute sustainability and new models of care. 6 platforms agreed and leads identified to ensure delivery. Agreed system control total

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Approved transformation cycle

ICP reporting into the Governing Body at every meeting via standard agenda item to ensure all outputs from the ICP are linked into the CCGs. Proposed revision of ICP Board Terms of Reference is underway. This will be supported by a revised sub- committee structure that will deal with and address cross organisation operational matters allowing more capacity at ICP to focus on strategic subject matters. Director of Transformation and Delivery is leading the planning and implmentation of the ICPs 5 year strategy Action plan

Action Due date Assigned to Latest update Status

A1. ICP Board to 31.08.2019 Denis Gizzi 01.08.2019: Awaiting Open – Current gap in develop an integrated outcome of ICP assurance strategic plan development session and risk will be updated with outputs.

Page Page GBAF 04 NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019

Risk due date extended from 31.7.19 to 31.8.19 to allow for this to take place

12.06.2019: An ICP development session is planned for 15th August. The session will focus on: -Vision -Aims -Values -ICS strategic intentions -ICP strategic platform -Tranformational methodology -priorities for 2020/21 and beyond

10.05.2019: work in progress A2. Restructure of ICP 30.06.2019 Jayne Mellor 12.06.2019: This action Closed – control Board to ensure the ICP has been completed mechanism Board can focus on the and a diagram top priorities and utilise developed to highlight proposed sub groups for which content is for support on more each meeting feeding operational content into the ICP Board A3. Compliance with 30.09.2019 Jayne Mellor 01/08/2019: First Open – current gap in Special Educational systems board control Needs and Disabilities meeting took place (SEND) legislation 31.7.19, discussed

Page Page GBAF 04 NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019

needs to be assessed SEND and pending re- inspection of LCC in next few weeks – group upated on 12 reccomendations and potential risks from re- inspection. Due to the level of risk this will feature as a separate risk on the corporate risk register. A4. A detailed 01.11.2019 Denis Gizzi 01/08/2019 ICS agreed Open – current gap in narrative of a 24 via accountable assurance month plan around the officers group to draft future commisioning this functions supported by a timeline road map to be developed

Progress 10.05.2019: New GBAF for 2019-20 following feedback from Governing Body Development Session 08.05.2019. 12.06.2019: Risk reviewed and updated. The ICP development session in August will dictate further actions for the action plan. 10.07.2019: Additional gap in control added regarding SEND 01.08.2019: A new gap in assurance has been added regarding the development of a 24 month plan around the future commisioning functions. A new control has been added regarding the Director of Transformation and Delivery leading the planning and implmentation of the ICPs 5 year strategy. The action around compliance with SEND legisltaion has been updated to reflect that this is a high risk and therefore will be added separately on the Corporate Risk Register.

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This page is intentionally left blank Corporate Risk Register

Next Current Risk Direction Review RAG Owner of Travel ORR 01 Referral to Treatment Date Status

Helen 01.09.2019 Curtis

Original Risk Current Risk Target Risk Likelihoo Moveme Target Impact Rating Impact Likelihood Rating Impact Likelihood Rating d nt Date 31-Dec- 4 4 16 4 4 16 4 3 12 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.

Existing Assurance Existing Controls Gaps in Assurance Gaps in Controls - 36+ week file received - Recovery action plan - RCAs for 52 week - Lack of defined on a weekly basis from - Contractual framework breaches are measures LTH which provides – contract performance usually late – we particularly around detailed insight into notice in place have not had efficiency, for movement on waiting - Demand management RCAs for the example theatre lists and an indication schemes recent breaches utilisation, and of RTT delivery - Deep dive analysis into for a number of clinic start times - Weekly Patient referrals and activity months (ORR 01 (ORR 01 02) Tracking List which - Fortnightly steering 09) - The ‘Four Eyes’ provides a view on the group meetings with - No efficiency work was focused number of open LTH measures have on surgery, pathways - Monthly operational yet been agreed whereas the main - Root Cause Analysis and contract Board between CCG and issue with capacity completed for every meetings Trust.(ORR 01 07) is around patient who breaches - Integrated Board - Escalation route outpatients. The 52 weeks, to date there Report which provides of concerns to be Outpatient has been no evidence oversight of RTT agreed to ensure Programme Board of harm identified trajectories and mitigation against have looked at - ‘Four Eyes’ review now mitigating actions this risk continues ways to apply the complete and provided - Weekly Management (ORR 01 02). ‘Four Eyes’ assurance on capacity Executive Team report findings to in surgery.( ORR 01 tracking open pathways outpatients, and a 01) - RTT position presented number of - Position clarified weekly to ‘Integrated schemes are regarding the 4000 Business Plan Weekly planned including open pathways Update Meeting’ paperless identified from the - Remedial Action Plan systems, placing IMSK service - the in place (ORR 01 03) forms within clinics CCG is now achieving - CCG representation at to monitor the pathways target. Outpatient efficiency (ORR 01 05) Transformation Board measures such as (ORR 01 08) start / stop times - CCG now receiving and utilisation information showing at (ORR 01 07). specialty level where - LTH not currently pathways are still high meeting RTT and still experiencing target (ORR 01 52 week breaches 04)

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(ORR 01 06). - The position on pathways at LTH is deteriorating significantly due to the Consultants pensions issue. LTH report a rise of nearly 3000 pathways since the beginning of the year (ORR 01 04) - ‘In-month’ data shows 52 week breaches are still occurring, however this is now down to 5 in mid August – the Trust were aiming for 0 by end June so this is over compliance date.(ORR 01 04)

Assigned Action Due Date Latest Update Status To 05.04.19 ‘Four Eyes’ work complete. Although this did focus on surgery, therefore schemes to be ORR 01 01 Receive outcome of ‘Four 31-Mar- Glenn developed for outpatients Complete eyes’ review into theatre utilisation 2019 Mather from these findings. A new action has been opened in this regard.

14.08.19 Escalation route of concerns to be agreed to ensure mitigation against this risk continues

12.07.19 RTT steering group raised that this is still a gap and that we would be escalating this as part of the failure to ORR 01 02 Agree efficiency measures 14-Apr- Glenn recover. Therefore action In with LTH in order to instil oversight and 2019 Mather has not met due date but progress scrutiny of efficiency of elective services this is being monitored. This has been discussed at both the Operational Contract meeting for the Trust and the Joint ICP Executive Review meeting.

17.06.19 Efficiency measures still not agreed

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with the Trust. Report written for escalation within the CCG. 06.02.18 action plan is in place and has been received by the CCG and will continue to be ORR 01 03 Receive updated Remedial 30-Nov- Sam monitored. There are Complete Action Plan 2018 James some specialty specific risks within this action plan, therefore a new action has been added regarding this. 14.08.19 Escalation route of concerns to be agreed to ensure mitigation against this risk continues. The national pensions

issue is contributing to this risk. There were some

changes made to the pension arrangements which means that consultants (or any clinician or manager) earning over a certain amount will be penalised for doing extra sessions. The Trust is

reliant on doctors doing extra sessions to keep

services running and keep capacity up to the levels needed; this is impacting on waiting lists and 28-Feb- Glenn In ORR 01 04 Review Remedial Action Plan targets. 2019 Mather progress 12.07.19. Action has reached compliance date and still not achieving. This was raised at the RTT steering group where it was agreed that this would be escalated. Therefore action has not met due date but this is being monitored. This has been discussed at both the Operational Contract meeting for the Trust and the Joint ICP Executive Review meeting.

17.06.19 RAP has reached compliance end date and 52 week breaches and pathways still underachieving.

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Report written for escalation within the CCG Complete, March 18 submitted figures have ORR 01 05 Determine if the IMSK open 28-Feb- Glenn been amended, and the Complete pathways will affect the year end position 2019 Mather CCG is now achieving the pathways target, however LTHTR still failing. 12.07.19. Action complete. CCG has now been sent ORR 01 06 End of year weekly data this information by LTH shows non-compliance against both showing at specialty level pathways and 52 week targets – CCG to 09-Apr- Glenn where pathways are still Complete receive confirmation from LTH that there 2019 Mather high and still experiencing is no compliance, including data showing 52 week breaches. specialty level pathways v trajectory. 17.06.19 both targets still not compliant 14.08.19 CCG representatives are now attending the outpatient programme Board which is providing an opportunity

for CCG input into scheme and action plan

development.

Glenn 12.07.19 CCG Mather representatives have been given an invite to attend the LTH outpatient ORR 01 07 Outpatient Programme Board programme board. This to implement schemes identified from the will give the opportunity to ‘Four Eyes’ findings to outpatients. These 30-May- gain assurance on this In include paperless systems, placing forms 2019 action. Therefore action progress within clinics to monitor efficiency has not met due date but measures such as start / stop times and this is being monitored. utilisation. 17.06.19 still no efficiency measures agreed escalation in progress.

04.04.19 new action added for monitoring. The breaches in ENT have been compounded by a consultant being off sick, who has now returned but the department still working through backlog. Glenn 12.07.19 this can be Mather undertaken via CCG attendance at Outpatient ORR 01 08 Trust to accelerate the 30-May- Programme Board which Complete Outpatient Transformation Programme. 2019 has now been agreed.

04.04.19 new action

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added for monitoring Glenn 12.07.19 Action complete. Mather This is being escalated through the contract meetings, and raised further with one of the Clinical Business ORR 01 09 CCG to escalate that RCAs 30-Jun- Managers. This will for 52 week breaches are usually late Complete 2019 remain as a gap in assurance until these continually are submitted as per given timeframe.

17/06/19 escalation in progress

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Next Current Directio Risk Review RAG n of Owner ORR 02 Quality contracts for domiciliary care Date Status Travel Helen 01.09.2019 Curtis

Original Risk Current Risk Target Risk Likelihoo Moveme Target Impact Rating Impact Likelihood Rating Impact Likelihood Rating d nt Date 31-Dec- 4 4 16 4 4 16 4 3 12 2019

Risk description The CCG has restricted control over Continuing Health Care patients in receipt of domiciliary healthcare as the contract framework for these patients is managed by Lancashire County Council. If there are safety and quality issues with these providers the CCG may not be fully aware, due to not having a direct contract in place for patients who receive care via spot purchase arrangements.

Existing Assurance Existing Controls Gaps in Assurance Gaps in Controls - Intelligence available - Domiciliary Care - No obligation for - A robust patient from Local Authority RADAR model has Providers to pathway is where there are been developed across submit quality required as safeguarding alerts Lancashire to identify data returns to the outlined in the raised issues CSU or to provide DOH National - All providers of CHC - Where an incident for assurance to Framework for care have to be these patients hits a Commissioners Continuing registered on a safeguarding threshold due to the CCG Healthcare and providers framework the CCG safeguarding not directly Funded nursing which is subject to team are made aware contracting this care framework regulation either by the Local service (action 01) 2018 is currently Authority or CSU - Limited resource not being adhered - LCC have given the available to to – this stipulates CCG a thorough provide the the need to assess update on the ongoing review of patients after the governance packages from the first 3 months and arrangements in place complex cases annually there- (action 03) team. (action 02) after. (action 02)

Assigned Action Due Date Latest Update Status To 14/08/019 First review of the provider returns has been undertaken by the CSU. 01 Quality based reporting system to be KPIs which were originally rolled out to all domiciliary providers to Jane In 01/05/19 requested to be included enable commissioners to have early sight Brenan progress for quality monitoring are of any quality issues within this service not reflective of the system. Urgent meeting took place this week to review the data alongside

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the service specification and contract. Further meeting to be held with ADAM to rectify the problem as this is also causing concerns for the providers. Quality monitoring within the domiciliary sector remains an area of concern and has been raised again by myself at the IPA steering group .Radar remains in place for this sector and monitoring of any information we may receive adhoc.

12/07/2019 – no change from June update, still progressing but with delay. This is being managed via the IPA programme board and CSU. By Nov 2019 the IPA Programme Board will be receiving a first draft service delivery proposal which will feature best practice from the CHC Maturity Framework and there is reference to Market Management and Contracts. Also the RADAR multiagency meetings include Domiciliary care provision, CSU/Operational processes for care brokerage, and take into consideration certain quality markers when placing, if package changes requested.

14/06/2019 – there has been a delay in mobilisation due to issues with the licence agreements. These have recently been reissued to CCGs and signed and returned to LA. Mobilisation to re- commence however Domiciliary providers potentially will be on wave 2 of the plan.

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The issue of reduced quality monitoring amongst domiciliary providers has been raised via the IPA Board and steering group along with being raised at the HL Regulated care quality sub group. This is an ICS concern and gap, with planning in progress via the CSU to mitigate the risks.

14/08/2019 Meeting took place to review QP data which has taken a backwards turn a number of nursing vacant posts for

the Central area, and little/no resilience in the

team. With that in mind, a further meeting has been arranged to rectify the position. 2 out of the four QP targets where achieved with improvement noted in the other two.

15/07/19 There is some long term sickness in the

CSU team and 2 nurse 02 Support the CSU CHC team to work assessors finished at the effectively and how to utilise the staff they end of June and these have in place, in order for them to be have not been replaced. productive and work in the most efficient Emma In 31/12/19 Instead, 2 new fixed term way. Assist CHC CSU team to do this by Orton progress posts have been created establishing good working relationships, and 2 individuals have support and advice on service delivery been recruited into these and staff resourcing. roles. However, these nurses are yet to start and this gap is impacting on the data. Regular assurance biweekly meetings continue between the CHC Lead and CSU Lead.

16/06/19 There has been further recruitment into the CSU CHC team and a new CHC Lead band 8a is now in post along with a further permanent band 6 nurse assessor. Regular assurance biweekly meetings continue between the CHC Lead

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and CSU Lead. Forecasts presented to NHSE have changed and now reflect forecasts on a ICS footprint for Q1-Q419/20 Full scheduling is now in place at the CSU which has increased productivity. As part of the ISC work the CHC Lead is involved with, includes looking in more detail at workforce development. Due date moved from 30.04.19 as action in this regard has been taken by this date, but further work continues therefore due date extended to continue to monitor this.

14/06/2019 LCC have sent an update providing assurance evidence of the local mitigating actions taken.

LCC follow the ‘Adult

Social Care Policy and Procedure for Managing Service Provider Quality and Performance in Commissioned Services’. LCC has a Homecare Framework of approved/accredited

providers of whom it will approach to deliver the 03 CCG to review if more local actions domiciliary care need to be put in place to protect our Helen 30/04/19 requirements of Complete patients rather than wait for actions to Curtis Lancashire funded service progress across the ICS footprint users within the OP/PD/LD/A/MH categories. The contract is proactively managed by the Contracts team and providers are required to submit data against the KPI criteria identified within the contract and specification. The contracts team have regular contact with providers and aims to meet on a quarterly basis.

In terms of knowledge of and dealing with

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qualitative issues, LCC also attend the monthly RADAR meeting, and have access to the MASH spreadsheet for review. They also log intelligence received regarding service provision (i.e. complaints, issues, queries etc) and identify and take proportionate and necessary action. They will utilise Information Sharing Protocol Principles to share certain information of concern.

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Next Current Directio Risk Review RAG n of Owner ORR 03 Personal Health Budgets Date Status Travel Helen 01.09.2019 Curtis

Original Risk Current Risk Target Risk Likelihoo Moveme Target Impact Rating Impact Likelihood Rating Impact Likelihood Rating d nt Date 31-Dec- 4 4 16 4 4 16 4 2 8 2019

Risk description There is a risk that the CCG is not in a position to meet NHS England’s requirement to be able to offer Personal Health Budgets to all New Homecare packages from 1st April 2019. This poses a reputational risk to the CCGs that we will not meet this target. Existing Assurance Existing Controls Gaps in Assurance Gaps in Controls - There has been an - CHC/IPA deep dive - Awaiting outcome recent agreement from meeting in place to from Patient Data all CCG’s to fund the oversee all CHC Impact CSU for a period of 6 actions. The group Assessment to set months to carry on the meets every 2-3 weeks up legal work required around and has senior framework to processes for PHB to attendance from the enable direct ensure that these are Chief Finance and payments to be offered s outlined from Contracting Officer and made to patients NHS England. Director of Quality and for PHBs (action However, how this Performance. 01) going to look in practice - Patient Data Impact - There are in terms of resource Assessment completed currently no made available from to enable CCG to make designated CCG the CSU to carry this direct payments staff to work on forward does require - Contract template in PHBs (action 02) further discussion. place to be used - There is currently between CCG and no process in - There is also a task patient when a PHB is place to ensure and finish group that implemented that 3 monthly and has been set up as part - A paper regarding 12 monthly of the wider ICS work progress with CHC has reviews and audits which we be looking at been submitted to the are being PHB’s in depth and Quality & Performance undertaken to considering options for Committee in July ensure PHBs are their on-going delivery, 2019. fit for patient need whether this be from and being spent CSU, integration with appopriately the local authority, or (action 03) be hosted by CCG - Service themselves. This will specification th commence on 16 May needed to outline

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and will meet every 3 how the process weeks for a period of 6 for a PHB will be months. followed (action 04) - Quarterly assurance - All CCGs across template reported to Lancashire to NHS England (action agree on a service 05) option as presented by the Commisioning Support Unit (action 06)

Assigned Action Due Date Latest Update Status To 01. Awaiting outcome from Patient 30/04/19 Emma 21.08.19 will be raised at Data Impact Assessment to set Orton, next task and finish group. up legal framework to enable CHC In direct payments to be made to Lead 04.04.19 new action progress patients for PHBs added for monitoring

02. Options review to be undertaken 31/10/19 Emma 21.08.19 There was a to assess the development Orton, discussion following the needed for current staff in the CHC IPA programme board area of PHBs to assign specific Lead 8/8/19 regarding the staff to this remit who can process options going forward, and I believe 2 or 3 have been ongoing PHB payments selected to be fully worked up into business cases, these are for the whole CHC end to end process which includes PHBs In 16.04.19 This is now progress forming the work of the PHB task and Finish group set up as part of the work going on at ICS level. Update to be provided in report to IPA Delivery group and Programme Board in October 19. Due date extended from 30.04.19 to account for this. 03. Implement a process to ensure 31/10/19 Emma 16.04.19 This is now that 3 monthly and 12 monthly Orton, forming the work of the reviews and audits are being CHC PHB task and Finish undertaken to ensure PHBs are fit Lead group set up as part of the for patient need and being spent work going on at ICS In appopriately level. Update to be provided in report to IPA progress Delivery group and Programme Board in October 19. Due date extended from 31.08.19 to

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account for this.

04. Design a service specification to 31/10/19 Emma 21.08.19 will be raised at outline how the process for a PHB Orton, next task and finish group will be followed CHC Lead 16.04.19 This is now forming the work of the PHB task and Finish group set up as part of the In work going on at ICS progress level. Update to be provided in report to IPA Delivery group and Programme Board in October 19. Due date extended from 31.08.19 to account for this. 05. Submit quarterly assurance 01/04/19 Emma 15.07.19 action complete template to NHS England to gain Orton, these submissions are in external assurance on the CHC place. Complete processes implemented for PHBs. Lead 04.04.19 new action added for monitoring

06. All CCGs across Lancashire to 31/10/19 Denis 21/08/19 awaiting for a agree on a service option as Gizzi, paper from MLCSU presented by the Commisioning Chief regarding the proposal Support Unit Officer post 6 months, and the task and finish group st haven’t met since 1 July as the last meeting was cancelled due to holidays, will be explored at next meeting.

In 16.04.19 This is now progress forming the work of the PHB task and Finish group set up as part of the work going on at ICS level. Update to be provided in report to IPA Delivery group and Programme Board in October 19. Due date extended from 30.04.19 to account for this.

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This page is intentionally left blank Agenda Item 7

Governing Body Meeting

Date of meeting 25 September 2019 Title of paper Integrated Care System Update Presented by Mr Denis Gizzi Author Integrated Care System’s Communications Team Clinical lead N/A Confidential No

Purpose of the paper The paper is presented to the Governing Body as an update on Lancashire and South Cumbria Integrated Care System.

Executive summary

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

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

Were any conflicts of interest identified at previous meetings

Integrated Care System Update NHS Chorley and South Ribble CCG Governing Body Meeting Page 105 Wednesday 25 September 2019 (mark X in the correct box below) Yes No

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

Integrated Care System Update NHS Chorley and South Ribble CCG Governing Body Meeting Page 106 Wednesday 25 September 2019

Healthier Lancashire and South Cumbria Integrated Care System (ICS) Monthly Programme Management Office (PMO) Briefing

Jul 2019

Version 1.0

Page 107

Contents

Section Title

1. Briefing Purpose 2. ICS Board Key Messages 3. ICS Executive Summary 4. ICS PMO Overview 5. ICS Programme Product Schedule 6. Communications & Engagement 7. Next Month Priorities (including scheduling of documentation) 8. Contact Us Annex.1 ICS Portfolio Monthly Highlight Reports See Separate Attachment

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1. PMO Briefing Purpose This briefing provides a monthly overview of the activities and highlights for each of the Healthier Lancashire & South Cumbria (HL&SC) ICS Portfolios to provide assurance and enable oversight for key stakeholders. The aim is to utilise the briefing as a conduit for communication and dialogue across all partners which form the HL&SC ICS.

2. ICS Board Key Messages The Integrated Care System (ICS) Board provides leadership and development of the overarching strategy for Lancashire and South Cumbria, oversight and facilitation of delivery of sustainability, transformation and design of the future state of health and care. The July 2019 ICS Board was a formal meeting and the key messages are: • The ICS Board received an update on the 20-week population health management accelerator programme. Population health management is a core capability of a mature ICS in the NHS Long Term Plan Implementation framework and one of the key domains for supporting the development of Primary Care Networks and neighbourhoods. Population health management provides a methodology to enable learning across system, place and neighbourhood levels. The Board supported the progress of the programme and a proposed roadmap for strengthening our population health management capabilities across the system. • The ICS Board received an update on the Estates and Infrastructure Strategy 2019 which covers some key areas requested by NHS England and NHS Improvement including disposals and capital. This update is agreed and approved as reflecting the current position across Lancashire and South Cumbria. The Board endorsed suggested wording for new hospital premises for inclusion in the document. It was noted further development of an updated L&SC Estates and Infrastructure Strategy will be reported later this year and subsequent to service strategies. • The ICS Board received the outcomes of a review of ICS governance. The purpose of the review was to ensure we have effective governance and partnership arrangements across Lancashire and South Cumbria Integrated Care System that helps us to plan and deliver services that address the needs of the population and bring together partners to support the seamless integration of services. The Board endorsed the overall approach and direction of travel in strengthening governance and partnership working. Support for further engagement with partners was endorsed with comments requested by the end of August 2019. Adoption of a final set of proposals is expected by the ICS Board in September 2019 and full implementation is planned to be complete by the end of the calendar year. • The Board noted a finance report on the month 2 outturn and updates on the system- wide cost improvement schemes for medicines management, MSK and back office functions.

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3. ICS Executive Summary

Executive July 19 Update Summary The Cancer Portfolio recommendations were presented at JCCCG on 6th June and agreed. Work is continuing on prioritisation templates, milestones Commissioning mapping and capacity mapping for each workstream. The outputs from this Development work will be used to inform consideration at COG of future alignment of capacity to support delivery of priorities. Prevention & Approach to Population Health Management discussed at the ICS Board on Population 3rd July and recommendations accepted. This includes BI support to the five Health pilot Primary Care Networks.

4. ICS PMO Overview ICS Strategic Plan Development: A date has been confirmed for national submission of the ICS strategic plan for the 27th September 2019. A programme plan has been developed to underpin the work required to take place to meet this deadline and details the expectations of the leads across the ICS organisations. Meetings took place on the 11th and 19th July 2019 between ICS and ICP strategic leads with regular meetings now in place. ICP strategic leads are currently working to establish their local ICP stakeholder group to engage and contribute to the development of the strategy.

There are several planned sessions as part of the communication and engagement plan, developed by the ICS Communications & Engagement Team, in relation to the strategy development which include:

o A clinical congress meeting, being planned to bring together clinical leads from across Lancashire & South Cumbria to build upon existing engagement and plans within ICPs and neighbourhoods to consolidate the clinical element of the strategy. Invites will initially be distributed via the ICS Care Professionals Board and ICP strategic leads to cascade throughout the clinical community.

th o Additionally there is a strategic and delivery plan development session being held on 15 August with ICP and ICS programme leads to rationalise priorities and programmes already underway, or planned for delivery in the future.

th o A Strategic Financial Plan conference was held on the 26 July, hosted by the ICS Executive Finance Lead. Outputs from this session will be shared in early August about the approach and assumptions to influence planning.

Annual ICS Programme Evaluation: The ICS 2018/19 programme evaluation has been finalised and is circulated with this edition of the PMO briefing.

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Healthier Lancashire & South Cumbria Programme Delivery Plan: The priorities and framework for the HLSC Programme Delivery Plan were presented at the July Accountable Officer and Chief Executive Officer meeting for approval. Clinical priorities had already been agreed and there are further discussions with regards to Lancashire & South Cumbria wide ‘Best Value’ programmes. Where a consensus has been reached these priorities will be further scoped to agree the objectives and timescales through the HLSC Programme Management Group (PMG).

Governance: A set of recommendations following the review of the ICS governance were presented to the ICS Board in July. The key messages section highlights that the recommendations were well received. The recommendations are now being disseminated via the ICP representative Board members to engage with their local forums in preparation for a decision on the recommendations at the September ICS Board meeting. In addition, further engagement will be taking place with non-executive directors and representatives to ensure that the proposals and subsequent action plan developed in association with these recommendations is coherent endorsed.

Quality: The ICS Quality Impact Assessment proposal is currently in development and will be shared with the ICS Care Professionals Board members during July 2019.

Integration: The Lancashire & South Cumbria PMO network are working up the detail against the list of programmes currently planned or being delivered across Lancashire & South Cumbria to share any learning and understand where there is opportunity to develop a collaborative approach to delivering some of these programmes. This work will also support the development of the ICS Strategic Plan and the group met on 19th July to discuss the plan and timeline ahead of the 27th September submission date.

Smartsheet: ICS Programme Smartsheet dashboards are now live on the system, which displays key information relating to current programme objectives, deliverables, milestones and more. Although live, the dashboards continue to be work in progress and will be updated over the coming months to reflect the new structure of the Healthier Lancashire & South Cumbria programme based upon the priority framework.

Smartsheet Training: The current schedule of dates for Smartsheet training is included within the table below:

Training Training Content Date & Time Intermediate Storing docs, Audit trails, Reports 26/07/19 -10.30-12.00

Beginner Intro, Core PMO requirements – overview 27/08/19 -9.30-11.00

Intermediate Storing docs, Audit trails, Reports 09/09/19 -9.30-11.00

Advanced Automation - Alerts, Links 13/09/19 -14.00-15.30

For any Smartsheet queries, or for anyone interested in booking onto Smartsheet training sessions, please e-mail [email protected]

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5. ICS Programme Product Schedule Scheduling: An ICS programme product schedule has been established for all ICS programmes to support forward planning at ICS meetings. A more detailed live schedule is contained within Smartsheet to capture the workflow for ICS programmes.

A summary of the product schedule for August 2019 has been included below:

Programme Product Meeting/s Purpose Planned Month for Completion Regulated Care Service Collaborative Approval Aug 2019 Specification Commissioning Board

A summary of the schedule for the upcoming month will be included within each briefing. 6. Communication & Engagement The ICS Communications & Engagement Team maintain the Healthier Lancashire & South Cumbria website; https://www.healthierlsc.co.uk/ which is kept up to date with the latest news and events.

There is also a monthly newsletter which provides a summary of the latest good news stories and case studies from across the ICS and its five local partnerships. The latest Newsletter is available here: Healthier Lancashire & South Cumbria Newsletter.

7. Next Month Priorities

• 2019/20 Healthier Lancashire & South Cumbria Programme priorities agreed to be formalised into the HLSC Programme Delivery Plan. The ICS Executive Director of Transformation and ICS PMO will be working with programme teams, the Chief Executive Officers and Accountable Officers to launch the programmes and their leadership. • Development of the Healthier Lancashire & South Cumbria Strategy in ongoing in line with the programme plan. An update will be included monthly within the briefing goingforward. • Final dates for the Clinical Congress meeting in relation to the strategy development will be confirmed and confirmed with stakeholders. • Strategic and delivery plan development session for ICP and ICS programme leads to take place on 15th August. • Communication and engagement through ICPs of the ICS governance review recommendations. A pack, which includes the recommendations report has been circulated to ICP Leads through the ICS Board to support this engagement. • Continuous development of the ICS programme dashboards. • ICS Quality Impact Assessment proposal development to be shared with ICS Care Professionals Board representatives and Directors of Nursing.

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8. Contact Us The mailbox address for the Healthier Lancashire & South Cumbria ICS Programme Management Office is: [email protected]

Please do not hesitate to contact us if you have any queries with regards to the content of this document or would like to get involved with the ICS portfolio

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This page is intentionally left blank Statement of Intent: Commissioning Reform – a rationale for change by April 2021 Introduction This document has been drafted after two recent workshops attended by commissioning leaders in Lancashire and South Cumbria. The workshops have been held to devise and agree a road map for commissioning reform, in the light of the work undertaken by commissioners and providers in recent years to introduce models of integrated care and the development of Lancashire and South Cumbria as an Integrated Care System. The paper has been written as a “statement of intent” and is for a primary audience consisting of the Governing Bodies of the 8 CCGs, the Board of Midlands and Lancashire CSU and for senior leaders in our ICPs. It is clearly understood that further materials including a case for change, an options appraisal and communications materials for member practices and commissioning employees will be required during autumn 2019. Commissioning leaders have a clear intention of building on the best work undertaken by CCGs, the CSU and NHS England working with our providers and partners to improve health and join up health and care services in neighbourhoods, integrated care partnerships (ICPs) and across the whole of Lancashire and South Cumbria. The purpose of this document is to:

• Act as a statement of intent • Set out a rationale for change in the current system • Outline the position we expect the system to have reached by April 2021 • Set out the first draft of a timetable, identifying a number of milestones required to move to the future state by April 2021. This document should be read alongside the more detailed roadmap action plan which has emerged from the two leaders’ workshops. The roadmap commits commissioning leaders to further development work to set out the actions which need to take place over the period leading up to April 2021. Ultimately, it is understood that a formal case for change will need to be submitted to NHS England and a process of consulting member practices and partners will be required. Statement of intent Commissioning leaders agree to recommend to their Governing Bodies that by April 2021, we will establish a single CCG in Lancashire and South Cumbria to act as a strategic commissioner. The CCG is established as a consequence of the development work to create 4 maturing Integrated Care Partnerships (ICPs) and 1 Multi-specialty Community Provider (MCP) and enable the development of Primary Care Networks (PCNs) working in neighbourhoods. Midlands and Lancashire CSU will act as a key partner to the single CCG and our integrated care partnerships, offering a consistent range of strategic and operational services. By April 2020, commissioning leaders expect that the 4 ICPs and 1 MCP will be operating in a recognisable but not necessarily optimal form across Lancashire and South Cumbria. This will require CCGs to agree additional delegated responsibilities for the Joint Committee of CCGs.

Integrated Care System Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 115 Signed by:

Dr G Joliffe Jerry Hawker Clinical Chair – Morecambe Bay CCG Chief Officer –Morecambe Bay CCG

Dr A Janjua Dr Amanda Doyle Interim Clinical Chair – Fylde and Wyre Chief Officer – Fylde and Wyre CCG CCG

Mr R Fisher Dr Amanda Doyle Lay Chair – Blackpool CCG Chief Officer – Fylde and Wyre CCG

Dr G Bangi Denis Gizzi Clinical Chair – Chorley and South Chief Officer – Chorley and South Ribble Ribble CCG CCG

Dr S Mukherji Denis Gizzi Clinical Chair – Greater Preston CCG Chief Officer – Greater Preston CCG

Dr J Caine Mike Maguire Clinical Chair – West Lancahire CCG Chief Officer – West Lancashire CCG

Mr G Burgess Julie Higgins Lay Chair – Blackburn with Darwen CCG Chief Officer – Blackburn with Darwen CCG

Dr R Robinson Julie Higgins Clinical Chair – East Lancashire CCG Chief Officer – East Lancashire CCG

Derek Kitchen Linda Riley Managing Director: Midlands and Director of Operations: Midlands and Lancashire CSU Lancashire CSU

Dr Amanda Doyle Andrew Bennett Chief Officer – Lancashire and South Director of Commissioning – Lancashire Cumbria ICS and South Cumbria ICS

Integrated Care System Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 116 Rationale for change This paper outlines a direction of travel to establish by April 2021 a single CCG in Lancashire and South Cumbria to act as a strategic commissioner. The CCG is established as a consequence of the development work to create 4 maturing Integrated Care Partnerships (ICPs) and 1 Multi-specialty Community Provider (MCP) and enable the development of Primary Care Networks (PCNs) working in neighbourhoods. A visual representation of this proposal is shown below in Appendix 1.

This direction of travel:

• builds on the best work CCGs, the CSU and NHS England have undertaken to join up care and build local partnerships in neighbourhoods/Primary Care Networks and ICPs over the last 4 years. It also endorses our agreed place-based approach to commissioning to maximise the contribution made by commissioners at the most appropriate level of place for the services under consideration. This includes action to be taken at the Lancashire and South Cumbria level. • confirms that the clinical leadership offered by GPs and other frontline professionals will be refocused to ensure the success of primary care networks and ICPs. The single CCG will also continue to be clinically led, ensuring that clinical commissioners can work closely with colleagues in each ICP/MCP/neighbourhood. • creates a focus for providers to work very differently, agreeing plans to improve the whole population’s health, using partnerships to improve the quality of health services and bringing the system back into financial balance. • releases resources from providers and commissioners to support communities to improve their own health and wellbeing. • addresses several examples of fragmented or variable commissioning in the current system. Examples include our approach to complex, individual packages of care, cancer and learning disabilities. There are further opportunities to align decision-making for specialised services commissioning more closely to local partnerships. • creates new energy for integrating commissioning activity between NHS and Local Government organisations at the right level of place: neighbourhood, ICP and ICS. • supports action to achieve the required 20% reduction in running costs which will be reused in the provision of frontline clinical care. • offers new opportunities for the effective and efficient use of commissioning support resources across the whole system. A single CCG working on the same footprint as the ICS is the typical model expected in the Long Term Plan. Under current statute, the CCG would be established under a constitutional model as a member organisation.

Integrated Care System Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 117 Where will we be by April 2021? By April 2021, in Lancashire and South Cumbria, we will have formally established a single CCG acting as a strategic commissioner. This CCG will operate in shadow form from October 2020.

The CCG will receive an allocation of NHS funding for the whole population of Lancashire and South Cumbria and agree long term contracts with 4 maturing Integrated Care Partnerships and 1 Multi-specialty Community Provider. The contracts will specify the outcomes and standards required from local providers. ICPs will continue to develop effective provider operating models which are capable of:

• Taking responsibility for improving the whole population’s health • Delivering safe and sustainable healthcare • Returning to financial balance ICPs will also test and spread practical examples of integrated commissioning with Local Authorities, beginning with opportunities linked to neighbourhoods (public health funds) and intermediate care. ICPs will continue to support the development of PCNs on their agreed footprints. PCN leaders will also be represented in the leadership and governance arrangements of each ICP to ensure the benefits of integrated care and clinical leadership are “locked in” to the evolving system. The single CCG (strategic commissioner) will agree a performance and accountability framework with each ICP and undertake an assurance role as part of its functions in the ICS. This framework will include an agreed approach towards performance improvement which shares and spreads good practice across the group of ICPs. It will also set out appropriate escalation measures which enable all ICPs to support improvement action in the case of major failures. The single CCG will agree a consistent commissioning operating model with each ICP/MCP which allows the discharge of a number of its statutory functions at a local level of place. The single CCG will retain clinical commissioning capacity and resources in order to commission services for a population in excess of any one ICP (i.e. 500,000+). It will also commission those service areas in which recommendations have already been made to commission at Lancashire and South Cumbria level. Commissioners working at this level will have specific linked roles to local ICPs and neighbourhoods. (There is further potential to explore Alliance models e.g. the Cancer Alliance to bring commissioners and providers together to take collective decisions) The single CCG will work with ICP and PCN leaders to devise and agree a common methodology for identifying resources to neighbourhoods. Due recognition will be required with all parties in the system about the scale of current deficits in the system and how the CCG will work with the ICS, ICPs and constituent partners to reduce these.

Integrated Care System Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 118 Indicative Timeline

The approach being taken to commissioning reform in Lancashire and South Cumbria is arguably more ambitious than in other parts of the country. Rather than simply undertaking a merger of several CCGs or appointing a single leadership team across several organisations, our approach has been to build on the models of integrated care which are developing rapidly in our neighbourhoods/PCNs and ICPs. This will lead to the embedding of functions, leadership and capacity which have previously been seen as part of commissioning (examples include service redesign, population health management, communication and engagement, priority setting) into our new integrated models of provision.

Having said this, the statement of intent which indicates a proposal to create a single CCG acting as a strategic commissioner, 4 ICPs and 1 MCP by April 2021 will require the existing 8 CCGs to make a formal application to NHS England for organisational change. On this basis, the national guidance relating to constitution change, merger or dissolution will need to be observed.

The table below is by no means an exhaustive list, but gives a sense of how quickly the system will need to move depending on the agreed level of ambition.

Date Action May – July 2019 Workshops of commissioning leaders develop statement of intent and roadmap July - August 2019 Informal engagement on future direction at individual CCG Governing Bodies September 2019 Statement of Intent considered in Governing Body meetings and responses sent to the ICS Director of Commissioning.

Oct-Dec 2019 Workshop 3 of Chairs and Chief Officers to confirm next steps.

Transition Project Team with Project Director to be established

Case for Change, Options appraisal, Communications & Engagement plans, draft HR/OD plans to be developed

January – March 2020 Member Practice and public engagement & consultation April – May 2020 HR/OD consultation, Resources, Governance, Constitutional framework, financial arrangements, SFI’s etc. all completed

Shadow working arrangements devised to include: • single committees • committees in common / joint committees) • agree statutory functional relationship with ICP Partnerships • principles and approach towards Integrated Care System Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 119 financial allocations

Proposals for shadow leadership team to be devised May 2020 Notification to NHSE of intention to merge 30th June 2020 JCCCG sign-off single recommendation to each CCG GB 30th July 2020 Each Governing Body to sign off (including all associated paper work) 30th September 2020 Submission of formal merger application 1st October 2020 Single CCG moves into shadow form 1st October 2020 ICP/MCP partnership governance evolves to reflect CCG operating into shadow form 1st April 2021 Single LSC CCG / Strategic Commissioner established

1st April 2021 4 ICPs and MCP established

Integrated Care System Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 120

Appendix 1: Commissioning reform in Lancashire and South Cumbria Integrated Care System - illustration This illustration shows how a single CCG could work closely with a group of ICPs/MCP, a provider(s) of Support Functions and NHS England’s Specialised Commissioning Team. Working within the ICS, the CCG will also expect to deliver closer alliances with a wider group of public sector and other partners.

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Lancashire and South Cumbria: Commissioning Development Roadmap Introduction CCG Chairs and Chief Officers held workshops on the 30th May and 30th July 2019 to discuss the main elements of a route map for the continued development of Lancashire and South Cumbria Integrated Care System and its constituent Integrated Care Partnerships and neighbourhoods. The workshops were facilitated by Mike Farrar and formal notes of both sessions have been produced and circulated. There are 6 major elements in the developing route map which are as follows:

1. Developing Integrated Care Partnerships 2. Developing Primary Care Networks 3. Reforming the role and approach to commissioning 4. Establishing a change management capability and approach 5. Managing the day to day challenge whilst transforming the system 6. Creating a new working culture at system level

This document proposes next steps to take forward these broad areas of the road map.

1) Developing Integrated Care Partnerships

Workshop Summary Next steps Lead(s) By When

All systems agreed that ICPs should be operating in a ‘recognisable but not necessarily optimal’ form from April 2020 (noting that this requires action from CCGs in advance of that date) CCGs to take legal advice on how to embed A Doyle on behalf of CCG End Sep 19 or delegate a consistent set of commissioning AOs - ICPs would be asked to achieve a minimum set functions into each ICP partnership board, of consistent design and operating principles, using JCCCGs to hold the ring. namely that they - CCGs to ensure ICP partnership boards have CCG AOs End Oct 19 a membership/TOR to discharge these - a) had a board capable of oversight of the whole delegated functions. system spending and service delivery (this would be manifest in the oversight of the single financial control total for example) Page 123 Page Integrated Care System Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019

CCGs to formally request Trust Boards to set - b) had some delegated functions that had been out clear delegations to ICP partnership CCG AOs End Nov 19 granted to the board by the statutory governance. Delegated functions to include organisations ICP approach to shared financial control total.

- c) had set in place to test a clear approach to a

shared contractual or funding arrangement (either alliance contract or capitation budget for services eg frail elderly, urgent care, children etc) CCGs to agree a collective HR framework - d) had capability to deliver for the system as a which enables the designation and CCG AOs End Nov 19 whole including the ability to direct some of the deployment of staff to work in ICS/ICP/PCNs st current commissioning staff through setting from the 1 April 2020 objectives rather than transferring employment (it was acknowledged that this would require CCG Directors to be offered aspirational A Bennett End Oct 19 appropriate staff engagement and consultation) interviews to understand preferences for working in future system

- e) had engaged PCNs and their CDs in the design of the ICP and included PCN presence in their board membership and governance processes

- f) had flexibility on the specifics of board membership and officers but would need to demonstrate capability and compliance with public service standards and values

- g) had data and oversight of quality assurance for Monthly staff briefings to be drafted for Sept, A Bennett via COG As per TT the system Oct, Nov, Dec

- h) had created a compelling shared vision which had been and was continuing to be developed

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through active staff and public engagement

It was acknowledged that this approach will be developed and agreed jointly with the Lancs and S Cumbria providers and with LA colleagues on both the commissioning and providing side. During the workshop it was also apparent that there is a need to agree a consistent framework of commissioning delegations into each ICP – actions here can build on work which has already taken place in several ICPs.

Notes from Workshop 2: 30th July

- Need to ensure that the work on developing commissioning is aligned fully with the work in the provider development stream in terms of ideology, timeframe and leadership roles - Need to keep the language and terminology consistent and use ICP generally as the term for local provider alliances - Need to keep touching base with each locality to understand any progress, any emerging best practice and any concerns over inconsistency.

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2) Developing Primary Care Networks (within the context of integrated neighbourhood services)

Workshop Summary Next steps Lead(s) By When It was agreed there should be consistent approach to supporting the development of PCNs that would include -

- a) action in each ICP to clarify ideology, their approach to their task and functions, and Each ICP to summarise and share current ICP(CCG) lead director for End Sep 19 potentially their governance actions to support local PCN development PCN development including leadership, governance and key objectives b) action at ICS level to ensure all are broadly - Peter Tinson/ Dr Mark End Sep 19 consistent with Key principles including time ICS Primary and Community Services steering Spencer via steering for GPs to engage, and any payments for group to provide a summary report to all ICPs group officers indicating levels of consistency of current development within an overall approach to neighbourhood development and identifying how good practice can be shared

c) action for CCG/ICP leaders to agree where - End Oct 19 consistency in the approach to PCN operating CCG AOs models will be beneficial and the support CCGs to confirm how they plan to involve PCNs capacity they might need in local ICP governance arrangements

- d) action to ensure PCNs are consistently and effectively engaged in the design and governance of ICPs End Aug 19 - e) action by the ICS Executive to identify Andrew Bennett resources from national programmes that ICS Executive to liaise with NHS England could be used to support PCN development in colleagues about availability of national Lancs and S Cumbria resources for PCN development.

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The timing of these actions would be to deliver these piece of work throughout the next 3-6 months

Notes from Workshop 2: 30th July - Need to reflect the excellent progress being made across the patch and the opportunity to promote this nationally - Need to demonstrate that all PCNs have a route into ICP governance

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3) Reforming the role and approach to commissioning

Workshop Summary Next steps Lead(s) By When It was agreed that the ICS Executive should facilitate the production of a next Next phase of commissioning plan to include clear phase of commissioning plan that would statements about the “destination” for the system in Andrew Bennett End Aug 19 build on the excellent work previously April 2021 and the role of the Joint Committee for undertaken on commissioning in an ICS. overseeing the process to get there. This would involve -

- a) a working session to set out what the local ‘commissioning’ presence in a post ICP world might be, that would not be part of the ICP (eg local authority Arrange workshop for local government/NHS Julie Higgins/Louise End Sep 19 ‘accountability’ mechanism and commissioners to develop more detailed proposals for Taylor approach to enable the opportunity to alignment of resources at ICP/ICS levels where play in budgets for wider health benefits appropriate. [Potential current examples include public - this must clearly include LA health grant, intermediate care, BCF] commissioners in the design and discussion)

- b) a commitment to reform the commissioning system over the next 24 months (i.e to April 2021) with an Commissioning leaders to set out roadmap with key CCG Chairs/Cos End Aug 19 agreed road map for transition during milestones up to April 2021 for agreement with key A Bennett this period to the new arrangements partners in the ICS setting out staging posts and milestones

along the way

c) a review of what management - functions (in CCGs, CSU and potentially providers) could be moved to a more CSU/CCG leaders to agree joint proposals for the collective central approach sooner in development of commissioning support functions at Matt Gaunt, Linda Riley, End Nov 19 Page 128 Page Integrated Care System Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019

that time frame. This would be seen as Neighbourhood/ICP/ICS levels – within the context of a Clare Thomason part of the contribution to management developing “group model” across L&SC cost savings and supporting the development of integrated care in neighbourhoods, ICPs and ICS. (Discussion identified potential to see this as part of a refreshed approach to

support functions for a group of ICPs

and a strategic commissioner.)

- d) a review and refresh of the JCCCG functions and governance to ensure it

was fit for purpose with support capability so that delegated functions

and decisions could be made clearer As part of the ICS governance review, set out and more future focused (ie set up to proposals for change to the terms of reference for the Andrew Bennett/Jerry End Oct 19 prepare for the reformed system rather Joint Committee of CCGs for implementation during Hawker than stuck in the current mode) 2019/20

This work would be led by the ICS Executive but crucially would be steered in partnership with the CCGs and reps from both the Chairs and the AO group.

Notes from Workshop 2: 30th July

- Need to have a revised and timed road map for the milestones within the next 24 months that embraces the role of the JCCCG in the short term, it’s relationship with the ICS level commissioning function, the ICS board

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and the ICS executive team. The changes proposed here will be enacted from the 1st April 2020. - Reinforced the 24 month time horizon for movement to a single CCG at ICS level by April 2021 with clear and consistent working arrangements operating in ICPs/MCP. - Need to create a clear narrative for this change that spells out the different leadership options for current CCG officers and board members (highlighting the roles within PCNs, ICPs, ICS level commissioning, and residual local roles working with LA colleagues, if this emerges as a potential option when considering a local presence in a new commissioning approach) - Need to ensure that the narrative and case for change speaks to staff at all levels and also to the public - Need to establish a communications strategy that uses the narrative with key stakeholders and sets out the case for change clearly and compellingly - Agreed to work with the CSU leadership team to co-design the new system support offer at ICS/ICP/PCN levels.

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4) Establishing a change management capability and approach

Workshop Summary Next steps Lead(s) By When - a) an expectation that localities would set CCG AOs to agree change management requirements CCG AOs/Andrew Bennett End Oct 19 out what they needed by way of change in conjunction with ICS and Regional Office colleagues management support and an agreement to share practice and identify collective resources if this added value,

- b) an agreement to work together on the Broader narrative about system change to be Andrew Bennett collective narrative and developed as part of continuing C&E plan to explain End Oct 19 comms/engagement plan that would be how the ICS partners intend to implement the Long needed as the overarching compelling case Term Plan. for change (this would need targeting at Andrew Bennett via COG staff, the public and the politicians in a Monthly staff briefings to be drafted for Sept, Oct, Nov, As per TT bespoke fashion) Dec

- c) identification of ambassadors or champions for the changes with clear and direct benefits expressed by them in support of the changes

Notes from Workshop 2: 30th July

- Need to recognise that changing structure is the first stage of changing practice in order to add value to every pound spent. In line with the localities’ feedback, there is a need to begin to focus on operational transformation and move to population health management - Need to take a collective view on the

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resources needed for change and ensure that as an ongoing ICS we can tap into national pots of money and new partnerships

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5) Managing the day to day challenge whilst transforming the system

Workshop Summary Next steps Lead(s) By When Actions that followed were -

- a) ICS/RO agreement on a process for RO, ICS and ICPs to agree revised approach to A Doyle End Sep 19 managing performance requests and assurance and performance management for reports (this would include an agreed remainder of 19/20. Assume shift away from single approach to escalation if finance or service organizational approaches to ICP-based approach. failure occurred)

- b) for the ICS and its constituent ICP partnerships to agree a protocol with the RO for whole system handling of significant issues/reports including CQC reviews, external reviews and performance challenges

- c) developing a clear contingency plan in ICS/CCG leaders to agree contingency plans for the the event of major deterioration of provider performance improvement of an ICP if there is no A Doyle End Sep 19 performance that enabled commissioners to sustainable change from current position –this may take a proactive series of steps to oversee involve an interim step which support action as if a performance and take control up to the strategic commissioner was already in place. system level with stronger provider oversight if needed

The first step to achieving this would be a meeting between AD and the ICS Exec with colleagues at the RO including Bill McCarthy.

Notes from Workshop 2: 30th July - Need to recognise the real concerns across Page 134 Page Integrated Care System Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019

the ICS on provider performance and be seen to act proactively in managing them - Need to build some potential collectively owned ‘flying performance improvement capability’ that could be dropped into different localities and organisations if needs be - Need to maintain a good relationship with RO on performance whilst recognising the pressure that this is putting on senior leadership time at the ICS - Need to be coherent in terms of the shared responsibilities for performance that commissioners and providers share, rather than allow the system to drop back into a blame culture. This may need some work together with providers and commissioners at ICS level

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6) Creating a new working culture at System level

Workshop Summary Next steps Lead(s) By When Actions to develop this would include -

- a) creating time and space for the leadership group to understand and Commissioning leaders to continue to meet at regular A Bennett March 2020 develop a new approach to intervals during remainder of 19/20 to review progress commissioning, of this road map.

b) enabling leaders from each locality to - Commissioning leaders to agree OD support for new AOs/A Bennett End Nov 19 get to know and support each other as approaches to commissioning in ICS/ICPs – as part of they move to adopt the new approach, change management approach.

- c) creating a mechanism to enable personal futures and aspirations to be CCG Directors to be offered aspirational interviews to A Bennett End Oct 19 identified so that existing skills and understand preferences for working in future system capabilities can be maximised.

Notes from Workshop 2: 30th July

- Need to ensure that personal aspiration interviews are happening - Need to reinforce the key points above about leadership behaviours as the system comes under performance pressures Page 136 Page Integrated Care System Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019

Agenda Item 8

Governing Body Meeting

Date of meeting 25 September 2019 Title of paper Integrated Care Partnership (ICP) Update Presented by Mr Denis Gizzi, Chief Officer Author Ms Jessica Partington, ICP Programme Manager Clinical lead Dr Gora Bangi, Chair Confidential No

Purpose of the paper This report provides members with an update on the progress of the Central Lancashire Integrated Care Partnership for the period July- September 2019. Executive summary This report aims to provide Boards and Governing Bodies with an update on progress with the Integrated Care Partnership in Central Lancashire, for the period July to August 2019. The report covers the work undertaken in the following areas:

1. ICP Board Business – July and August 2. ICP Mobilisation – Board and Leadership Development 3. Working as part of the wider ICS 4. Big Six Strategic Framework – Platform Specific Updates

It also looks ahead to the next period (September – October 2019)

Recommendations

Boards and Governing Bodies are asked to note the update for information.

Any queries or further information can be gained from the ICP Programme Manager, [email protected]

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

Integrated Care Partnership (ICP) Update NHS Chorley and South Ribble CCG Governing Body meeting 25 September 2019 Page 137 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

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

Integrated Care Partnership (ICP) Update NHS Chorley and South Ribble CCG Governing Body meeting 25 September 2019 Page 138 1. INTRODUCTION This paper provides an update on progress within the Integrated Care Partnership during the period July to August 2019, and looks forward to the next period.

2. INTEGRATED CARE PARTNERSHIP UPDATE (July – August 19)

2.1. ICP Board Business – July and August In July, during the ICP Board, they concluded the following business; • Received and discussed a re-fresh of the Integrated Care Partnership strategy • Received and discussed an update upon Financial and Economic Reform (Platform 5) • Approved the Integrated Care Partnership System Management Reform Platform Brief (Platform 6) • Discussed and developed actions towards managing the shared control total across the system • Received an update upon the Integrated Care Partnership Estates Strategy

In August, the ICP Board was utilised for a Board development session which has highlighted areas required for future development of both the ICP Shadow Board and the Integrated Care Partnership as a whole.

2.2. ICP Mobilisation – Board and Leadership Development The Independent Chair of the Integrated Care Partnership Shadow Board, Paul Connellan was appointed in 2018 on a fixed-term basis. Paul left his post as Independent Chair at the end of his contract on 2 September 2019. We would like to thank Paul for his input and commitment over the last 12 months and wish him well for the future. A recruitment process is now underway to appoint a new Independent Chair and interim arrangements have been put in place to ensure continual delivery of the ICP plan and priorities as well as facilitate the planned September meeting of the ICP Shadow Board. An away day was held for the ICP Board on 15 August. This helped to accelerate the development of the ICP Board to begin in earnest. As part of this development, work is currently underway to create a full programme to support individual Members; and to progress the maturity of the Partnership into the next phase by increasing the effectiveness and advancement of the Partnership Board in its strategic aims.

2.3. ICP Operational Meetings Throughout the period covered by this report the following significant operational changes have been made within the ICP which have seen a more collaborative approach from partner organisations: • The A&E Delivery Board has been refreshed with a review of the workstreams that are overseen by it. The Terms of Reference have been amended and

Integrated Care Partnership (ICP) Update NHS Chorley and South Ribble CCG Governing Body meeting 25 September 2019 Page 139 approved along with a governance structure for the Board and workstreams. A Senior Responsible Officer (SRO) group of these various workstreams has been established which escalates serious concerns upon operational issues to the ICP Senior Leadership Team. • The Elective Care Board has also been refreshed with its inaugural meeting scheduled for the end of September. Terms of Reference are currently in draft form and reflect the governance within the ICP. Consideration is being given to the workstreams that it oversees, such as the current outpatient work across the ICP. • There are proposals to establish a Children’s and Young Person’s Board within the ICP to ensure that all specialities serving this patient group are being dealt with in a collaborative approach across the ICP, and that the ICP Board are sighted upon the developments in this area. Draft Terms of Reference are currently being discussed with the proposal to accept this Board into the ICP governance structure being taken to the October ICP Shadow Board. • Due to the pressures of the joint control total between CCG partners and the Trust, a joint PMO function has been put in place across the two organisations to manage the joint Finance Improvement Programme which will report into the Finance Investment Activity Group (FIAG) with updates reported into the ICP Board to provide assurance and oversight.

2.4. Working as part of the wider ICS

a) ICS Documentation The ICS have recently published several documents which have required action within the ICP. The documents and details as to how the ICP are dealing with the proposals are as follows: • NHS Long Term Plan Implementation Framework – ICP is responding to the planning requirements (please see section b below). • Lancashire and South Cumbria ICS Commissioning Reform and Organisational Development Action Notes – This document outlines what the ICS expects of their ICPs over the coming years, KPIs have been mapped against ICP Business Plan 2019/20 with identified gaps being escalated to the leads of the relevant Strategic Platforms and plans being developed to address them. • ICS Maturity Matrix – set within the ICS Parameters described by NHS England, this document provides an overview on the arrangements needed to build strong health and care systems across the country. The development of the ICP has been mapped against this matrix to gauge our maturity at place level, within the wider ICS development. • In the absence of an ICP Maturity Matrix but receiving confirmation from the ICS that one is expected upon the same variables, current ICP progression has been mapped against the Matrix to ascertain areas for development which are being cross- referenced to the outputs of the Board development session in August. • ICS Governance Review – The ICP, involving all partner organisations have issued feedback to the ICS upon their recommendations to change their governance structure and proposals for a Partnership Agreement. Further discussions are now being held within the ICS and we await guidance as a result. • NHS Interim People Plan – Discussions are currently underway in relation to how the requirements of this document are being developed within the ICP.

Integrated Care Partnership (ICP) Update NHS Chorley and South Ribble CCG Governing Body meeting 25 September 2019 Page 140 • NHS Patient Safety Strategy - Discussions are currently underway in relation to how the requirements of this document are being developed within the ICP.

b) ICS Strategy Development

The ICP held a planning workshop on 01 August 2019, attended by representatives from all partner organisations, including clinicians, to discuss the priorities for the ICP for the five year plans required to inform the ICS five year strategy. Priorities both clinical and non-clinical (referred to as enabler workstreams) have been identified and the required template and narrative have been submitted to the ICS as a first draft. The ICP is currently developing finance, activity and workforce data to support these plans and developing a further narrative to read alongside.

The ICP remains involved in regular briefings and meetings, externally with the ICS and also internally with partners, to discuss the progression of these plans particularly in light of the very tight deadlines associated with this work. The ICP are reviewing the current data analysis mechanism, the Clinical Analysis Review Team, to ensure that it is fit for purpose to support the transformation methodology adopted by the ICP within the integrated planning function.

2.5. Big Six Strategic Framework – Platform Specific Updates The big six strategic framework are 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; • System Management Reform – The Platform Brief has now been approved and work is in progress in relation to all workstreams in particular; - Integrated planning – ICP five year plan developments - Integrated system performance management – Joint performance management post agreed and job description approved - Integrated quality and safety – Discussions underway within the ICP in relation to the NHS Patient Safety Strategy - Developing the new system structure and delivery model – Draft paper developed and workstream to be considered in further detail at September ICP Shadow Board

• Wellbeing and Health in Integrated Neighbourhoods – A governance structure has now been developed to assist in the formation of the GP Networks along with a Network Manager post (Joanne Cooper) to both oversee and support this. A project group has been established to roll out population health management across all nine networks. A solution design event for COPD respiratory event was held in August with a further two arranged in October 2019 and February 2020. The workshop in August was dedicated to Early Detection and Diagnosis of COPD., where patients and clinicians from the whole health economy came together to identify

Integrated Care Partnership (ICP) Update NHS Chorley and South Ribble CCG Governing Body meeting 25 September 2019 Page 141 models of delivery. An options appraisal for the delivery model is being worked on and will be presented at WHIN programme board for consideration.

• Our Health Our Care Acute Sustainability – The Our Health Our Care Joint Committee met on the 28th August to consider a report and recommendations linked to the acute sustainability workstream (Platform 4). The report presented the clinically-led process and methodology used to generate a long-list of thirteen options for change, based around the principles of delivering more and better care closer to home, and improving clinical outcomes for the people of central Lancashire.

The Joint Committee determined unanimously to consider all thirteen options further through a substantive process of enhanced clinical scrutiny, including a Clinical Summit, an expanded role for the programme’s Clinical Oversight Group and further work with local primary care network leadership teams. The Committee also determined to explore further the opportunities for enabling capital for a new build site in central Lancashire, based on a feasibility study completed in 2017. In addition to the other expert clinical reference information developed by the programme, we will also be engaging the North West Clinical Senate, an independent and multi-professional group of clinicians who will scrutinise the programme options and the Model of Care developed. These actions will continue over the Autumn and ICP colleagues will be regularly updated.

• Integrated Care Partnership Development – As part of the governance review, a mapping exercise of the emerging ICP governance structure and its fit within partner organisations and the ICS composition is now underway. This will help us to identify the gaps in governance and decision making processes across the ICP, clarify reporting and highlight how individual workstreams and other projects contribute to the ICP strategic direction. Work has also commenced in developing a Board Assurance Framework with expected outputs being presented to December ICP Shadow Board.

3. LOOKING AHEAD TO THE NEXT PERIOD (September - October 2019)

In September 2019, the ICP Board meeting will look to; • Discuss the Intermediate Care Report and the proposed actions for the partnership to take any recommendations forward • Discuss and approve the required submissions to the ICS in relation to the development of the five year plans, including planning templates, finance, activity and workforce planning templates and narratives to support both • Discuss an update for OHOC (Platform 4) • Review a draft target operating model and system operating model (Platform 6)

Integrated Care Partnership (ICP) Update NHS Chorley and South Ribble CCG Governing Body meeting 25 September 2019 Page 142 • Discuss the control total update in accordance with the joint financial improvement programme

In addition, during the next two months, the business of the ICP will focus on; • Further Board development sessions • Developing the five year plans for submission to the ICS • Mobilising the workstreams within System Management Reform (Platform 6) • Seeking endorsement for the Children’s and Young People’s Board • Mobilising the Elective Care Delivery Board

Integrated Care Partnership (ICP) Update NHS Chorley and South Ribble CCG Governing Body meeting 25 September 2019 Page 143

This page is intentionally left blank Annex 1. Of ‘Monthly HLSC PMO July Briefing’: ICS Programme Highlight Reports

Programme July 19 Highlight Report Portfolio Name Achieved this month:

Very successful Maternity Assembly held on June 14th. LMS Governance Lead now in post for a 6 month contract looking at LMS governance arrangements Meeting arrange with Lead maternity commissioner to progress future maternity commissioning arrangements

Choice & Personalisation – A draft Lancs & South Cumbria Personalised Care Plan was launched at Maternity Assembly and has received a lot of positive feedback. It has now gone out for further consultation. Collaboration with service users (MVPs, Dadsnet, FAB etc.) continues. Meeting arranged with Lynette Harwood Maternity Personalisation & Choice Lead NHS England to discuss our work.

Postnatal Care – A national guidance update has requested that we conduct a gap analysis against 6 key themes: Personalised Care; Transfer of Care; Return to Home; Physiotherapy; Infant Feeding Mental Health and Transfer of care from midwifery to health. The deadline for this is October 2019.

Infant Feeding - System-wide standardised policy and 30 guidelines completed and sent out for wider consultation across all Acute & Better Births organisations. Training task and finish group established: standardised training curricula and resources agreed; pooling of all Specialised training courses for system-wide delivery; purchase of BFI workbooks for workforce.

Digital Maternity - Funding has now been agreed for 0.1 of WTE midwifery digital representative from each trust to work centrally with the LMS on digital maternity agenda. Identified and escalated a need for a formal LMS wide agreement on the implementation of an interoperable maternity management system. A draft site map has been developed for a Better Births website.

CoC: Local PIDs being developed with models to support "most women receiving continuity of carer". Data reporting still indicating increasing percentage of women on pathway*; Interim data collections systems being implemented and tested. Reporting results at next meeting. Continued staff engagement. National and Regional CoC Leads attending July workstream meeting. Main risk: Transition to "new models" in order to ensure "most women" receive CoC will take time and may impact March 2020 35% target achievement. Need to understand other cost implications. And need fit for purpose systems to ensure we meet data capture requirements and take admin pressure off teams. *guidance now stating bookings after 28 weeks are not to be including in figures, means we can no longer count Caesarean Sections - this will reduce figures from LTHTR significantly. Page 145 Page

Workforce Transformation: First standalone workstream meeting to be held in July. Planning underway for following workshops to be held in September/October. Health Coaching: All Practice Midwives engaged and activity looking into which teams will pilot training and PAMs (Patient Activation Measures) Full project dossier to be agreed.

Community Hubs - Maternity care: Each locality developing local plans with support. Meetings no being held bi-monthly. Requires close working with commissioners and ICP partners in each patch.

Bereavement: Next meeting end of June to explore training opportunities and development of an LMS wide Job Description to ensure protection of the role going forward and skilling-up other midwives.

Next month:

Continue working closely with LPRES to establish maternity scenarios for information sharing.

Collate feedback regarding the IF Network branding designs.

Need to put an action plan in place to achieve Midwifery Led Settings trajectory for March 2020.

Diagnostic Radiology – Work has continued to progress within the newly formed radiology workstreams: • the radiology data group has commenced work on collating each trusts NHSi submission for assets which will then inform the planned radiology procurement scoping meeting in July• the radiology pathways & collaboration group has agreed upon recommending adoption of RCR iRefer guidelines for radiology across Lancashire & South Cumbria and the group is now exploring appropriate governance and storage solutions, to ensure the pathways are accessible and remain current. A second

strand of work compiling current time lined pathways for diagnostic radiology required through published guidance has commenced• the radiology workforce & training group has met initially to theme outputs, from the previously held workshop, with regard to radiographers and the next steps will be to complete for radiologists• the digital integration group have presented a comprehensive position statement, detailing to the L&SC Diagnostic Radiology (DR) Working Group, plans for image sharing proof of concept. At the next L&SC DR meeting, potential suppliers will be presenting proposed models to enable integration of Acute & Diagnostics existing digital radiology systemsInterventional Radiology – In June the Interventional Radiology group agreed a set of metrics to Specialised be developed for the group, measuring adherence to developed pathways, the group agreed to the development of a survey to support. Work has continued with the two IR leads at ELHT and LTH to understand the current capability and capacity within IR, as part of the development of a regional IR resource plan.Endoscopy –The Nurse Endoscopist Network forum has continued to meet regularly. The June meeting was a joint meeting with nurse endoscopists and endoscopy service managers. The group reviewed 2018 endoscopy action plans and detailed the progress made in addressing the actions identified following the 2018 L&SC Endoscopy review. A position paper detailing the progress made in the development of L&SC endoscopy services will be taken to the L&SC Diagnostic Steering Group in July. The group agreed the outstanding issues to be taken forward through the

Page 146 Page L&SC endoscopy meeting and also agreed to develop a set of Lancashire & South Cumbria Endoscopy metrics which will seek to measure the impact of endoscopy action plans. Issues:No issues to escalate

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Achieved this month: Met with HR Directors to commence a workforce related sub-group to develop a plan to engage staff, help them to understand the aims of the programme and the impact of any change and have methods in place to share information, concerns, questions etc. A Head and Neck Steering Group meeting took place on 02/07/19: - The co-dependencies framework to document the dependencies of Head and Neck services on other services was agreed.

- The programme's risk register was reviewed, resulting in a suggestion to document the risk of needing support from BI teams and the possible lack of capacity in this area. An additional risk of needing clarity on the plan for implementation of the approved model for delivering head and neck services was included. - There was a request for commitment to the programme's Data subgroup to ensure the programme's data requirements can be fulfilled e.g. to support the monitoring of KPIs and clinical standards. - A visual (rather than purely narrative) representation of the shortlisted options was shared with the group that depicted where elements of head and neck services would be provided based on each model. This resource was well received by the group. Acute & - Some of the criteria being used to score the shortlisted options cannot be scored effectively without site information as panel Head & Neck Specialised members' scores could vary widely depending on the location of the hub and spokes. For this reason it was agreed that the criteria relating to locations would be managed separately - arrive at the preferred clinical model first and then apply the criteria relating to location, finance and pathways. - The timeline for the scoring exercise and approval process was shared with the group. - A second Workforce engagement event has been planned for Friday 13th September.

Planned next month: - Continue to develop the scoring evidence and data pack as a resource for the scoring exercise. - Follow up meeting with the HR Directors re workforce engagement. - Presenting information on the Head and Neck services programme at the Lancashire Health Overview Steering Group meeting. - Presenting workstream progress at CCB and asking them to add a decision to review and approve the preferred model to the JCCCB 2019/20 work schedule

Key Deliverables this Month: • Greater Preston/Chorley and South Ribble CCG, Morecambe Bay CCG and Blackpool CCG have all agreed to commission an integrated community rehabilitation service. East Lancashire CCG’s business case will be considered via CCG governance processes in July 2019. • Two patient/public engagement events have been scheduled for September 2019, one in Preston and one in Kendal. Invites have been sent and the events will be widely advertised via the communication and engagement team.

Acute & • The task and workforce mapping sessions have been completed at each site. The Stroke Workforce group has met to review the Stroke Specialised refined data and agree areas requiring further focus. • The Case for Change has been endorsed at the Care Professionals Board and the ICS Board and was due to be endorsed at the July Joint Committee of CCGs meeting however this has been cancelled so will now be endorsed at the August (informal) and September (formal) meetings.

Page 147 Page • The Stroke Rehabilitation subgroup have held three task and finish groups. These are “Definitions and Criteria” and “Interface between acute and community services” and “Digital”. The task and finish groups will support continuous improvement within rehabilitation services.

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• A workshop has been scheduled for 18 July for stroke and radiology teams, along with ICS Digital team colleagues, to explore the use of artificial intelligence for reading of scans. • Training and education sessions have been arranged for staff working in Stroke services. This includes Orthoptist training, Stroke Masterclass, Pilates and SSNAP training days. • The Ambulatory care operational model has been circulated to Acute Providers for endorsement and internal Provider gap analysis • Commenced scoping of Orthoptists services across Lancashire and South Cumbria acute stroke organisations. • Scoping work around Social Care and its current services into stroke patient discharge is in the process of being collated, this will be twofold scope of what Social Care are commissioned to undertake and what is actually delivered, with the premise that a paper will be developed to identify gaps and potential solutions.

Key deliverables for next month- • Circulate the Case for Change and Stroke Model of Care document to the JCCCG for endorsement. • Share the recommendations from the task and workforce mapping with the workforce subgroup and arrange a wider session with representatives from each trust to review. • Continue to plan for the Patient/pubic engagement events in September 2019. • Review outputs from Rehabilitation task and finish groups and agree next steps. • Discussion at the Strategic Stroke Improvement Group to review and agree the Ambulatory care operational model. • Meeting on 04 July with Orthoptist leads across Lancashire and South Cumbria to continue to scope the service. • Collate Social Care current services. • Review previous proposed options evaluation process/criteria and compare to recent processes used within other programmes of work, e.g. Vascular, Head & Neck

Achieved this month: Met with HR Directors to commence a workforce related sub-group to develop a plan to engage staff, help them to understand the aims of the programme and the impact of any change and have methods in place to share information, concerns, questions etc. At the June Vascular Programme Board (VPB) meeting: - It was agreed to delay the scoring process until the associated costings of the single centre and two centre short listed options

were worked up to understand the differences involved.

- The Chair of the Policy Development and Implementation Group gave a presentation on the variation in Varicose Vein Acute & commissioning policies and the impact on patients and providers. Links will be made with the clinical and ops leads at both ELHT Specialised Vascular and LTHT to discuss this work further. Services - The programme's risk register was reviewed, resulting in the residual probability score for two risks being reduced from 2 to 1 as the programme benefited from extremely good support to the Programme Board and clinical engagement throughout the programme. An additional risk has been added to reflect the lack of clarity around the implementation plan once the preferred clinical model is known.

Page 148 Page - The Data Subgroup feel the data pack, to support the case for change and provide information on current performance which will help the appraisal of the shortlisted options, is as final as it can be. The pack is made up of information sourced directly from the Trusts (including recently updated critical care data), HES and GiRFT as supporting appendices.

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- A document was presented that outlined the scoring and approval timelines. In terms of the approval forums, further information is needed around which Specialist Commissioning meeting and assurance meeting at Wigan CCG the proposed preferred clinical option will go to. - Board attendees were asked to split into small groups to work through the scoring information pack and comment on whether the information provided was suitable and if additional information was required. It was agreed that time would be dedicated to work through the evidence pack’s contents at the next meeting of the Vascular Programme Board.

Planned next month: - The Vascular services programme’s Communications event takes place on Tuesday 2nd July at Royal Preston Hospital. - Follow up meeting with the HR Directors re workforce engagement.

Achieved in month: 1) System Review – Following the feedback events in May and June 2019, work is progressing to develop a single System Improvement Plan to address the recommendations of the review and to collate several pre-existing incomplete improvement plans (e.g. the QI plan from the RCoP visit to ELHT). The AMH ICS Team intends to hold two away days with mental health commissioners in June 2019 to develop actions to respond to the specific commissioning recommendations of the review.

Executive oversight of plan will be held by the ICS Mental Health Improvement Board.

2) Staffordshire Visit – The ICS MH Team visited North Staffordshire Combined Healthcare Trust (NST) on 24th June 2019, alongside broad representation from LCFT, LCC and Lancashire Constabulary. Leaders from NST presented on how they used listening into action and undertook a fundamental shift in business and culture. This included: a bottom up approach to patient outcomes, a clear vision and strategy, strong relationships with the VCFS, a community aligned leadership model (including professional leadership) and joint commissioning approaches. The learning from this visit will contribute to the development of the System Improvement Plan.

All Age Mental Adult Mental 3) Mental Health Investment Standard – Discussions between CCGs and LCFT to agree commitments against the MHIS have Health Health been supported by the ICS. The contract with LCFT for 2019/20 has now been finalised and is currently in the process of being formally signed off by CCGs.

4) Frequent Flyers/Review of the Multi-Agency Oversight Group (MAOG) - The reviewed MAOG held its second meeting in June 2019 and was well attended by the agreed membership. Locality reports provided by the local MAGs were presented and will be a standing item at future meetings covering frequent s136 detainees and frequent attendees at EDs across L&SC. The Mental Health Crisis Care Concordat action plan has been updated to include the recommendations from the System Review, as well as the CQC report for LCFT re the BTH ED and s136 suite, to minimise duplication. Work is underway to agree a MH awareness training package which will be available for Acute hospital staff, Police Officers, NWAS paramedics and LA staff. The training will include specific information regarding C&YP and patients with LD as well as a possible MH crisis. The training package is being produced in a partnership between the MH ICS, LCFT and leads from the target organisations.

Page 149 Page 5) Super-Stranded – an initial scoping meeting was held in June 2019 to explore the potential for existing health funded MH IPA activity to be recommissioned as planned services. The benefit of this would be a streamlined discharge pathway; improved

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quality ‘closer to home’; and reduced commissioning costs for CCGs through economies of scale. Following the meeting, the MLCSU IPA Team has agreed to undertake analysis of 12 months activity and to group placements by different categories such as diagnosis, gender, age, length of stay, cost and location. A clinical review will then be completed to ‘sense check’ the groupings. It is expected that this work can be completed within 3 weeks to allow for the group to meet again in July 2019 to review this information and agree next steps.

Panned for next month: 1) Continued implementation of the FYFV, Mental Health Delivery Plan, NHS Long-term-plan and Mental Health Improvement Plan.

2) Continue to mobilise the Commissioning Development Framework, prioritising Organisational Development and the development of a Mental Health Commissioning Strategy

Issues: it should be noted that the Mental Health system across L&SC continues to experience considerable operational capacity and demand pressures.

Achievements: The Transformation Plan was presented to the BwD Children's Partnership Board, the BwD Health and Wellbeing Board and the Blackpool Health & Wellbeing Board. All meetings positively received the Plan and were happy to endorse the direction of travel.

The internal governance arrangements for the programme have undergone a full review over the past few months as we join with

colleagues from South Cumbria. The Partnership Board's Terms of Reference are currently under review, as is the Board's membership. It is hoped that these will be finalised in July.

CAMHS Redesign - Co-production sessions are progressing on schedule with submission of the clinical model due on 12th July. CYPEWMH Planning for the evaluation process is now underway.

Next Month: The submission of the CAMHS Redesign Clinical Model will be received - 12 July 2019. This will then be the subject of a full evaluation process The review of the programme's work priorities will be evaluated by CDG2 and COG

Issues and Risks: Nothing to raise

Period for report: 01/06/19 – 30/06/19 Transforming Achieved this month:

Page Page care highlight Change in Learning Disability and/or Autism Beds: report 96 as at 30/04/19: 97 as at 31/05/19:

15 97 as at 30/06/19: Target Q1 94 beds

0

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Programme Plan restructured to reflect 4 agreed priority projects: Priority 1: A new model of CCG commissioned inpatient care is developed, mobilised and made operational Project Board established, TOR agreed, Mobilisation Work plan in place, 1st draft Communications & Engagement plan produced. Next Steps: Consultation meetings arranged for periphery housing families Priority 2: A new model of community services is developed, mobilised and made operational Project Workstream to be set up, planning in progress CCB signed off Commissioning Intentions Paper setting out Community services future commissioning plan, Initial meetings held with lead partners, draft process agreed Next Step: Agree detailed mobilisation Plan, appoint Programme Management Lead Detailed programme plan to be developed Priority 3: Deliver the nationally monitored inpatient trajectory Trajectories agreed CCG's and NHSE. Admissions numbers have risen over first quarter and ICS behind on agreed discharge trajectory. Amber status for Q1 but unless recovery/improvement may move to red next quarter. Trajectories may need to be reviewed to take account MM Legal Judgement which could delay some discharges. Programme of work underway to assess MM judgement risks (added to Risk Log in May 2019)

Priority 4: Explore joint governance and decision-making arrangements with the Local Authorities 3 Year Plan fully signed off - Final Step Easy Read Plan to be written & PMO Documents updated. Sub-project will then be ready to close

Commissioning Intentions Paper signed off CCB Governance Paper to TCP Programme Board June/July. Workstream restructure underway

Learning from Death Review (LeDeR): Reviews of process and governance completed, Recovery Plan being drafted to go to TCP steering Group July, awaiting confirmation of additional NHSE funding to assist with clearing backlog. Concerns over capacity of CCG’s to deliver business as usual reviews, health checks to be completed July. Red status Q1 but Amber overall, may move to Red unless additional CCG/Provider resources found to deliver NHSE target performance Workforce Action Plan was presented to TCP Board in June

Planned for Next Month: Detailed Mobilisation Plan for Priority 2 Project Community Service redesign Finalised budgets for 2019/20 and agreement on resource levels to deliver Priority Projects LeDeR Recovery Plan to be presented to TCP Board in July Update on Housing Strategy to TCP Board in July Issues Increased risk in meeting agreed discharge trajectories and reducing beds Increased risk in not meeting LeDeR performance measures age age Collaborative Booking & Referrals Management and Bookings Services Scheduling - · Having reviewed the scale of referral and bookings services across Healthy Lancashire and South Cumbria, it was decided to

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Central approach this ICP by ICP. The first ICP selected is Greater Preston and Chorley & South Ribble. A workshop has been Lancashire ICP scheduled for the 9th July where processes will be mapped. Additional mapping and review of the MSK pathway will be included.

Next steps: a task & finish group will be established to act upon the findings of the workshop and make recommendations for next steps. Blackpool Fylde & Wyre ICP booking and scheduled will be reviewed next.

Initial meetings have taken place with Legal leads from all Trusts to gauge appetite for exploring collaborative working. Legal Collaborative Next steps: a meeting has been scheduled to explore opportunities 5th August 19.

· The task and finish group has been established, with the deputy CFO at Blackpool Fylde & Wyre CCG as user lead. · Financial leads representing all organisations throughout the ICS footprint are working together to identify opportunities for reduced transactions and subsequent delays in financial transfers between partners. This is expected to reduce processing costs and processing times between partners in the ICS. Non-Patient · The project scope and terms of reference have been agreed. Transport · An initial scoping of financial data has been agreed and data collection is ongoing. Collaborative Next steps are to agree the categorisation of transactions and the cost implications/opportunities to all of the partner organisations. Processes will then be developed to streamline the inter-organisational transactions.

Temporary Workforce · The task and finish group has been established with the HR director for Lancashire Teaching Hospitals Trust leading. Meetings are held fortnightly. · The group is working together to establish a market management approach which uses the leverage of bulk spend across the region to re-shape the market relationship, improve control and allow the trusts to set out mandated requirements for suppliers to

our region. Key benefits of this approach include: improved quality and compliance, ensuring that all providers are on framework and only professionals that are fully compliant are presented to trusts; incentivising the right behaviour from agency providers Temporary though a tiered approach to opportunities; professionalising the market; removing or demoting agencies whose staff work on Staff Workforce bonus/shift; creative approaches to specific speciality shortages; harmonised T&Cs meaning that agencies and staff cannot play collaborative off one trust against another; reduced spend through consistent rate cards across the region. · The group has gathered data and have agreed bank rates for Nursing and Midwifery staff which will reduce competition a nd improve retention rates as well as agreed a core offer of training and benefits. A paper is currently being drafted to present to trust boards that will demonstrate the potential improvements in both quality and costs. The proposal is costed, with timelines for implementation developed. It will also include a proposal for a Nursing and Midwifery agency framework across all trusts. · A subgroup has been convened to develop the agency specification with input from key clinical personnel. This, along with

Page 152 Page the bank arrangements agreed, will be presented to HR directors and boards in the trusts.

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Next Steps: scoping and data collection for review of Medical Staff rates (bank and agency), preparation for framework roll out for Nursing & Midwifery Agency and Bank rates across all Trusts

Achieved this month: Planned Care, UEC, AMH and LD are progressing work to complete the prioritisation template. Workforce mapping is continuing in parallel with this work. Interim outputs from this work will be considered at COG on 16th July with a final versions used at COG in August to consider how capacity might be best aligned to support delivery of priorities.

Current milestones for workstreams have been mapped along with benefits, measures, decision dates and places. These will be updated to reflect the outputs from the prioritisation work and will be used to inform the JCCCGs work programme.. Commissioning Commissioning Development Development The Cancer Portfolio recommendations were presented at JCCCGs on 6th June and agreed.

Next month: Work will continue on the actions from the April COG meeting including prioritisation, workforce and milestones.

Issues: No issues

Blackpool Emergency Services Pathfinder update: Project Manager met with A&E representatives. It was agreed that the paramedics would need to liaise with the British Red Cross worker when they receive a call from a 'High Intensity User' (HIU) who might be best served in being supported out of hospital than within. Plans are now being formulated based on this. Digital Exemplar update: iPlato deployment approaching 90% deployment. 915k preGP licenses enabled Digital Empower the 124k MyGP users Person 13k MyGP users in last month 15k appts booked in last month 7k appts diverted NHS Orb project update: The App to be launched on Apple store on 21 July., Digital & IT Population Health Management Programme: On 3 July, the Director of Public Health, Dr Sakthi Karunanithi presented to ICS Board, key achievements and next steps of the PHM Accelerator programme. There were representations from Chorley Central, Digital Pennine Lancs (Burnley) and Optum. The Board were very receptive and agreed this will support implementing the Long-Term Estates and Plan as well as the emerging PCN. Technology Transformation Plans are now being drafted on how the programme will be managed going forward. Digital Discharge project

Page 153 Page Funds update This is a new project, there will be 5 projects that will sit under the umbrella of Digital Discharge and are working through project proposals/ IG and consulting with relevant partners on the best delivery models. 1) ELTH Remote monitoring of ventilated patients.

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2) Remote monitoring of patients to support earlier discharge from ICU– ELTH - We are working to introduce a wearable medical device in the form of a biosensor. 3) Clitheroe Community Hospital Discharge pathway activity levels - Working with the Integrated Discharge Team to implement and use Fitbits within a test for change as a rehabilitation aid, to monitor activity, formulate specific treatment plans and accurately evaluate the outcomes of treatment whilst on the ward and then evaluate discharge pathway activity levels. 4) Digital health and wellbeing hub – Blackburn Central Library - Blackburn Library are creating a health and wellbeing hub in an area of the building that is open and visible to the public. Initially we will be working with them to provide digital techno logy that was utilized in the Test Bed Programme to promote the use of using digital technology and self-care. In addition, we are looking to build in a walk in GP video consultations area which would be utilized by homeless people, people who are not registered with a GP etc. 5) Exploring video conferencing as an aid to discharge - Xuper - This could be a solution suitable to be used at scale. E.g. To support timely discharge to care homes.

Progress continues on the HSLI programmes A) Patient Platform - Cloudwick and ANS have arranged connectivity transfer from Cloudwick to ANS for AWS. Provider of the platform has now commenced building the test environment. An overview of the platform was showcased by Nick Wood (CCIO) and Pete Smith (SRO) at the iLinks event held at Aintree on 4th July. B) Decision Support Tools Progress to update :

• Development of implementation critical paths for localities has commenced with UHMB. • LCFT are engaged with UHMB with a plan to begin a pilot in the Morecambe Bay localities from September 2019 • Scoping of the Morecambe Bay solution is underway and further sessions have been arranged to complete this work. • Smartsheet has been updated with the project risk register. • Further engagement has been undertaken with East Lancs and with Fylde Coasts colleagues.

Next Steps Digital Health System • Locality implementation critical paths to be finalised. Led Investment • Smartsheet updated with key project documents • Finalise the scope of the Morecambe Bay A&G solution & confirm implementation costs to be confirmed/formalised. • IG arrangements to be confirmed. • Mapping of interoperability to be carried out for each locality • Establish baseline data requirements to underpin benefits realisation planning C) Sharing of Health and Social Care Records PM has met with the CIO at ELHT to agree process to release/transact funds. It was agreed to document, and track spend. A Change Manager has been identified at the Blackburn Council to assist with the project. GL has met with the change manager to discuss our project plans and has been shared the detailed plan and additional (draft) governance documents with the change manager. Arrangements to generate PO number to fund this post is being planned. GL met with Servelec rep on 14/06 to discuss our requirements in terms of system integration between the two unitary

Page Page councils and LPRES. We have asked for the commercials and costs involved to configure the systems. Email reminder has been sent. We are now raising this issue with relevant senior managers, as the time delay will impact the delivery of the overall project. 15

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Digital Deployment of Docman across Lancashire. User Access Testing (UAT) to commence on 12th Aug. Integrate Services Digital No further update. Programme Lead has been appointed and will commence post in Aug. Projects had lost some momentum Managing however with this appointment, we aim to pick up the momentum and report on this. services more effectively Digital Pioneers Project update: 51 applications have been submitted. Digital Of those approved 25 have started their projects, 2 have a start date of September 2019, 4 have withdrawn and 5 did not meet Support the the criteria. frontline The remaining 15 were discussed at a panel meeting on 1st July 2019 and discussions are ongoing to confirm which applications are successful.

The Our Digital Future ICS delivery plan was approved at ICS Board early this year.

Project managers have since been appointed, and SROs identified for many of the identified programmes of work.

The 5 ICPs are working on understanding the implications of the plan to them locally, with each being asked to provide a Digital Delivery response that will be consolidated and presented to the ICS Board in August.

Governance and leadership of the Digital Programme is also being refreshed – with the support of the ICS Programme Management team – to ensure a robust governance and assurance framework exists around this key enabler workstream to optimise pace and success.

Estates achieved this month: 1. PID superseded by NHSE business case which is a co-produced document with Birmingham and Solihull CCG and is being submitted to NHSE on the 4th July. A significant amount of work has been undertaken during a 7-day turnaround to meet NHSE deadlines and produce the business case for digitalisation of Lloyd George Records 2. First HEDs Programme Board took place on the 12th June, LD Steering Group took place on the 19th June and CAMHS first Steering Group set up for 24th July. Education and Training first Steering Group to be set up before end of July. 3. Final draft of MOU progressing for sign off on the 9th July Finance & Estates 4. Wave 5 and Strategic Capital Planning workshop took place- well attended event which helped inform the estates strategy Estates highlight report update 5. Estates and Infrastructure Strategy submitted to the ICS Board on the 3rd July ready for submission to NHSE/I on the 15th July 6. Business Case training (5 Case) set up for Lancashire and South Cumbria for NHS provider Trusts and colleagues for August 2019 7. Smartsheet reporting and programme plans set up for estates workstreams

Page 155 Page 8. Scoped alternative office accommodation and underway with evaluation, costs and proposal. 9. Library House surgery visited to look at specific storage issues and further visit to be planned for Bay Medical. Estates planned next month:

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1. Continue to develop Smartsheet reporting 2. Business case templates to be developed 3. Further HED Board to be set up by LCFT 4. Future capital planning workshop planned for November 2019 5. Secondary Care questionnaire (paper medical records) visits to be organised to enable correct completion of required information 7. Set up backlog programme and reporting 8. Strategic Estates Team formal ICS update meetings with Trusts who have successful capital schemes. Met with BTH (W4), need to meet LCFT (W4), Pathology(W3) and ELTH (W1) 9. Continue consolidation of LAR report 10. Continue supporting provider Trusts with business case and capital planning 11. Initial discussions about future updates for L&SC Estates and Infrastructure Strategy (and supporting ICP Estates and Infrastructure Strategies) to be held at Motor Group 12. Need agreement off NHSE to agree process for office moves

Recruitment completed for two new roles with start dates on 22 July and 12 August. Engagement plan being implemented across ICS with elements led by ICPs to support the strategic narrative. Toolkit launched to support local teams and leaders. Healthwatch are undertaking public focus groups. Involvement, Comms & Marketing Campaigns launched for Diabetes - Your Diabetes Your Way and Cards for Kindness initiatives. Communication engagement Engagement report summarising the co-production programme for the CAMHS redesign in development for evaluation process. & engagement Building Health Partnerships event planned for July to support establishment of local test initiatives, development of principles for working between VCFS and statutory sector and set up of a Voluntary Sector Partnership Alliance aligned to ICS.

Early: clinical codes being finalised with support of the CSU.MOU with the national team agreed. Facilitator identified. promotional materials being developed. Launch with expressions of interest on 1st August. SHADOW: care home vents completed. Evaluation being drafted to go to regulated care quality group. ACP: developing plans with the education hubs to extend the programme utilising Macmillan funding. ACST: procurement process underway. EPaCCS/LPRES: network report finalised. Meeting planned Palliative care with Digital Workstream to appoint project manager. Macmillan Collaborative project: Steering group membership still to be highlight report finalised; commissioning representation and hospice representation outstanding. Locality plans due in this month; they will inform the investment application. PBNA Toolkit: finalised awaiting additional information for the foreword and then this will be disseminated with a how to guide. Out of hospital Quality Workstream HLSC Contract and Quality Management System - The system has been live for a couple of months and providers have experience of completing and reviewing the questionnaires (e-forms). Providers have been invited to review the system and Regulated care current e-form questions in a workshop to provide opportunities to feedback on 1st August. programme

highlight report Page 156 Page Enhanced Health in Care Homes - All CCG’s have submitted their completed EHCH benchmarking templates and work is underway to analyse the returns. There is a national review of the current EHCH Framework, which was published in 2016, the focus areas are the clinical elements 1 and 2. Enhanced primary care support and multidisciplinary team support. These are

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reflected in the long-term plan and the national ‘Aging well’ agenda.

Finance & Contracts Workstream Service specification - The service specification has been sent to Healthwatch for service user viewpoint and further clarification meetings are taking place with colleagues from CCGs and Local Authorities. A process of engagement with care providers will be undertaken with a survey in July and an event in September to assess feedback, alongside a review of the implementation of the service specification within each of the partner organisations.

Fees development – A CCG CFOs meeting taking is place in July to update on issues relating to the Regulated Care Workstream and in particular, the pricing framework for contracts.

Workforce Workstream Apprenticeships - The Strategic Apprenticeship Group are submitting a business plan to go to LWAB in July for a Rotational Integrated Apprenticeship, working with colleagues from across health, social care and the county council. It is for 100 apprenticeships integrated across L&SC with placements in social care/ acute/ primary care/ mental health, to launch March 2020 with approx. 20 in each ICP undertaking a Level 3 health & social care apprenticeship.

Social Care Recruitment Summit - The work continues with the development of our Social Care Recruitment Summit in October. Key speakers have been confirmed and we are also in the process of asking stakeholders to 'hold the date'. Providers will receive details of ‘How to deliver apprenticeships’, Careers fairs and local FE/HE courses available to social care staff.

Trainee Nursing Associate Programme - On 27th June a workshop took place for Nursing Home and Domiciliary Care Service Managers at UCLAN to introduce the Nursing Associate programme and delivered messages of how this can support future workforce requirements, explained apprentice and employer commitments, and next steps for local recruitment to the programme. The workshop was attended by Service Managers, Proprietors and Clinical Leads, and has potential to rollout to other areas.

Diabetes Prevention Programme (NDPP):

Programme Update From August 2019, wave 4 of the NDPP will begin, with Lancashire & South Cumbria coming together as an NDPP footprint with a new Provider and a digital element.

Bi-weekly transition calls continue to be held until 15th August 2019 to track progress & ensure key milestones are being met Prevention & during transition to new provider and new geographical region. Population Diabetes Health Wave 2 of the programme in Lancashire draws to a close, with 31st July 2019 being the last date to refer to the current provider. The partnership have met the target number of initial assessments set by the National Diabetes Programme Team and move into utilising an additional 10% cap increase over June and July as agreed with NHSE.

Page 157 Page Key Risk & Issues A number of risks have been highlighted during transition:

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• Transfer of patients between providers – work is being done to enable transfer of patients with as little disruption as possible, so as to not disengage patients or referring practices. • Staffing – x2 current members of staff are working on fixed term contracts. Work is being carried out with both providers and the CCGs involved to manage these positions going forward. • Leadership of the new Partnership for wave 4 to be reviewed as the geographical area and provider change. Capacity of CCG Leads to be discussed at the next CCB for the new partnership over the 3-year contract for Lancashire and South Cumbria. Currently managed extremely well by Fylde Coast CCGs, however equity of workload may need to be considered going forward.

Diabetes Treatment & Care Programme (T&C):

Programme Update All Delivery Plans and signed MoUs have now been submitted and signed off by the North Regional Diabetes team for the x8 Project Sites who have received tapered funding during 2019-20.

Site Assurance visits by the SCN are currently being diarised to discuss 2019-20 quarterly returns. Q1 project delivery and finance returns will be due end July 2019 from project sites. The SCN team continue to work with project leads to meet submission deadlines, assure project delivery milestones and monitor KPIs.

Structured education ICS project Morecambe Bay will roll out Your Diabetes Your Way website in July 2019, promoting self-referral onto face to face and/or digital structured. Supporting documentation for practices and their patients is in transit and should simplify the referral process during appointments and on diagnosis. The self-referral website will be promoted on BBC Radio Lancashire (Blackburn) 4th July by Active Lancashire during a talk on diabetes and getting active.

Key Risk & Issues • Project sites are at risk of having future quarterly funding withheld if they continue to miss deadlines • Local plans for further funding once tapered monies are utilised are essential, as these monies may not fully cover staffing costs for a full year. Sites will need to ensure that they can fund roles once project funds have been utilised.

The MECC link https://www.mecclink.co.uk/cumbria-lancashire/ has a number of providers listed. It's going to develop into a great resource for practitioners. - Train the Trainer procurement: A provider has been commissioned and a contract issued; - The Communication Campaign proposal is close to being finalised. Next Steps: MECC 1. Mapping senior stakeholder engagement and partnerships; 2. Options for an engagement / launch event e.g. 'World Café' approach – possibly joining with planned event(s) that MECC could link with;

Pag 3. Programme development is gathering pace:

a. Focus Groups for MECC branding and packaging are ready to be scheduled and we have secured commitment from multiple e 158

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services and partners; b. Train the Trainer courses - starting in autumn 2019

Programme update The Lancashire and South Cumbria (L&SC) Level 1 Demonstrator site for Personalised Care 2018/19 has now ended, with L&SC defined as an exemplar site. Activity reporting far exceeded the annual targets set by NHS England, with almost 92,000 community-based approaches recorded and over 56,000 self-management interventions provided. The small team currently working on this agenda will continue to spread the acquired knowledge and experiences nationally, whilst seeking to scale up this

agenda at pace, in line with the new 2019/20 Memorandum of Understanding (MOU). Current areas of focus will remain (PAMS, CBA, SM, PCSPs & PHBs), plus the addition of new areas, such as shared decision making, etc, the targeting of specific population groups and expansion of the PC model across additional service areas, such as End of Life care. PAM usage continues to be scaled up and has been used throughout the PHM accelerator programme. The PHM pilot areas have used PAM to help tailor their interventions and also to measure outcomes. In this programme PAM has been used within primary care and third sector community services. Health coaching training programmes have been running regularly to continue to support our wider workforce gain knowledge, skills, and confidence to have better conversations with the people they are working with.

Key developments this month: PHB Task & Finish Group met on the 11th June. Presentation of the Personalised Care Model and PHB model at the L&SC Delivery & Oversight Group for EoL on the 19th June. Personalised Personalised Care Event: Making it Happen, took place on 26th June – Over 130 people attended. Care Meetings booked in throughout June/July for AC/TP to meet with each of the ICP Personalised Care Leads and Population Health Management Leads.

Risk There is a risk to the programme as a whole, particularly in terms of the spread and scale of the Personalised Care Model throughout 2019/20. Continued leadership and direction, together with extra capacity within key co-ordinating and delivery roles will be required to further expand personalised care approaches across the system.

Additional information:

• Over 130 delegates attended L&SC PC ‘Making It Happen’ Event which will enable spread and scale across a wide variety of organisations and services

• Demonstrator site activity end of Year 1 achieved almost 92,000 community-based approaches recorded and over 56,000 self- management interventions provided.

Population Health Management update: The 20-week accelerator programme concluded on 07 June with its objectives Population Page successfully achieved. Neighbourhoods are now working collaboratively to apply their leanings and spread adoption and change. Health 3 of the 5 neighbourhoods have identified their next. Population Health Management Programme: On 3 July, the Director of Public

15 Management Health, Dr Sakthi Karunanithi presented to ICS Board, key achievements and next steps of the PHM Accelerator programme.

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There were representations from Chorley Central, Pennine Lancs (Burnley) and Optum. The Board were very receptive and agreed this will support implementing the Long-Term Plan as well as the emerging PCN.

Plans are now being drafted on how the programme will be managed going forward. Programme Update: The Stroke Prevention Alliance recently produced a comprehensive five year Stroke Prevention Strategy which, in line with the successful experience of other countries, has a central focus on the identification, diagnosis and management of the key risk factors for Stroke of AF, Blood pressure and Cholesterol often referred to as 'Know Your ABCs' as outlined within the recently published NHS Plan. It is of note that both our community case finding approaches for both Atrial Fibrillation and Hypertension

have now gone live and evaluation results are expected later in the year. Our clinical engagement approach with ICPs/CCGs is continuing and we are actively linking in with the RightCare NPI approach to help ensure a co-ordinated and system wide response. In order to support ICS System Leaders, we have additionally produced a 'Stroke Prevention – Spotlight on Stroke Hypertension' Infographic and envisage expanding this approach to other key risk factors if this approach is felt to be helpful. Prevention Finally, we are now actively in the process of considering how best to support local development of NHS LTPs now that the national Implementation Framework has been published. Key risks/issues: 1) Whether key enablers are in place, i.e. sufficient workforce capacity in primary care, sufficient clinical leadership at ICP level and levels of funding to deliver on current action plan. Conversations will need to continue at ICS Level and between the ICS Work streams to continue to move this forward. Discussions currently ongoing through the ICS Primary Care Transformation Team (AMBER) 2) Whether the ICS system will be able to agree on a common set of standards, metrics and targets to support the delivery of this work programme. Currently being explored through the ICS Primary Care Standards document. (AMBER) 3) ICS Clinical Leadership Funding. Mitigating actions: Currently relying on historical underspend from 18/19 to support delivery for 19/20. Now resolved. (GREEN) Strategy - The UEC strategy paper is currently being drafted by the Urgent Care Leads and the UEC ICS Team following the release of the LTP. The draft paper will be shared with the Urgent and Emergency Care Network (UECN) in August for endorsement and will be presented at the Joint Committee of CCGs in September. The L&SC UEC vision has been agreed and will be recirculated as part of the strategy work. Work continues through the UC Leads to finalise the Terms of Reference and review the current membership of the UECN.

Respiratory - Following discussion at the North Region Respiratory event on 15th May, and the Urgent and Emergency Care Network (UECN) there was agreement to develop a brief Strategy around COPD and Asthma. The intention for this is to provide a Urgent & UEC Highlight Lancashire and South Cumbria ICS direction, with implementation by each ICP. emergency report Care Integrated Urgent Care - Following a presentation at the UEC Network from Greater Manchester on the work done so far on their IUC model, there was a commitment to exploring if something could be tested within the L&SC Urgent Care system, continuing from the scoping work that had started earlier this year. Further meetings have been arranged to progress this work.

Workforce - A baseline is being pulled together to understand what work is already being done. A scoping paper will then be

Page 160 Page pulled together to look at which areas of the UEC pathway can be explored in further detail. This will be linked into work being done in other workstreams, for example discussions with Primary Care will take place to ensure links are made around PCN development.

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Digital UEC - The Business Case for the Response & Lifting Service was supported by the CCB and has now been approved by the CCGs. Procurement will begin for this service across the ICS footprint in the next couple of months. The Escalation Management System across the ICS will be put in place shortly, the implementation plan has been circulated. EMS+ was made for health and social care organisations at strategic, tactical and operational levels to measure operational pressures, and effectively co-ordinate patient flow through their health economy. Real-time decision making is made possible using live flows of information from A&E, ambulance and hospital wards and real-time patient tracking. There are plans for the access to Mental Health Crisis Plans in ED to link to existing systems.

Patient Transport Services – A workshop session was held towards the end of June with commissioners, NWAS and the Acute Trusts to consider short, medium and long term actions that can be taken to support the current contract and inform the future contract. There was good representation with a commitment to meet again in July to look at some of the short to medium term actions discussed.

Mobility Hub: The LSC web pages launching It’s Your Move are being finalised and due to be published later this month. The Provider Trusts are confirming their priority focus for supporting colleagues to move and retain their skillset in the Lancs and South Cumbria area. LSC Clinician Passport: The Clinician Passport for the Urology Collaborative is progressing. It is also being used to support staff movement through a virtual rota across 2 Provider Trusts. Early discussions are commencing regarding oral and maxillofacial and head and neck cancer work streams. Discussions are underway regarding a passport for dentistry across

Lancashire Teaching Hospital and Morecambe Bay Trust. LSC New Starter Portal: This is a digital on boarding system approved by LWAB. Provider Trusts are agreeing internally how to provide new starter information for the new portal. The Workforce team have also supported the recent Primary Care Roadshows.

As part of the work to develop L&SC as an exemplar region for HEE’s Global Engagement programme, UHMB hosted a visit with officials from the Pakistan government on 12th June who took the opportunity to meet some of the overseas nurses recruited via Workforce, 1. Workforce the programme to hear about their experience. East Lancashire and Lancashire Teaching Trusts will each host a visit of 4 Leadership & Development officials from the Government of Kerala, India on 16th July in support of the ongoing programme of recruitment of nurses from that Organisational Highlight area of India. We will shortly start to evaluate if there is scope to offer a global exchange programme via GLP for our qualified Development Report nurses to support their development to help to attract and retain the nursing workforce in L&SC. We will also commence work on the medical workforce strategy for international recruitment across the ICS and a joined-up approach to the Certificate of Eligibility for Specialist Registration (CESR) process for doctors.

Careers: As part of the work to increase Cadet/Health and Social care student numbers across the full range of organisations, we have been working with Colleges across Morecambe Bay. As a result of this work, BHCP will now host over 170 student placements across Health and Social Care from September. The Task and Finish group for the Rotational Integrated Apprenticeships have now written the business case and hope to go out to key stakeholders in each of the ICP to progress understanding of how a rotational model might work and which elements of the Adult Care standard might be used for each

Page 161 Page organisation. Now that our system wide Apprenticeship network is working well, we have begun work on developing an Apprentice network for Apprentices. We have piloted an Apprentice swap opportunity and intend to roll this out quarterly.

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Talent management o Attended the NRTB to make links and introduce HPS, had a development meeting with other system talent leads and NWLA to discus and scope the role. Recruited to the band 5 business support officer, the band 7 is going to external advert. o The High Potential Scheme (HPS) – had a successful kick off meeting on the 26th June with partners from across each ICP and the National leadership academy. We set the scope, and honed actions and timeframes for the programme roll out. Decided to spend the rest of this year promoting the scheme, identifying assessors, honing the development programme and getting candidates. Have pushed the assessments back to January 2020 with our first cohort on boarding onto the programme in April / May 2020. Will start to identify possible assessors in the next 2 months. ICS wide system leadership development o The 100 leaders program for mental health and cancer leaders/influencers – this is in the initial stages of development meeting have been taking place with Cancer and MH leads in order to scope the programme and make it as effective and useful as possible. o A project plan is in development for this. Organisational development o ICS leadership behaviours – attending various exec team meeting to present the plans for this and are following up with individual execs and their teams to ensure full by in. Once buy in is achieved will carry out a board and sub-board diagnostic of system leadership culture, this will inform an OD programme of work and support. Will develop the diagnostic and test throughout July and August 19. o ICS internal behaviours – completed a proposal to exec and will start to engage staff on this in July and August. o An OD collaborative – The Innovation Agency are support us with scoping this work contact has been made with the OD leads to begin this work. Issues: There will be possible resource issues going forward, the talent roles are out to recruitment but may take up to 3 months to get the posts occupied. In the meantime, work is ramping up around 100 leaders, HPS and talent mapping. A resource mapping exercise is underway to inform discussions around this." Page 162 Page

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Lancashire and South Cumbria ICS Programme Evaluation 2018/19

May 2019

Version 1.2

Page 163

Contents

Section Title

1. Executive Summary

2. 2018/19 Priorities

3. 2018/19 Deliverables and Benefits

4. Lessons Learnt

5. Action Plan

6. 2019/20 Delivery Plan

7. Recommendations

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1. Executive Summary The Lancashire & South Cumbria Programme comprises twelve portfolios of work to be delivered across Lancashire & South Cumbria, categorised by clinical, strategic and enabling themes. Portfolio Leads and an Executive sponsor were confirmed for each portfolio during October 2018. Each Portfolio Lead provides leadership and direction to their portfolio on behalf of the partners across Lancashire & South Cumbria.

This paper evaluates the key deliverables and challenges of these portfolios and their programmes through 2018/19 with an update on the progress made and the associated benefits. Throughout the year teams have experienced significant challenges affecting programme delivery which predominantly relate to the need to strengthen governance and agreed systems and processes. These are explored as themes within section 4 and have led to the development of a subsequent action plan (section 5) aimed at resolving or minimising the impact of these challenges in the future.

Work continues in 2019/20 with the programme teams under the Lancashire & South Cumbria Programme focusing on their existing objectives for the 2019/20 Delivery Plan. However, with the development of the revised ICS strategy and pending agreement on the ICS-level clinical priorities and programmes, it is anticipated and planned that these objectives will be redefined in 2019/20.

2. 2018/19 Priorities The priorities for the Lancashire & South Cumbria Programme in relation to the twelve portfolios were initially developed through the strategic framework approved by the ICS Board in May 2018. Clinical priorities were agreed by Accountable Officers and Chief Executives and selected because of the urgent need for change due to the fragility of services affecting the region. This led to some existing programmes of work across Lancashire & South Cumbria being formalised as part of the Lancashire & South Cumbria Programme and new programmes established to effectively deliver the priorities, the scope of the work and objectives agreed.

Since this time, progress, monitoring and reporting has been overseen through the Portfolio Management Group, the ICS PMO and for the commissioning development programme; the Commissioning Oversight Group. An end of year evaluation was carried out during March 2019 with the programme teams, and the outputs of which are summarised within subsequent sections.

3. 2018/19 Deliverables and Benefits Due to the quantity and scale of the programmes, Table 1 below outlines the key deliverables against each relative portfolio, during 2018/19 and the associated benefits realised through programme delivery. This table is intended to provide a highlight of the work undertaken by each portfolio and their outputs. Any benefits anticipated during 2019/20, or from objectives not yet fulfilled, are not included within this report and will be monitored until completion by the Programme Management Office, along with the portfolio teams.

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Table.1. Portfolio Deliverables Benefits Better Births Better Births  Development and implementation of a suite of pathways for Mental Health in the Perinatal Period including:  Facilitation of a cross discipline, North West Coast wide clinical  Universal pathway for antenatal and postnatal mental health network for Perinatal Mental Health including shared learning and  IAPT pathway for clients in the perinatal period including resources for clinical teams supporting documents  Inclusion of families with lived experience of Perinatal Mental  Local implementation pathways for Specialist Perinatal Health in the development of services. Mental Health Teams  Shared learning and improved consistency across approached  Development of awareness raising materials for supporting and multiple pathways within providers. pre-conception care for women with mental health needs  Local heath and care services for women level were possible to  Support to the development of the new Specialist Perinatal improve access and health and wellbeing outcomes. Acute & Community Mental Health Team and Mother and Baby Unit  Long-term reduced cost of long-term conditions across the system Specialised  Development of a regional guideline for Perinatal Mental  Women supported in developing their own care plan and choices Services Health / improved monitoring.  Better Training Better Births consortium extended to include  Evidence shows that continuity models improve safety and all 4 maternity providers in joined up consistent training. outcomes. In particular:  A joint policy agreed and implemented for the care of women  7 times more likely to be attended at birth by a known midwife who may need neonatal intensive care.  16% less likely to lose their baby and 19% less likely to lose their  Regional guidelines developed to improve maternity safety baby before 24 weeks   Community Maternity Hubs set up across identified 24% less likely to experience pre-term birth  15% less likely to have regional analgesia neighbourhoods in Lancashire & South Cumbria 16% less likely to have an episiotomy  Standardised personalised care plan agreed  Reduction in the need for additional procedures; and cost benefit  Continuity of Carer model and pathways in place (for most to the wider maternity system. women). Exceeded target of 20% with 30.6% of women  Increased number of women breastfeeding their babies: improving health booking into maternity services being booked onto a outcomes for mother and child Continuity of Carer pathway in March 2019 across the LMS.  Improved resilience in workforce and reductions in costs of locum/agency

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Portfolio Deliverables Benefits  Sustainable workforce transformation plan & strategy in  Reduce cost of identified processes and procedures where digital place including exploring of radical workforce reform and solutions have been implemented. Also providing a better experience for increased utilisation of technology women using services.  Implementation of digital solutions for maternity services i.e.  Women can access their personal maternity record on-line giving them Digital Personal Care Record greater visibility, control & knowledge of their personal health information  Implementation of the UNICEF Baby Friendly Initiative (BFI) across all acute and community providers Paediatric Services Paediatric Services

 Establishment of an acute paediatric work stream board  Completion of a Case for Change demonstrating the fragile  Shared learning and establishment of a clinical network approach nature of acute paediatric services and the need for urgent to acute care review and recommendations for:  Able to quantify and demonstrate the position in order for  New innovative workforce solutions resources to be committed  Potential changes to in patient sites  Position agreed to work with Specialised Commissioning  Modelling of future provision of HDU / L2 PCCUs across colleagues for the future provision of L2 PCC and specialised L&SC resulting in 1-2 units in the future surgery.  Development of consistent pathway for children diagnosed  with ASD / ADHD in response to the Ofsted SEND inspection  Reduced variation  Development of formulary of diagnostic tests for children  with developmental delay  Meets urgent action required by Ofsted  Full workforce review undertaken of women and children’s  services  Fundamental element of the case for change  2 Children’s Assemblies run for anyone working in paediatrics

Stroke Services Pathway Redesign Stroke Services Pathway Redesign

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Portfolio Deliverables Benefits  Development of a single Lancashire & South Cumbria  Consistent and evidence-based model for delivery to all the continuous improvement provider plan Lancashire & South Cumbria population with agreed consensus  Development of a report and associated business case for amongst clinicians. Improvements already made to standardise integrated community stroke rehab service provision and existing elements of the service. recommendations.  Significant staff, patient and clinical engagement through the  Development of an ambulatory care model / pathway for development to gain support for the model which will ease stroke services. implementation of the model and pathways.  Modelling completed to support development of options for  Clear understanding of current pathway regarding impacts delivery of hyper acute stroke care (operational flow and financial) of service enhancements

Head & Neck / Vascular Services Head & Neck / Vascular Services  Collaborative working between provider organisations with Robust process, governance and engagement followed with significant clinical engagement. arrival at options for both clinical models.  Wider staff and patient communication & engagement ongoing  Key external stakeholders e.g. Specialised Commissioning, GIRFT and RightCare engaged and members of Steering Group to gain support for the model.

Diagnostic Services Diagnostic Services  Improved, sustainable services and improved quality and reduced  IR network pathways for Out of Hours emergencies and variation for patients needing services. service definition.  Collaboration amongst providers in these service areas including  Out of Hours GI Bleed pathway agreed regional networks established to support ongoing collaboration  Endoscopy review report/recommendations and action plan and relationships. delivered. Cancer Alliance Cancer Alliance  Improved support to patients with cancer. Endoscopy nursing  Investment in Cancer Workforce: Endoscopy Nurses, support has also supported improved booking procedures for Urology, and Lung Cancer nurses patients undergoing a diagnostic scope

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Portfolio Deliverables Benefits  Purchased additional ‘kit’ to implement Point of Care testing  Reduced delays for CT and MRI for patients awaiting cancer in radiology in all 4 Trusts diagnosis due to not having a recent blood result at the point of the  Investment into the Upper Gi Surgical Centre to establish a Imaging appointment pre-habilitation service to Upper GI cancer patients  Support earlier diagnosis of bowel cancel. Significant data  Implemented FIT for symptomatic patients in all GP collecting now being undertaken to produce some audit results to practices across the Alliance footprint continually improve this service and outcomes  Funded and supported a Patient Navigator in each of the 4  Support into Trusts to help achieve compliance of the 62d cancer Trusts waiting time target particularly in Lung, Upper Gi, Colorectal and  Extensive pathway redesign in Upper GI Prostate Lung and Prostate pathways Colorectal cancer pathways  Improved the patient experience and minimize delays – supporting  Supported Providers with the implementation of mpMRI compliance with cancer waiting time targets. Wide ranging system before biopsy in the Prostate pathway improvements in all pathways improving flow and efficiency  Funded a pilot to introduce GP direct access for Lung CT  Improved the patient experience, minimize pathway delays and requests at Blackpool (for suspected cancer patients) achieved compliance with national guidance  Commenced planning for multi diagnostic clinics in all 4  Pilot successful so GP direct access for CT lung continues at Trusts (vague symptom clinics) Blackpool. Enhanced patient experience and minimised delays in  Implemented a new pathway? for breast cancer patients in the patient pathway. Supported earlier diagnosis for suspected follow up – Risk Stratified Follow Up. Pathway agreed and lung cancer patients implemented in all 4 Trusts  Planning developed and service will commence in at least one of  Project Plan established to design and build an IT solution our Trusts in Q1 to support Risk Stratified Follow Up and a patient portal to  Enhanced patient experience – less visits to Hospitals after support patients on self-managed follow up treatment. Provided some capacity in hospitals to accommodate  Commenced designing e-books for some cancer tumour the continual increase in demand groups  Example of strong working between the Cancer Alliance and the  Well Being & Employment Service established in all 4 ICS Digital Solutions Team Localities (sub-contracting to Lancs County Council)  Improved patient communication – patients will be able to access  Rolled out a bowel screening alert in high percentage of GP information about their cancer and support via an e- book system Practices across the Alliance (implemented in 160 + GP  Example of partnership working between Alliance and Local practices) Authority. Service is available to all cancer patients who wish to seek wellbeing support and introduction back into the workplace

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Portfolio Deliverables Benefits  Supported GP Practices to participate in a standardised  An electronic alert now enables GPs to be notified of a patient who audit – Significant Event Audit of patients diagnosed with has declined a bowel screening invite through an opportunistic Lung Cancer in the last 3 years (400 returns from 150+ GP event when they visit their GP (‘Every Contact Counts’) practices)  Shared learning and implementation of recommendations from the  Continued development of the Cancer Alliance Dashboard audit results – partnership working with UCLAN to support the  Funded an endoscopy review across the Alliance including evaluation of this a review specifically to look at capacity for the bowel  Central point of cancer data intelligence to support planning and screening programme service delivery  Sustained support to the Network Site Specific tumour  Results have provided valuable information which has also been groups shared with the ICS diagnostic group  Patient Experience – strengthened our ‘Patient Voices’  Continued strengthening of clinical leadership, through the tumour membership specific groups to support the cancer alliance work and the national cancer agenda  Link re-established with a patient experience user group to provide valuable patient / service user insight into cancer developments

Primary Care Primary Care  41 Primary Care Networks (PCNs) have been established  Significant engagement with GP workforce and relationships built across the ICS as a result of this to drive forward further development of PCNs.  ICS-wide primary care plan has been developed which  Digital technology is improving efficiencies and again better includes all components of primary care services not just access. medical and as such dental, pharmacy and eye care  Improved access to primary care services services are also starting to align to PCNs.  Better integration between pharmacy and primary care as well as Out of  100% Delivery of extended access improving access for the population by creating additional capacity Hospital  Delivery in full of GP Resilience programme and in the new roles. implementation of online consultation. This was delivered through the digital exemplar programme and commended for it’s robust process.  Delivery of £2m cyber security technology bid under ETTF Delivery of Clinical Pharmacy programme

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Portfolio Deliverables Benefits  New workforce roles hasve been established such as PAs and Clinical Pharmacists .

Palliative Care  Advance Care Planning facilitator training; at end of Jan 19 Palliative Care there were 1,313 front line staff trained.  Improved care planning for patients at the end of life within  Developed early identifcation tool for use in generalpractice Lancashire & South Cumbria  Developed shadow early identifcation tool for use in care  Additional capacity to support LPRES with the digital workstream homes and domiciliary  There is now an understanding by ICS/neighbourhood of gaps in  care SPC advice and 7 day working  Rolled out Advance Care Planning facilitators and training  Being incorporated into ICS population health work days for front line staff  Produced an overview of use of electronic palliative care co- ordinating systems across L&SC Regulated Care  Successful collaborative procurement of Web based Quality Regulated Care & Contract Monitoring tool which will be a single tool with a  Promotion of collaborative working, standardization and single set of monitoring questions irrespective of whether the consistency applied to quality monitoring and the service provision is being commissioned by the NHS or LA. specification of regulated care services across health and local  The programme team have led and supported providers with government. the rollout of GDPR and the need to complete the DSPT  Consistent application and compliance with GDPR. toolkit for providers within the sector.  Improved relationships and pathways across NHS and local  A single service specification across all LA’s and NHS has government. been developed.  Reducing the vacancy crisis within the domiciliary care market to  Through the workforce campaign (local “pop-up” events) maintain service delivery across Lancashire & South Cumbria. have been able to support some local providers to engage Making providers more sustainable to continue delivery of service. with potential candidates to fill vacancies and support engagement with the potential workforce market.

Children & Young People’s Health

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Portfolio Deliverables Benefits  Completed children’s needs assessment identifying 6 key Children & Young People’s Health impact areas: smoking in pregnancy / perinatal mental  An understanding has been developed of the key areas affecting health/ infant feeding/ dental health/ school readiness and CYPH. Informed plans can now be developed for future services 'life' readiness and interventions.  The Adverse Childhood Experience (ACE)/Trauma Informed  Awareness is raised of ACE and there is now a shared Approaches work has included engagement of key public understanding and relationships developed across key sector leaders on ACEs and trauma informed care work (3 stakeholders which have influence over this area. safeguarding boards, public sector leaders, ICS Executive). The 2nd North West Conference on ACEs and trauma  Integration with better births ensures that there is an informed care (Jan 2019) understanding of the pathway and continuation of care through a  Delivered a shared lexicon on ACEs and trauma informed child’s development from birth and throughout childhood. care.  Engaged with Better Births programme – outcomes include the recruitment of a Prevention Lead within the Better Births team who is supporting maternity units on infant feeding, smoking in pregnancy and maternal obesity.  Developed a commissioning framework for NHS/ LA children and young people’s services.

 Roll out of 111 Online across Lancashire & South Cumbria.  Improved equity and capacity in access to non-emergency  Extended GP access implemented. services to support ED attendance and admission avoidance.  Upgrade of Urgent Treatment Centers  There is now additional capacity in primary care and within  Implementation of the Ambulance Response Programme communities for urgent care services. Urgent & (ARP).  Supported timelier discharge of patients from an acute setting and Emergency  Implementation of direct booking from 111 into Out of Hours returning them to their place of residence. Care & Urgent Treatment Centre.  Improved understanding of where capacity is available within the  Implementation of Home First and alternative pathways for system to support timelier discharge and transfer of patients once patients requiring a Continuing Healthcare (CHC) well enough to leave an acute setting. Assessment.  Real time care home capacity tracker for all CCGs

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Portfolio Deliverables Benefits  A Strategic Dashboard has been created to track, monitor  A single version of the truth to underpin emerging pressures and predict Urgent & Emergency Care pressures and across the health and social care system and evidence to prioritise interdependent indicators. further transformation and change.

Adult Mental Health (AMH) Adult Mental Health (AMH)  AMH was in the first phase of the commissioning  Improved collaboration amongst the network of AMH development and has aligned the commissioning across commissioners for centralised functions and improving Lancashire & South Cumbria consistency for the care provider, and service delivery.  Shared agreement on ICS Priorities for Adult Mental Health  Improved awareness, engagement and reduced stigma of mental services. health. Children & Young People with Mental Health (CYPEWMH) Children & Young People with Mental Health (CYPEWMH)  System wide collaboration and improved consistency and  The “Mental Health Anti-Stigma Campaign” has been priorities for CYPWMH. mobilised across Lancashire.  Singular approach to pathway redesign ensuring that there is  ICS wide CYPEWMH 2018/19 Transformation and Business equity in access, quality and improved consistency in provision for Mental Health Plan has been developed. CYPWMH (Commissioning  Outline of the Clinical Model for the CAMHS Redesign which  Improved outcomes and experience for mothers requiring & will be further developed and finalised during 2019/20. Transformation) inpatient mental health support and their babies within Lancashire.  The specialist inpatient Mother and Baby unit located within  Additional provision, capacity and quality of health-based places Lancashire opened in October 2018. of safety to meet the increasing demand for CYPWMH  Two Places of Calm opened (Blackpool and Ormskirk)  Shared understanding and evidence base of the all-age eating  A Shared Care Protocol for CYP attending acute setting has disorder services to inform future commissioning, service redesign been implemented. and provision.  All-Age Eating Disorder Service Review has been completed  Lancashire Schools Resilience Consultation completed. 

Transforming Care Transforming Care  There are two newly developed, co-produced, Community  Collaborative working between NHS, local government and Service Specifications (SST & CLDT) housing has been enhanced.

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Portfolio Deliverables Benefits  A clinical bed model has been developed for the CCG  National recommendations from Winterbourne has ensured that commissioned bed requirements for Transforming Care. services, systems and approaches are aligned with national best  A new central programme strategy / work plan has been practice to improve experience, safety and outcomes. produced as well as Strategies developed for workforce, and  Services developed based on national service models Housing.  Improved Patient Experience & co-produced services  Development of a resettlement framework in South Cumbria  Focus on effective community-based support and reduced levels  Delivery of Transforming Care, a National Response to of urgent care and hospital admissions Winterbourne View Hospital: final Review Report (June  Some reduction in time spent in hospital has also been seen. 2012)  Implementation of Building the Right Support (NHSE October 2015)

Population Health Management Population Health Management  Worked with a provider (Optum) commissioned by NHSE to  Developed and strengthened Population Health Management data work on the 20-week Accelerator Programme and focus on and intelligence network for economic analysis and data sharing our Neighborhoods and its population. across the System.  Establishment of PHM Academy to spread learnings and  Built on our BI, clinical, Executives/Leadership teams’ capabilities knowledge across the region. to embed Population Health Management approach and strengthened current systems to support this. Prevention & Population Prevention Prevention Health  The Stroke Prevention Alliance produced a comprehensive  Reduction in hypertension and cardiovascular disease five year Stroke Prevention Strategy which, in line with the successful experience of other countries, has a central focus on the identification, diagnosis and management of the key risk factors for Stroke of AF, Blood Pressure and Cholesterol often referred to as 'Know Your ABCs' as outlined within the recently published NHS Plan.  The Bereaved by Suicide workstream has scoped and identified 9 pilot projects that will be run over the coming year

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Portfolio Deliverables Benefits to test and fill the gaps in service across Lancs and SC ICS. Self-Harm pathway work is developing at pace and workshops are being held. Out of Hospital Out of Hospital  Design, implement healthcare solutions in acute and primary  Establish integrated care models to effectively manage in the care settings e.g. video consultation, MyGP App, etc. community anticipated growth in demand for secondary care.  Developed communities of practice for innovation and  Predictive analysis for patients most likely to end up in hospital to improvement. Healthwatch report that connected with over target for support 1,500 citizens to hear and respond to their views on digital  Effective short-term high-impact secondary prevention measures adoption. to reduce demands.  MyGP App users pp to 92,402 across the ICS. Appointments booked via MyGP - 11,639.  Designing and enhancing Cancer pathways.

Acute & Specialised Acute & Specialised  Designing protocols on information sharing/networked  To provide better support for self-care. Digital & IT services • Maintaining or enhancing clinical outcomes  Agreeing use of National Standards across L&SC services • Raising standards of care  Worked with providers to prioritise and design sustainable • Improving citizens’ experience of care models for e.g. development of a Patient Platform to enable • Maintaining the safety and sustainability of services citizen access to their full range of records and enable 2 way  Strengthened the digital capability of PCNs across the region. communication with their MDT .  To ensure patients can access the right services at the right time  Exploratory piece to consider consolidation of Electronic within L&SC. Patient Records and digital discharge prescriptions, etc.  To reduce any service variations relating to quality of care.

Urgent and Emergency Care Urgent and Emergency Care Secured investment to implement and facilitate Hospital Flow  Benefits to be realised once implemented. and manage capacity in Urgent and Emergency care.

Mental Health Mental Health

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Portfolio Deliverables Benefits  Suicide Prevention training programme contracted and  Inequalities to access to early intervention and crisis care to be commenced. Identify frequent self-harmers accessing A&E reviewed and resolved. and NWAS.  High quality prevention programmes in place and in flight to  Purchase and development of Suicide Prevention Grass address people at key moments in their lives. Roots App.  Developing work on Mental Health Crisis Plan.  A single control total is now agreed for Lancashire & South  Reducing the financial risk to individual organisations. Cumbria health partners.  Collaborative working amongst Lancashire & South Cumbria  ICS NHS estates strategy has been developed. health partners and a commitment to collectively achieve financial  The ICS is secured as one of 5 pilot areas for the NHSE GP stability through agreed mutual aid. IT legacy Lloyd George Notes across 233 GP practices.  Single strategy to better evaluate and distribute NHS estate and Finance &  Now part of the national disposals pilot to produce a single, assets across Lancashire & South Cumbria. Estates standard dataset of disposals which will continue into  Significant NHS estate in primary care released for alternative 2019/20. uses.  Wave 1 capital scheme at Lancashire Care Foundation Trust  Secured capital investment will enable and support delivery of the completed - 1 of the first ICS capital schemes to go live Lancashire & South Cumbria wide strategy. nationally.  Achieved 23 million ICS capital investment.  Lancashire & South Cumbria wide strategy for workforce  There is now a set of agreed and shared priorities to continue the Workforce produced provision of high-quality outcomes to improve workforce.  Over 200 job offers made via the initial rounds of recruitment  Improvement to careers offer and extending coverage of this Leadership & via the Global Health Programme activity. OD  Progress on workforce plans in various portfolios (stroke,  Filled vacancies to reduce the shortage of key clinical and non- radiology etc.) clinical postholders.  Established Communications & Engagement network  Developed channels for communications including reduction in Communicati ensuring consistency, collaboration and shared learning duplication between communications and engagement teams  Development of the Healthier Lancashire and South  Clear, concise information available to a range of audiences on & Cumbria website  Well-developed relationships with internal and external partners to Engagement  Strategic and operational C&E support to all programmes the ICS within the ICS

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Portfolio Deliverables Benefits  Engagement with the Voluntary, Community, Faith and Social Enterprise Sector and local Healthwatch  Strategic Narrative now developed for consultation to inform  Collective agreement across Lancashire & South Cumbria further strategy development and alignment of priorities partners of the challenges and priorities to move forward.  Successful establishment of ICS teams to deliver the  Capacity and resource to deliver the benefits of the programmes Strategy, Healthier Lancashire & South Cumbria programme. being delivered centrally across Lancashire & South Cumbria wide Form &  Establishment of early governance for change management  Providing structure and organisation to the HLSC programme for Structure and programme delivery more efficient delivery and providing oversight and assurance to  ICS Board development support the building of partner relationships.  ICS Governance review established  Improved transparency and relationships across Board members and their partner organisations.  ICS-wide activity and financial operational plan submitted;  Greater collaborative planning between CCG and Trusts broken down by individual organisations.  Highlighting differences between operational and financial  Discussions on methodology for agreeing priorities across outcomes the partnership established  Further refinement of the assurance process across Lancashire Planning & and South Cumbria which included a key enabler review including Performance population health, workforce etc.  Articulated issues and risks that face the operational efficiency and effectiveness of the Lancashire and South Cumbria health economy  Some sharing of good practice  Development and agreement of a common framework for  This has provided clear place-based commissioning Commissioni commissioning across 8 key areas within Lancashire & recommendations together with underpinning proposals for South Cumbria. governance, assurance, leadership, clinical leadership & ng  Joint Committee of CCGs development and work plan workstream priorities. Development agreed for 2019/20  Plan for the year ahead so that partners can build these priorities into their plans for 2019/20 and further. 4. Lessons Learnt

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ICS teams and partners working to deliver the Lancashire & South Cumbria programme have experienced challenges throughout 2018/19. These have been identified at individual project level and will be addressed in 19/20. However for the purpose of this evaluation, they have been categorised into common themes which are presented in fig.1 below:

fig.1. Page 178 Page

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5. Action Plan

To address the key challenges presented in fig.1. the following action plan has been developed for the Healthier Lancashire & South Cumbria Programme with indicative timescales and appropriate responsible leads identified.

Indicative Action Responsible Timescale

1. ICS priorities agreed and outline strategic framework for the ICS Executive July 19 HLSC 2019/20 Programme Delivery Plan 2. Update of programme objectives based upon ICS priorities. ICS Board Subsequent executive agreement of the 2019/20 HLSC Programme Aug 19 Delivery Plan. Leads 3. Establishment of a HLSC Programme Board and associated Executive governance to ensure that there is direct reporting on Director of Sep 19 progress and risks of the 2019/20 Delivery Plan to the ICS Transformation Board. 4. Establishment of associated KPIs and financial monitoring PMO, Finance Sep 19 for each priority programme and; Leads & 5. The systems and processes to be developed to monitor Programme Ongoing these and effective realisation of the benefits. Leads 6. Review and reallocate resources for programme teams based upon ICS priorities, alignment with the 2019/20 ICS Executive Sep 19 delivery plan and equitable provision. 7. Review and clarify the scope of enabler team objectives based upon required capacity to fulfill their enabler support ICS Executive role for the priorities identified for 2019/20. Subsequent / PMO & Sep 19 development of enabler role as coordinated support to the Enabler Leads ICS priority programmes. 8. Commission business intelligence capacity to support programme teams with their programme scoping, development and delivery. This support will also improve the PMO Jul 19 subsequent monitoring of KPIs and assessment of the potential and realised impact of the programme. 9. Project Team Forum meeting to be established as an informal, operational delivery arm of the Programme Board PMO Aug 19 and to support the management of interdependencies across programmes. PMO & 10. Smartsheet dashboards to be developed for each ICS Programme Aug 19 programme as a summary with live progress updates. Leads 11. ICS Governance Review completed and agreed Executive implementation plan established based upon ICS Board Director of Sep 19 approval. This includes, roles, responsibilities, decision Transformation

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making, meeting structures, members, TOR, interface / Strategy between ICS, ICP & Neighbourhoods. Director 12. Co-ordination and scheduling processes adapted following Sep 19 ICS Governance Review PMO 13. Refresh the ICS Delivery Plan & Portfolio Management PMO /ICS Framework to reflect the outputs of the ICS Governance Corporate Review, commissioning development priorities, ICS strategy Oct 19 Business and structures based upon the impact to priority Office & programmes. Programme 14. Compliance with Portfolio Management Framework Ongoing Leads & teams

In the future, the Lancashire and South Cumbria Programme Board, introduced within the action plan, will undertake periodic reviews of all lessons learnt and incorporate agreed solutions as business as usual. Systems for ongoing monitoring will be established and detailed within the governance of the Portfolio Management Framework for all priorities and programmes considered under the Lancashire and South Cumbria Programme.

6. Lancashire & South Cumbria 2019/20 Programme Delivery Plan

An initial draft of the Lancashire & South Cumbria Programme Delivery Plan for 2019/20 was circulated during April 2019 following a workshop held with current Executive Sponsors, Portfolio Leads, and Programme Leads during March 2019. The aim of the workshop was to gain a shared understanding of the programme objectives for 2019/20 and their associated milestones. Discussions and information captured then formed the initial draft of the 2019/20 Delivery Plan. However, ongoing discussions through the Accountable Officers and Chief Executive Officers meeting, with regards to the ICS priorities and agreement on the ICS level programmes continues and has paused further development of the Programme Delivery Plan.

In the meantime, work within the portfolios, and their programmes, is continuing under the existing arrangements and structure, carried forward from 2018/19. However, with reference to the action plan outlined in section 5, once there is a consensus on priorities reached there is likely to be a ‘reset’ of the structure and governance of the Programme and this will influence the development of the 2019/20 Programme Delivery Plan. Updates to the plan, and its structure and governance, will be maintained through the Programme Management Office and released in agreement with the ICS Executive Team.

7. Recommendations

Further recommendations to support the development and delivery of the Healthier Lancashire & South Cumbria Programme are listed within this section for review and any subsequent decision or direction by the ICS Executive Leadership team.

A. Formation of an ICS senior managers meeting to provide a place for key corporate discussions to avoid confusion and disruption to the agenda of other forums that are aimed at Programme Management.

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B. Agree the programmes’ priorities to be delivered through the Lancashire & South Cumbria by July 2019. C. Review of the Executive Sponsorship assigned to support these priorities, define this role and confirm their responsibilities. D. Timely review and confirmation of the resource allocation to the priority programmes. E. Ongoing support and adherence to the agreed ICS governance and programme management so that there is a consistent approach and application across all programme teams. F. Establish additional capacity in financial management support as part of the ICS Function to support programme teams in the development and successful delivery of value for money with their programmes.

Upon receipt of confirmation the recommendations will be incorporated into the HLSC Action Plan accordingly and progress updates reported through the HLSC Monthly PMO Briefing.

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People and Structure Plan Developing the new system structure and delivery model

183 Page

16/09/19

Developing a New System Structure and Delivery Model

Executive Brief: Strategic Context:

Why? Contextualising why a Target Operating Model and What? System Operating Model is needed and how it fits Case for change? into the context of the ICP Where in our ICP it’s needed Strategy (Platforms 1 to 6) and by when? Formation of (ICP) technical design authority Page 184 Page

2

Central Lancashire ICP (Target Operating) Model

Page 185 Page This is the central feature & focus that requires an agreed design authority (agreed by ICP)

3

Target Operating Model

 Calibrate with the ICP ‘blueprint model’

 How it fits (with PCNs, ICS, Transformation of Commissioning, Potential Provider Collaboration Modelling)

 Why it is the preferred (best) model to drive ICP viability/durability/resilience/future policy alignments

 Determines how the business processes operate to drive optimal value (quality, performance, economic return)

 Benefits of the Target Operating Model for ICP system controls (performance/quality/ economics/ sustainability/ T2V / ROSI) Page 186 Page

4

System Operating Model  Calibrated with the ICP Target Operating Model – it describes how the ICP (organisation) will operate, system by system.

 Its the internal clockwork, the cogs that need to synchronise, to drive and ensure effective and efficient care system design and delivery.

 It’s the vehicle that: • Designs care process (has a design authority with purpose) • Calculates actuarial value and measures adoption • Attributes accountability / responsibility to contributors • Sets and manages market / operating conditions • Does the CEQI (continuous economic & quality improvement) • Connects assets for optimal value and quality assured outputs • Does the CEPI (continuous engineering and performance improvement) • Calculates optimal asset distribution to corporate & business activities

Page 187 Page • In short – it’s the way that we will engineer our (ICP) internal form to meet the requirements to discharge the agreed functions.

5

Assets, Optimising & Structuring

Q. How do we best re-order our considerable people & talent assets?

Q. What are our options for restructuring?

Q. What HR processes do we need to apply?

Q: What’s the timescale for structural transformation Page 188 Page

6

Governance / Accountability Arrangements

Distributing Authorities ICP

Internal Corporate (ICP Leadership) Internal Prime Vendor (ICP Provider Partners) Internal Technical (ICP people and skills) External Providers (Supplementary Providers) External Technical (Support Services)

Delegating Authorities ICS /JC CCGs

What is best to delegate to others? What aspects of collective (ICS) delegation does the Central Lancashire ICP wish to lead? e.g. Cancer Page 189 Page

7

Technique / Technical

 Economic & Efficiency (integrated) model + Single PMO

 Transformation / Improvement Science (consistency methods)

 Application of standardised techniques for improvement

 Conversion of analogue (resource hungry) care processes & care delivery systems into digital single (resource efficient) care processing

 Single Internal (ICP) and External (ICS) Assurance Systems

 OD PLAN – Future proofing Page 190 Page

8

Outline Operating System Structure (Draft)

ICP – Executive Leadership The Executive Management Team Draft The ICP Board

ICP – Core Sub-Divisions Draft The Executive LeadershipFunctions

ICP – Technical & Commercial Strategic Economics, Efficiency Programmes, Technical Accounting, IT, Digital, Governance, Legal, Commercials & Contracting (internal & external), Market Design & Regulation

ICP – Integrated Planning & Care System Coherence Care System Research & Design, BI&KM, Actuarial, PC&PCN, Care Process Effectiveness

ICP – Operational & Care Delivery Care System Operational (day to day) Effectiveness, Regulation & Contribution, Continuous Process Improvement, Integrated Care & Clinical Logistics

ICP – Enabling Systems Integrated Hard & Soft Systems (single shared / back office services) + Single PMO and Integrator Function

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9

Next Steps & Recommendations

 Support the development of a more detailed technical plan

 Through the ICP Senior Leadership Team (& PMO) provide overview and continuous scrutiny as the model develops

 Establish co-production (engagement) with Executive / Functional Leads

 Connect development with emerging ICS strategy

 OD Plan – Engage & Support Staff Groups (Skills Harvesting & Opportunities) Page 192 Page

10

Agenda Item 9

Governing Body Meeting

Date of meeting 25 September 2019 Title of paper Our Health Our Care Programme Update Presented by Mr Denis Gizzi, Chief Officer Author Mr Jason Pawluk, OHOC Programme Director Clinical lead Dr Lindsey Dickinson, GP Director Confidential No

Purpose of the paper This paper provides an update of progress relating to the Our Health Our Care (OHOC programme relating to the Acute Sustainability work stream.

Executive summary

The paper describes the progress made on the OHOC Acute Sustainability programme since the preceding update received by the Governing Body. The narrative outlines the current status of the programme with respect to the NHS England Stage 2 assurance process.

The paper provides a summary of the information supplied to the OHOC Joint Committee on the 28th August, the decisions taken at that meeting, and the next steps and direction agreed – particularly with regards to enhanced clinical scrutiny of the programme options.

Recommendations For the Governing Body to endorse the need to deliver continued progress relating to the Our Health Our Care programme.

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 ☒

Our Health Our Care Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting Page 193 25 September 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 ☒ ☐ ☐ 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

Our Health Our Care Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting Page 194 25 September 2019

Our Health Our Care – Programme Update

1.0 Introduction and Overview:

Alongside the strategic objectives of the Our Health Our Care programme, the ambition of all organisations commissioning and providing healthcare for the population of Greater Preston, Chorley and South Ribble is simple and crystal clear: we want to achieve the best possible outcomes for patients. In order to develop this ambition relating to the Acute Sustainability platform of the Our Health Our Care programme, there are four main documents which need to be developed in sequence, broadly answering the following questions: • Case for Change - why do we need to change? • Model of Care - what do we need to change? • Option Modelling– how could we make changes? • Pre-Consultation Business Case subject to the approval and content of the above how can we demonstrate that the programme is ready to commence a formal consultation process with the public (following and including the independent and external clinical assurance processes led by the Clinical Senate)?

The first question “why do we need to change?” was answered in the Case for Change for the programme. This was approved, subject to an amendment, at a meeting of the OHOC Joint Committee on 13th December 2018. The second question – “what do we need to change?” was addressed in a Model of Care which was supported unanimously by the OHOC Joint Committee in a further meeting in public on the 13th March 2019. These approvals provided the mandate for the programme to enter the third of the four stages, now addressing the question – “how could we make changes?”

Only at the completion of these four stages will the programme to engage the regulator, NHS England to affirm that what is called the “Stage 2” process has been completed. This will allow the regulator to determine if the programme is ready to commence a consultation. By this point, the programme will also have further engaged the Lancashire Health Scrutiny Committee by this stage, commencing with a session on 24th September.

A meeting of the Our Health Our Care Joint Committee took place on the 28th August to consider a clinically led report and recommendations as to “how we could make

Our Health Our Care Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 195 changes.” This paper summarises the contents of the paper, the decision of the Joint Committee, and how the next steps of the programme will now be configured.

2.1 Purpose of the OHOC Joint Committee 28th August

The report and recommendations presented to the OHOC Joint Committee on the 28th August sought to respond to the challenges described in the Case for Change and create a range of options which would be compatible with the clinical vision described in the Model of Care.

The approach described in the paper was reflected three-stages, summarised as follows:

• Stage A: Agreeing the approach and methodology. • Stage B: Exploring alternatives to major service change (from the longlist). • Stage C: Shortlisting options.

A fuller explanation of the steps and components involved in each of the steps was previously provided to Governing Body. A total of thirteen options for change were generated by the programme, with a recommendation to continue detailed modelling, scrutiny and assurance-based activities linked to eight.

The report also referenced an option which was not possible to formally generate, due to the lack of capital funding, namely a new build site on an unspecified Greenfield location in central Lancashire. The report detailed how such an option had been preferred, arising from a feasibility study undertaken around three years ago.

A copy of the report can be found by following this link.

https://www.chorleysouthribbleccg.nhs.uk/download.cfm?doc=docm93jijm4n7363.pdf&ver =13593

2.2 Governance Process Followed – Stages A to C

As explained in the main body of the report, the work comprising Stages A to C inclusive was clinically led, taking account of the relevant assumptions and viability criteria linked to the clinical standards and co-dependency framework published in the Model of Care. The process also considered the opinions received by the programme from external reference points, including the Royal College of Emergency Medicine, the Care Professionals Board representing Healthier Lancashire and South Cumbria, and the reports previously received by the programme from NHS England/Improvement.

The options generation work was developed via the Clinical Oversight Group (COG) and the Finance, Investment and Activity Group (FIAG) of the programme. Outputs

Our Health Our Care Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 196 were initially reported to the Programme Oversight Group (POG), whilst the Integrated Care Partnership Shadow Board and the Communications and Engagement workstream group (CEG) also received regular updates. Approved outputs from the programme at each stage boundary were shared with the Governing Body Development Sessions scheduled in May, June, July and August.

The purpose of the meeting in public of the OHOC Joint Committee was to consider formally the work products associated with Stages A, B and C as defined papers, brought together in to a report with recommendations. The OHOC Joint Committee also reviewed and considered the programme risk register, which is discussed at the Programme Oversight Group, taking account of issues and concerns from across the three workstream groups in the programme.

During the development of Stages A to C the programme continued to engage with stakeholder reference forums including the Stakeholder Reference Panel, the Patient Voice Committee (PVC) and the Patient Advisory Group (PAG). In addition to the ongoing engagement work with clinical staff, vulnerable patient groups, and those from protected characteristics groups, this communication ensured effective engagement with these groups during the options development phase. Informal engagement also continued with primary care representatives, Governors of partner organisations and elected members, with the programme also maintaining its relationship with the regulator (NHS England) and the North West Clinical Senate.

2.3 Decision and direction indicated by the OHOC Joint Committee

The determination of the OHOC Joint Committee, by unanimous approval, varied from the initial recommendation presented in the report. The decision, providing clarity and direction to the programme, can also be summarised as an extension of Stage C: 1. All options on the table: All 13 options would be considered further, and this position will be outlined to the Health Scrutiny Committee on the 24th September. No final decisions on any of the options was made and an open-minded approach was maintained.

2. New Build option: The feasibility study previously undertaken for a new build acute site in central Lancashire and referred to in the background section of the options paper, would be subject to a request for funding from the Chief Officer of the CCGs and Senior Responsible Owner of the OHOC programme to the Department of Health and Social Care.

3. Preferred approach – significant capital investment to transform care outcomes: With respect to this preferred approach for significant capital investment in a new build site in central Lancashire, the Committee reflected on the position outlined in the background section of the report, namely:

Our Health Our Care Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 197 “Local commissioners will continue earnestly, and in an open-minded way, to work with others to build the case for significant capital investment across both primary, community and acute care. Local commissioners believe that such an approach will improve patient experience, quality, and care outcomes and for the benefit of people in Central Lancashire. Such an approach will support the delivery of a long-term sustainable solution to the planning and delivery of healthcare services of a growing population with changing needs.

Local commissioners will continue to work in partnership across Healthier Lancashire and South Cumbria to identify how capital funding may be acquired and the conditions upon which a future application for investment is more likely to be successful. Local commissioners stand ready to review and revisit all options should significant capital investment routes become open. Local commissioners agree that, in the circumstances of the present Case for Change and the Model of Care developed by the programme, it must consider options at this stage which are based around the resources currently available to the health economy, seeking to deliver the best outcomes for patients.” In taking the decision to outline and pursue further the case for significant capital investment in central Lancashire, it should be emphasised that the Committee agreed that, at this stage, there appeared to be neither a funding route for enabling capital, nor a confirmed funding stream for capital of this scale.

However, the purpose of exploring this option further was to improve confidence in the process overall and to evidence that this preferred approach would be given primary consideration alongside all other options for change. The Committee continues to recognise that consultation can only occur if it can be demonstrated that an option is viable. In addition to clinical criteria, this assessment also considres other factors, including funding streams and affordability, as specified by the regulator, NHS England.

4. Enhanced clinical scrutiny would take place relating to all of the options, further ensuring that no alternative route has been omitted in Stages A and B. This would take place via a number of routes, namely:

o Clinical Summit: A Clinical Summit, drawing together primary care network leads, partners, and secondary care clinicians and others, such that the options for acute change could be fully discussed, scrutiny be applied, and the links/dependencies with the out of hospital workstream of the programme be adduced. This has been arranged for the evening of the 3rd October. This forum will present the opportunity for an ongoing dialogue and process of scrutiny to ensure that the appropriate options are generated and that best

Our Health Our Care Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 198 clinical outcomes for the people of central Lancashire result. This will involve significant close working with the Wellbeing and Health in Integrated Neighbourhood (WHiN) platform and a discussion around how the system economic and financial reform strategies may act as enablers to successfully and sustainably redesign care across the whole central Lancashire system.

o Clinical Oversight Group – scrutiny role: An enhanced and extended role for the Clinical Oversight Group for the programme, additionally comprising of greater primary care network clinician engagement; secondary care clinicians and the role of other non-medical professional groups, such as nursing and allied health professionals.

o Independent Clinical Director: The planned appointment of an independent clinical director for OHOC who will oversee the clinical scrutiny and support the programme through the remaining stages.

o Primary Care network – engagement and scrutiny: Further engagement with each primary care network leadership team and the Peer Groups in Chorley and South Ribble and Greater Preston respectively. In the case of the former group, this will take account of the recent formal establishment of primary care network leadership teams and in the latter reflect the ongoing partnership working with the Peer Groups which has taken place over the past 18 months to 2 years.

o Independent Clinical Senate: The independent clinical senate will visit both LTH sites on 16th and 17th September to provide a report on the options and the scope of work undertaken with respect to developing a sustainable Model of Care. The independent clinical senate is satisfied that it has received sufficient information from the programme relating to the Model of Care, such that it can provide assurance at this stage and usefully add to the information which will be relied upon by the OHOC Joint Committee in determining which of the options are viable. The formal report from the clinical senate will be received by the end of November. Part of the role of the independent clinical senate will be to test the rigidity of proposals which could see more care delivered outside of the acute sector. They will also receive the opinions outlined in the reports published by the Royal College of Emergency Medicine and the Healthier Lancashire and South Cumbria Care Professionals Board forum.

o Activity and Impact Modelling: Detailed activity modelling will take place relating to the options. This work is currently being developed and will be shared in the public domain when complete and accepted as part of the Pre-Consultation Business Case for the programme.

Our Health Our Care Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 199 This modelling will project planned patient movements across each outpatient, elective and emergency care categories, across specialties and the existing operational sites used by patients in central Lancashire. This work will also include a detailed Equality Impact and Patient Impact Analysis, also incorporating an analysis of travel and access considerations relating to the options.

3.0 Next Steps Only when the above work is complete will the options be narrowed to a shorter list and be described in a Pre-Consultation Business Case. Based on the decision to proceed with considering all options, it is now very likely that a formal public consultation, based on an open and fair approach, will take place once the contents of the Pre-Consultation Business Case are agreed to and the approval to consult has been received by regulators. Continued engagement with the Health Scrutiny Committee for Lancashire will be needed on this basis. The Governing Body should note that no decisions relating to the options will be taken at the Health Scrutiny Committee on the 24th September – the principal purpose of this discussion is to update the Committee as required, in its capacity as a statutory consultee. The programme continues to organise the above steps expeditiously and is unable to specify the next date where the OHOC Joint Committee will meet. However, it is unlikely that the OHOC Joint Committee will formally meet again this year, so as to allow the above actions to be completed thoroughly. The OHOC Joint Committee maintains the view that it is properly constituted to decide the short list of options but is seeking the broadest clinical engagement practical to inform its view. At a pre-consultation point, the programme will also engage the view of neighbouring commissioning organisations who may be affected by changes proposed in the options. This will also form part of the next steps of the programme. Concurrently, the programme will continue to develop its communications strategy to build public awareness around Our Health Our Care and its objectives, the options which have been published, and the achievements which are being delivered for patient benefit across all three pillars of the programme.

Jason Pawluk OHOC Programme Director 12th September 2019

Our Health Our Care Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 200 Agenda Item 10

Governing Body Meeting

Date of meeting Wednesday, 25 September 2019 Title of paper Integrated Board Report Presented by Mrs Helen Curtis, Director of Quality and Performance Mr Matt Gaunt, Chief Finance Officer Mrs Jayne Mellor, Director of Transformation and Delivery Author Mr Glenn Mather, Associate Director of Performance and Effectiveness Clinical lead N/A Confidential No

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 May 2019 and June 2019. 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 including achieving cancer waits, mental health and A&E waits standards.

Achievement against the RTT 18 week referral to treatment has remained steady in Quarter 1 at circa 88% for both CCGs outside the 92% target. At the end of July there was no one waiting over 52 weeks for treatment in either CCG.

Both Greater Preston CCG and Chorley and South Ribble CCG failed to meet the Quarter 1 target for the 62 day cancer pathway. The position remains challenged

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body Page 201 25 September 2019 moving into Q2 of the financial year. The A&E performance continues to remain below the STF trajectory; however, there has been a slight improvement in the quarter with the performance at 83.82% in July.

Lancashire Teaching Hospitals reported 78 12 hr breaches in A&E during Quarter 1 of 2019/20; this is historically high for quarter 1, although significantly below the number reported for Q4 of 2018/19.

Performance in respect of diagnostic tests still remains challenged. Against a 1% target, Chorley and South Ribble CCG year to date is 3.97%, whereas Greater Preston CCG is currently 5.64%. A refreshed action plan was received in April 2019 and assurance has been provided that new equipment has been approved and posts recruited to.

In mental health, the target level for IAPT prevalence has still not been agreed contractually between lead commissioner and Provider. Both Greater Preston and Chorley & South Ribble CCG underachieved against the 2 week psychosis and target.

There were no MRSA cases reported in Quarter 1 of the 2019/20 financial year.

Stroke performance against the 4hr target has significantly improved in June 19 to 72.7%, albeit still below the target rate. A number of posts have been recruited to and approval granted to ring fence beds on the stroke ward, which appears to be having a positive effect.

Recommendations The Committee is asked to note the IBR and support the improvement actions.

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 Quality and Performance 11/09/2019 Report was noted Committee

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body Page 202 25 September 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 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 Assurance will continue to be delivered to the Quality and Performance Committee.

Integrated Board Report NHS Chorley and South Ribble CCG Governing Body Page 203 25 September 2019

This page is intentionally left blank Chorley and South Ribble CCG Greater Preston CCG Integrated Board Report

September 2019

Integrated Board Report

NHS Chorley and South Ribble Governing Body Page 205 25 September 2019

Contents

1. Introduction 2. Executive Summary...... 3. Integrated Business Plan 3.1 Wellbeing and Health Integrated Networks (WHIN) Platform 3.2 Quality Innovation Productivity and Prevention (QIPP) 3.3 Performance 4. Quality and Performance Dashboards 5. Quality and Performance Exception Reports 6. Improvement and Assessment Framework Dashboards 7. Improvement and Assessment Framework Performance Exceptions 8. Leadership ...... 8.1 Workforce...... 8.2 Complaints ...... 8.3 Freedom of Information (FOI) requests...... 9. Glossary ...... Appendix 1 Aristotle Report

Integrated Board Report NHS Chorley and South Ribble Governing Body 25 September 2019 Page 206 1. Introduction

The purpose of the Integrated Board Report remains focused on reporting 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 are 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 May and June 2019. However, more recent data has been included where possible.

Integrated Board Report NHS Chorley and South Ribble Governing Body 25 September 2019 Page 207 2. Executive Summary

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

Achievement against the RTT 18 week referral to treatment has remained steady in Quarter 1 at circa 88% for both CCGs outside the 92% target. At the end of July there was no one waiting over 52 weeks for treatment in either CCG.

Both Greater Preston CCG and Chorley and South Ribble CCG failed to meet the Quarter 1 target for the 62 day cancer pathway. The position remains challenged moving into Q2 of the financial year.

The A&E performance continues to remain below the STF trajectory; however, there has been a slight improvement in the quarter with the performance at 83.82% in July.

Lancashire Teaching Hospitals reported 78 12 hr breaches in A&E during Quarter 1 of 2019/20; this is historically high for quarter 1, although significantly below the number reported for Q4 of 2018/19.

Performance in respect of diagnostic tests still remains challenged. Against a 1% target, Chorley and South Ribble CCG year to date is 3.97%, whereas Greater Preston CCG is currently 5.64%. A refreshed action plan was received in April 2019 and assurance has been provided that new equipment has been approved and posts recruited to.

In mental health, the target level for IAPT prevalence has still not been agreed contractually between lead commissioner and Provider. Both Greater Preston and Chorley & South Ribble CCG underachieved against the 2 week psychosis and target.

There were no MRSA cases reported in Quarter 1 of the 2019/20 financial year.

Stroke performance against the 4hr target has significantly improved in June 19 to 72.7%, albeit still below the target rate. A number of posts have been recruited to and approval granted to ring fence beds on the stroke ward, which appears to be having a positive effect.

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)

A number of contract notices expired at end date of their respective contracts, where new contracts are issued the notice can either be formally brought into new contracts under Service Development & Improvement Plans (SDIP) or continue to be manged in collaboration with providers and through contract meetings in a supportive rather than punitive manner. The latter has been exercised following the spirit of improvements in ways of working in a collaborative manner as outlined in the long term plan.

Integrated Board Report NHS Chorley and South Ribble Governing Body 25 September 2019 Page 208 The CCG currently manages the following informally:

LTHTR: • CPN - 62 day Cancer: – failure to achieve required performance for service users waiting from referral to first definitive treatment. The CCG has requested an update to the Remedial Action Plan (RAP) to further understand pressures on the service. • CPN - Stroke Performance: - non-achievement of stroke performance and five consecutive months of deteriorating performance. • CPN - RTT: - concerns that planned trajectories will not be met, delays in receiving RCAs, a number of 52 week breaches and over target against the maximum incomplete pathways KPI. Recovery Plan received from LTHTR. Now at end of recovery process and Trust are not compliant. This will be escalated via the formal contract process and through the Elective Care Delivery Board. • CPN - Diagnostics: performance under national standard. Deadline for compliance was end March 2019. This was escalated through the RTT Steering Group, and an updated RAP is now required. These discussions will now take place at the new Elective Care Delivery Board.

The following notice has not expired and continues to be managed formally.

GTD: • IBN - Failure to report data into the national SUS (Secondary Uses Services) system.

Integrated Board Report NHS Chorley and South Ribble Governing Body 25 September 2019 Page 209 3. Integrated Business Plan 2019-2020

3.1 Wellbeing and Health in Integrated Networks (WHIN) platform

The Wellbeing and Health in Integrated Neighbourhoods (WHIN) Board has been established, it meets monthly and oversees delivery of the WHIN platform plan.

The formation of networks

A specific governance structure has been established to support the development of the Networks.

Progress to date includes:

It has now been agreed that the first phase of the Integrated Care Teams will include the district nurses and will be mobilised from October 2019. Further work is progressing to identify which services will form part of subsequent phases.

A project group has been established to roll out population health management across all nine Networks. Discussions have also been held with the Clinical Directors of all nine Networks who have agreed it is a key priority.

A local Central Lancashire Asset Review is has taken place to support the development of the review. A draft version of the review has now been shared with the CCGs for comments.

Integrated Board Report NHS Chorley and South Ribble Governing Body 25 September 2019 Page 210 A capitated budget model has been developed and is being piloted with Networks. Work is also progressing on how the concept can be rolled out across all nine Networks.

The WHIN programme plan has a number of projects within it; all projects have an identified lead, deliverables and associated timescales. The plan is being uploaded onto the CCGs Programme Management Office system for assurance and reporting purposes. There is a clear governance structure with the WHIN Board reporting progress against the plan to the Integrated Care Partnership Board.

New models of care (end to end transformation programmes)

The stroke strategy board agreed the work plan for Early Supported Discharge; the project has been delivered over Q1 and Q2 of 2019/20. The Early Support Discharge service is in mobilisation, it will go live on October 1st.

A Social Prescribing workshop took place to inform the model. Funding for two pilot Networks in Central Lancashire to trial a social prescribing digital platform has been secured from the ICS.

A further workshop has taken place and each Network has an implementation plan for social prescribing, all Networks will have prescribers in post by the end of September. A world café event is planned for October, with the voluntary sector and the Networks to further develop relationships and agree processes for social prescribing. The digital platforms are being mobilised.

A Diabetes group has been established to implement a new model of integrated diabetes care across Central Lancashire footprint within 2019/20. Work continues towards the delivery of the Community Integrated Diabetes Service and clinical model/pathway to be implemented from the 1st October 2019. This will result in the end of the current Diabetes Pilot service as this will transition to the new pathway.

The service specification has been finalised and shared with partners, including the Clinical Directors of the Networks. Whilst there is a general agreement with the content of the specification further work is taking place on the KPIs and outcomes that the service/pathway will be monitored against. There is also further work required to re-allocate the capacity and resource to facilitate the model.

To ensure continuity of provision the mobilisation plans will focus initially on the practices that are involved with the Diabetes Pilot and then wider roll-out throughout the year.

A solution design event for COPD respiratory event was held in August with a further two arranged in October 2019 and February 2020.

The workshop in August was dedicated to Early Detection and Diagnosis of COPD, patients and clinicians from the whole health economy came together to identify models of delivery. An options appraisal for the delivery model is being worked on and will be presented at WHIN programme board for consideration.

• A Network based model, developing skills and knowledge of a defined number of practice staff with an interest in respiratory condition management. Utilising appropriately trained and accredited HCAs to undertake the technical testing (spirometry), with advanced nurse practitioners / practice nurses interpreting the results.

Integrated Board Report NHS Chorley and South Ribble Governing Body 25 September 2019 Page 211 • Quality assurance underpinned by specialist respiratory practitioners to include respiratory physiologists, Specialist practitioners and Consultants.

• A model that encompasses support from respiratory consultants able to provide advice where diagnosis is more complex, or where there is multiple co-morbidity to aid treatment planning.

A Gynaecology group has been scoping work undertaken to ascertain whether additional conditions could be seen within the community. Work is being undertaken to assess how clinics would be run and maintained including:

• Potential to develop a Directory of Service across networks • Introducing Care Navigation at the front-end of the service • Skills analysis and training needs analysis of primary care clinicians/staff • Estates

The Gynaecology Project Group has sought and received data from Lancashire Teaching Hospital, Lancashire County Council, Family Planning Services and Networks.

A Clinical Design Event has been arranged for September to review existing pathways, workforce and estates and scope which services can be undertaken within Networks rather than a hospital setting. Future pathways will also be considered including an infertility pathway and opportunities for further clinics to be delivered in the community including colposcopy clinics. We have representation from at least one Clinical Director from each CCG and also representation from LTH, LCC, LCFT and the Voluntary Sector.

A series of End of Life workshops have been held to inform an action plan focussing on the following areas:

• Improved communication and timely sharing of records (including EPaCCS) across the health economy. • Supportive Palliative Care at Home Service – opportunity for St Catherines and Macmillan with the whole health economy to develop this service for central Lancashire • Access to Anticipatory Medication and Syringe Drivers • Focus on Palliative Care Education and Training – across the health economy • Compassionate communities and signposting to service

The main focus of these work streams is to enable the following:

• Increase in patients dying in their preferred place of care • Supporting patients with advanced individual care plans and increase in Electronic Palliative Care Co-ordination System (EPaCC’s) • Delivery of the end of life care model via the 9 primary care networks through specialist care input • Increase in Identification of patients who are at last 12 months of life using Gold Standard Framework (GSF)and Multi-Disciplinary Teams (MDT’s) at Primary Care Network (PCN) using population prevalence packs • Reduction in patients dying in hospital • Reduction in avoidable end of life admissions to hospital

Integrated Board Report NHS Chorley and South Ribble Governing Body 25 September 2019 Page 212 3.2 Quality Innovation Productivity and Prevention (QIPP)

To support the investment plan, the CCG’s required a productivity and efficiency savings target of £14.0m as reported to the Governing Body in May 2019. Against this target there was £9.4m of identified schemes leaving a gap of £4.6m.

Of the £9.4m identified schemes, £5.2m is fully signed off with project plans ready for implementation. The balance of £4.2m is ‘work in progress’ with detailed plans and actions yet to be agreed. There is, therefore, a significant amount of risk associated with the ‘work in progress’ balance and the unidentified element of QIPP.

The CCG’s are currently working with NHS England’s QIPP wave 5 to identify further potential opportunities to reduce the current gap in savings.

As at the 31st July 2019, the year to date performance shows the plan is underperforming by £0.6m. Contingency of £0.5m has been utilised to mitigate the year to date position and therefore the forecast gap is £4.1m.

Target QIPP 14,032

YTD Risk Net QIPP QIPP overview Plan YTD Plan Actual (Shortfall) Adjusted (Shortfall) as at 31st July 2019 / Benefit FOT / Benefit

£000 £000 £000 £000 £000 £000

Acute SLAs 3,165 1,507 1,507 - 3,165 -

Mental Health SLAs 165 55 55 - 165 -

Community SLAs 934 300 298 (2) 934 -

IPA (Individual Patient Activity) 500 75 75 - 500 -

Prescribing 4,688 1,588 1,530 (58) 4,688 -

Primary Care (426) 27 27 - (426) -

Other Programme 217 11 11 - 217 -

Running Costs 202 - - - 202 -

Sub total - assigned QIPP schemes 9,445 3,563 3,503 (60) 9,445 - Unidentified QIPP 4,587 510 0 (510) - (4,077)

Total QIPP 14,032 4,073 3,503 (570) 9,445 (4,077)

Integrated Board Report NHS Chorley and South Ribble Governing Body 25 September 2019 Page 213 A more detailed breakdown of the schemes by CCG can be found in the table below:

QIPP Breakdown 2019-2020

Integrated Board Report NHS Chorley and South Ribble Governing Body 25 September 2019 Page 214 3.3 Performance

Current Position KPI End 2018/19 YTD June 19 A&E 4 hour target 79.21% 83.82% 82.58% 95%

There is evidence that the 2018-19 Winter Plan aimed at reducing demand on the ED Department, has had some success, as actual A&E performance is above the underlying predicted performance. An A&E Delivery Board Plan for 2019/20 has now been agreed based in part on a review of the effectiveness of schemes within the 2018/19 plan. This plan focuses on the following areas:

• Alternatives to A&E • Same Day Emergency Care • Acute Flow • System Flow • System Escalation

The plan seeks to deliver key aspects of the NHS Long Term Plan and will be monitored via a focused set of both operational and system-wide measures including reducing Length of Stay, increasing activity in alternative services, increasing morning and weekend discharges, reducing days on high OPEL levels, and eliminating 12 hour breaches.

Current Position KPI CCG End 2018/19 YTD June 19 Cancer 62 Day CSR 69.39% 64.81% 75.80% 85% GP 75.00% 76.79% 80.36%

The 2018/19 Operational Plan included projects to redesign 3 cancer pathways – Colorectal /lower GI, Lung and Prostrate Cancer.

The Remedial Action Plan concentrated on delivery of performance against the 2 week target as compliance against this significantly improves the opportunities for meeting the 31 day and 62 day targets. Lancashire Teaching Hospitals NHS Trust (LTHTR) have identified a number of pathways which were not meeting the target and identified specific actions for those pathways with an appropriate timeline. The CCG have asked for an update against those timelines.

The CCG has also completed analysis which was presented at the CART group. LTHTR have highlighted that 2 week referrals account for a higher proportion of overall referrals for certain pathways, further analysis is ongoing to understand this impact.

The GP Quality Contract for 2019/20 includes KPIs for Bowel and Lower GI cancers.

Current Position KPI CCG End 2018/19 YTD June 19 RTT 92% CSR 86.5% 87.9% 87.8%

Integrated Board Report NHS Chorley and South Ribble Governing Body 25 September 2019 Page 215 GP 87.5% 88.5% 88.5%

Elective schemes that impact on RTT performance are mainly focused upon transformation and redesign. The Wellbeing and Health in Integrated Neighbourhoods (WHIN) platform is focused on the redesign of pathways in 4 areas – Diabetes, End of Life, COPD and Gynaecology – to support the development of new models of care within Primary Care Networks. The 100 day challenge initiative – which sought to drive more efficiency through a joint approach to pathway redesign projects – looked specifically at Urology, General Surgery and Gynaecology. Other redesign projects are taking place in the Neurosciences and for children’s services. Furthermore, a new elective systems management group has been set up to review current elective schemes (such as GP triage) and drive further efficiencies and savings.

Current Position KPI End 2018/19 YTD June 19 Stroke Performance – 54.72% 72.73% 4 hour target 90%

Ring-fenced stroke beds are now online, which should prevent outlying patients being placed in these beds. Early indications have highlighted positive impact on performance and staff morale. Early supported discharge is aiming to go live in October 2019. Stroke Specialist Nurse cover is now operating seven days a week from 8am to 12pm.

An integrated community stroke service will provide early effective community stroke rehab to all stroke patients leaving hospital, with an offer of early intensive intervention based on need. This service is being developed in line with the Integrated Stroke Service Specification recommend by the Stroke review Board and signed off by all Lancashire and South Cumbria CCGs.

Integrated Board Report NHS Chorley and South Ribble Governing Body 25 September 2019 Page 216 4. Quality and Performance Dashboards

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5. Quality and Performance Exception Reports

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

Expected Issue Action Recovery Workstream: Urgent Care Lead: Kate Burgess Accident and Emergency - Programme Lead: Kate Burgess Percentage of A&E attendances admitted, transferred or discharged within 4 hours of arrival LTHTR 83.82% at an A&E Department Target: 95% Current position: 06/2019 ICS 84.10%

Current Issues: Improvement Plans: A&E Main issues remain in flow and breaches in waiting for There were number of schemes which operated as a result of the winter plan with the aim trajectory beds and high bed occupancy. of reducing demand on the A&E department and improving flow within the hospital. The best at CCG held a workshop to review the effectiveness of the winter plan schemes and an M06 and Performance shows a slight improvement on the May A&E Delivery Board plan for 2019/20 was approved on 14th June. M07 at 2019 figure 90% The pressures on flow continue within the hospital at Lancashire Teaching Hospitals with Data from LTHTR monthly SITREP shows performance occupancy at an average of 98% throughout April 2019. for GTD at 98.9% in June 2019 and at 68.3% for A&E. There is a plan in place with a number of actions focusing on the following areas: • Alternatives to A&E • Same Day Emergency Care • Acute Flow • System Flow • System Escalation A&E Delivery Board Plan on a Page:

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Trolley waits in A&E no longer than 12 hours Current position: 06/2019 LTHTR 22 Target: 0 Current position: 03/2019 ICS 170 Current Issues: Improvement Plans: Unable to Main issue is insufficient capacity to move patients and As above, with a focus on flow, streamlining the discharge processes and developing a predict accuracy of reporting. There has been a significant minor injury stream will improve the 12hr breach position. expected reduction in the number of breaches in June 2019 from recovery March 2019. • The ED safety checklist is completed for all patients to ensure the safety of the patients has not been compromised. • A local SOP has been agreed between the CCGs and the Trust to ensure there are robust reporting processes in place. • The CCG receive timelines on all 12 hour breaches these are reviewed by the Quality team in order to identify any themes and trends that have occurred. • Ambulance Response and Handover times - Programme Lead: Suzanne Hebashy Category 1 - Time critical and life threatening NWAS 00:07:21 Target: events Current position: 06/2019 CSR CCG 00:09:02 00:07:00 GP CCG 00:06:50 NWAS 00:12:23 Target: Current position: 06/2019 CSR CCG 00:15:16 00:15:00 GP CCG 00:10:52 Category 2 - Potentially serious conditions that NWAS 00:22:19 Target: may require rapid assessment, urgent on-scene Current position: 06/2019 CSR CCG 00:23:33 00:18:00 clinical intervention/treatment and/or urgent GP CCG 00:20:00 transport NWAS 00:47:21 Target: Current position: 06/2019 00:40:00 CSR CCG 00:46:27 GP CCG 00:42:33 Category 3 - Urgent problem that requires NWAS 02:32.15 treatment to relieve suffering and transport or assessment and management at scene with referral CSR CCG 02:24:10 Target: where needed within a clinically appropriate Current position: 06/2019 02:00:00 timeframe GP CCG 02:15:49 Page 230 Page

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Category 4/4H/4HCP - Non urgent problem that NWAS 02:58:44 Target: requires assessment and possibly transport within Current position: 06/2019 03:00:00 CSR CCG 03:28:46 a clinically appropriate timeframe GP CCG 03:24:06 Current Issues: Improvement Plans: Response time improvement requires operational The CCG have now setup bi-monthly meetings to discuss specific performance concerns reconfiguration of vehicle profile. Call volume remains for central Lancashire. Following the first meeting NWAS have agreed to set local high. recovery trajectories that we can use to measure improvements against. Actions include: 1. Auto clear, being piloted at RPH so ambulances are turned round more quickly. 2. For Category 1 calls there is an auto dispatch in operation which allocates the nearest ambulance to the call. NWAS have calculated that this is presently taking 1 minute off the response times. 3. Promoting alternative transport for patients into hospital. 4. An increased target for See and Treat. 5. Update of the staffing rotas. Ambulance Handover Delays CDH (30-60mins) 2 RPH (30-60mins) 18 Target: 0 Current position: 06/2019 CDH (60+mins) 0 RPH (60mins+) 2 Current Issues: Improvement Plans: Main issues affecting performance are flow through the 1. The specific ambulance handover triage area within A&E, which has improved hospital and processes for rapid handovers. Unclear handover times. protocols for clinical coordinator handover. 2. Performance has improved significantly for these indicators. 3. LTHTR were one of six North West sites to take part in the “Every Minute Matters” Collaborative Programme whose aim was to reduce average hospital handover to 20 minutes by March 2019. 4. The work done by the LTHTR team in improving processes, and the strong supportive leadership put into this initiative, has resulted in the Trust having the best performance and most sustained improvement in this area. Stroke standard - Quality Lead: Wendy Hope Non-Achievement of 4hr standard for stroke Target: 90% Current position: 06/2019 LTHTR 72.73% admission Current Issues: Improvement Plans: September Underperformance was largely due to capacity issues. 1. The CCG continue to meet with the Trust on a monthly basis to monitor the progress 2019 of the Remedial Action Plan (RAP). 2. Following the decline in May’s performance (due to a significant increase in the number of stroke presentations), June’s figures showed a marked improvement:77%

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of stroke patients were admitted to the Acute Stroke Unit (ASU) compared to 43% in May; and the median time for admission to the ASU fell from 5h10m in May to 2h57m in June. This improvement was linked to the planned ring-fencing of beds on the ASU, which commenced on 3 June. In total, there were 10 breaches in June, of which 6 were deemed unavoidable. Ongoing performance will be monitored for the next 2 months to ensure sustained improvement. 3. Workforce: Further to the successful recruitment of stroke consultants, 1 consultant started in May and another is due to start soon (awaiting confirmation of start date). In addition, 2 temporary Stroke Specialist Nurses have been appointed (started) to cover maternity leave. 4. Two stroke patient and carer events are due to take place in September. These will focus on the stroke programme priorities that are being progressed across Lancashire and South Cumbria. 5. The early supported discharge service is currently under formation and expected to ‘go live’ in October 2019. Workstream: Elective Care Lead: Donna Roberts RTT - Programme Lead: Steve Flynn RTT pathways waiting no more than 18 weeks from CSR CCG 87.88% referral Target: 92% Current position: 06/2019 GP CCG 88.54% ICS 86.73% Current Issues: Improvement Plans: RTT Both CCGs are under the 92% threshold, performance Following the issue of a Contract Performance Notice to LTH for 52 week breaches and forecast has plateaued over the last 3 months with no increasing numbers of incomplete pathways, a Recovery Action Plan (RAP) was agreed flat at discernible improvement, with a similar picture at between Trust and CCG. A weekly RTT steering group, with key members from the 80%. LTHTR which is now at 80.47% - the LTHTR position is CCGs and LTHTR, has continued to meet - this group is supporting timely action Yearend driving the underachievement. The CCG position is planning around long waits and RTT, as well as monitoring whether the RAP actions and forecast much higher because of a significant level of activity at trajectories are on track on a regular and frequent basis. From September 2019 onwards for providers who are achieving well above the 92% this will be replaced by the Elective Care Delivery Board. pathways threshold. at 32,112 Capacity issues regarding workforce and beds are Main actions to address poor performance include: affecting performance, as well as a backlog of 1. Deep dive analysis on activity and demand for high volume specialties continues, with validation work, an increased growth in GP referrals in LTHTR now fully engaged in the process and acting on Deep Dive findings. This will a small number of specialties, and growth in consultant be used in joint reviews of referral activity. initiated referrals in a number of other specialties. The 2. LTHTR are undertaking transformational work across a number of specialties two 232 Page specialties most under pressure of late (outside of including MSK and ophthalmology. Integrated Board Report NHS Chorley and South Ribble Governing Body

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the pension’s issue) have been Ophthalmology and 3. NHSI have put daily calls in place with the Trust to review all 52 week breaches. Oral Surgery – the latter in particular has seen 4. Oral Surgery plan includes the use of a triage process to ensure LTHTR only receive significant growth in demand in the last 12 months and the more complex referrals, the use of Tier 2 facilities to support the Trust and a corresponding rise in long waits. However, changing the skill mix within Tier 2 to get them to pick up more work currently done in Ophthalmology demand and the PTL have reduced in the acute sector. NHSE have also made available an Oral Surgeon to work with the 201920. Trust to review referrals, and redirect as appropriate. Significant growth in demand continues in this specialty. Pathways have increased significantly since April, 5. A significant increase in 2 week wait referrals is driving up overall demand in specific growing by nearly 3000 pathways – this is driving up specialties – the CCG has completed a deep dive in this area which should result in the CCG position. The Trust have stated that the issue targeted actions, and a Recovery Action Plan is already in place for Cancer. with Consultant pensions – the reduction of pension tax 6. The recovery process has reached the end of the trajectory period and both 52 week relief for high earners has led to them being penalised and pathways trajectories have been missed significantly, with little assurance that for doing extra sessions – has led to a significant these issues will be resolved in the short term. The CCG is currently forming options reduction in consultant overtime and therefore in as to how to escalate this and other provider performance issues, with consideration session capacity. The most growth is being being given to the Integrated Care Partnership and other parts of the new NHS experienced in General Surgery, Breast, Colorectal and landscape. Urology. 7. The health economy has been accepted onto the NHS England Outpatient Transformation Programme, focusing on the development of a strategy to reduce outpatient firsts, follow ups and procedures. Zero tolerance RTT waits over 52 weeks for CSR CCG 0 incomplete pathways Target: 0 Current position: 06/2019 GP CCG 0 ICS 9 Current Issues: Improvement Plans: July 2019 Following a sustained focus on long waits, including 52 week breaches are included within the Recovery process laid out in the RTT section new performance reporting and frameworks put into above. place at the Trust which have targeted long waiting The Trust was aiming to be at 0 at the end of June but there were 2 further breaches in specialties, numbers of 52 week breaches have July, and a potential 4 for August. This will be escalated through the new Contract reduced significantly. There were no breaches for both Executive meeting in September. CCGs in June. LTHTR had 4 breaches at the end of June, however these were a combination of NHS England commissioned services (Oral surgery and Neurosurgery) and patients who fall under other CCG areas (ENT and Trauma and Orthopaedics). Percentage of Service Users waiting 6 weeks or CSR CCG 3.44% more from referral for a diagnostic test Target: 1.00% Current position: 06/2019 GP CCG 5.45%

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ICS 2.50% Current Issues: Improvement Plans: June 2019 The 6 week diagnostic target, which was already a The CCG issued a Contract Performance Notice (CPN) to LTHTR in early December to (compliance concern, deteriorated significantly in December at both address the underperformance. The CPN is being discussed in the fortnightly RTT date exceeded) CCGs and has remained high, despite some steering group meetings. The main points to address performance in the plan are: improvement in February and March as a result of the 1. Replacement of the CT scanners are in progress. Mobile scanners will be used recovery process. There were a total of 106 patients whilst the new ones are installed. waiting over 6 weeks in June at Chorley and South 2. Endoscopy, initiatives including insourcing capacity, reviewing use of the suites Ribble, 93 of which were at LTHTR. Greater Preston and the structure of the estate. underperformance relates to 206 breaches, 196 of 3. Echocardiography – Bank cover for echo cardiographers, outsourcing clinics to which were at LTHTR. This is reflected in the independent sector and upgrading capital. underperformance at LTHTR at 4.51%, the eleventh month in a row that the Trust has failed this target. CT is back on track, and endoscopy is improving, however, significant underperformance The issues relating to the deterioration in December remains in Echocardiography, whilst further issues have arisen in Cystoscopy and were with computed tomography (CT), audiology Neurophysiology. In Echocardiography: assessments, echocardiography and 1. Capital funding has been approved for equipment, which was delivered in July. endoscopy. However, this latest deterioration is mainly 2. There are currently 2 technician vacancies – to cover these posts one locum has driven by Echocardiography, with further issues in been appointed and started in July, and the Trust are trying to secure a second. Cystoscopy and Neurophysiology. 3. Reviewing Cardiologist job plans to increase numbers of Echo sessions.

The CCG has requested a rewrite of the recovery plan to address these issues, specifically to address the problems in Cystoscopy and Neurophysiology.

Workstream: Cancer Waiting Times Lead: Donna Roberts Cancer Waiting Times - Programme Lead: Steve Flynn Percentage of Service Users referred urgently with CSR CCG 92.39% suspected cancer by a GP waiting no more than two weeks for first outpatient appointment Target: 93% Current position: 06/2019 GP CCG 93.23%

ICS 89.67% Current Issues: Improvement Plans: The performance in CSRCCG equates to 49 breaches The CCG has completed a Deep Dive into Cancer demand. LTHTR have indicated that against the pathway across the breast, colorectal and there has been an increase in the proportion of overall referrals that are allocated to the 2 skin pathways. week pathway; their conclusion is that GPs may be using this pathway to circumvent long 90% of the breaches at Lancashire Teaching Hospitals waits with routine referrals in certain specialties. The CCG will complete further analysis Page 234 Page

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on the 2 week pathways are due to patient choice; to prove or disprove this theory. however, there are capacity issues with patients on the breast pathway. LTHTR continue to subcontract assessment on the Breast Care pathway to Ramsay There continues to be a significant increase in demand Euxton Hall. for 2 week wait referrals.

Percentage of Service Users referred urgently with CSR CCG 92.19% breast symptoms (where cancer was not initially suspected) waiting no more than two weeks for Target: 93% Current position: 06/2019 GP CCG 94.12% first outpatient appointment ICS 68.78% Current Issues: Improvement Plans: The performance for CSRCCG equates to 5 breaches The CCG has an ongoing Remedial Action Plan against the performance particularly in all due to patients cancelling their appointments. with a target of 75% of appointments being seen within one week.

The CCG has asked LTHTR to provide an update to the Cancer Performance Plan to understand the effect of actions undertaken within their own timeline. Percentage of Service Users waiting no more than CSR CCG 95.65% one month (31 days) from diagnosis to first definitive treatment for all cancers Target: 96% Current position: 06/2019 GP CCG 92.79% ICS 95.49% Current Issues: Improvement Plans: The performance for CSR CCG represents 4 breaches The continued pressure on bed occupancy within LTHTR particularly on HDU beds, has on the pathway; these breaches were mainly due to led to a number of cancellations on the cancer pathway. The actions plan against A&E elective capacity 2 of which were on the Gynaecology performance aim in part to increase capacity by both reducing the number of A&E pathway. attends and improving flow through the hospital.

The performance for GP CCG represents 8 breaches on the pathway. The breaches were across the Urology, Head and Neck, Gynaecology and Colorectal. The breaches were due to Elective Cancellations delays in diagnostics and treatment being delayed for medical reasons.

Percentage of Service Users waiting no more than CSR CCG 91.67% one month (31 days) from diagnosis to first Target: 94% Current position: 06/2019 definitive treatment for surgery GP CCG 92.59%

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ICS 91.53% Current Issues: Improvement Plans: Expected The performance represents 2 breaches for CSRCCG The CCG continues to work with LTHTR with regards to the ongoing Cancer Remedial improvement and 2 breaches for GPCCG. Action plan. by Q2. Recovery by All of these breaches were due to elective capacity, two Outsourcing continues to be delivered at BMI Alexandra at Cheadle as an interim March 2020 for Gynaecology, one for Skin and one for Urology. measure. Percentage of Service Users waiting no more than CSR CCG 100% 31 days for subsequent treatment where that treatment is an anti-cancer drug regimen Target: 98% Current position: 06/2019 GP CCG 95.45% ICS 99.13% Current Issues: Improvement Plans: The performance for GPCCG represents two breaches Please see above. on the pathway, one for skin which was patient choice to delay and one on the lung pathway due to the patient having their treatment delayed for medical reasons. Percentage of Service Users waiting no more than CSR CCG 92.59% 31 days for subsequent treatment where the treatment is a course of radiotherapy Target: 94% Current position: 06/2019 GP CCG 97.06% ICS 97.71% Current Issues: Improvement Plans: The performance for CSR CCG represents two Please see above. breaches on the pathway, one on the Breast pathway and one on the Gynaecology pathway.

The breach on the breast pathway was due to patient choice, the breach on the Gynaecology pathway was due to elective capacity. Percentage of Service Users waiting no more than CSR CCG 64.81% two months (62 days) from urgent GP referral to first definitive treatment for cancer Target: 85% Current position: 06/2019 GP CCG 76.79% ICS 73.68%

Current Issues: Improvement Plans: The performance at CSR CCG represents 19 breaches The CCG has an ongoing Remedial Action Plan against the performance particularly in on 236 Page the pathway, 18 of the breaches at LTHTR. The with a target of 75% of appointments being seen within one week. Integrated Board Report NHS Chorley and South Ribble Governing Body

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breaches are spread across a number of pathways, with Urology being the largest single number at seven. The CCG has asked LTHTR to provide an update to the Cancer Performance Plan to understand the effect of actions undertaken within their own timeline. The reasons for breaches were complex diagnostic pathway, diagnostic delays and outpatient capacity.

The performance at GP CCG represents 13 breaches on the pathway, 11 at LTHTR. The breaches are spread across a number of pathways, with Urology being the largest single number at seven. As with CSR CCG, there were a number of reasons for these breaches including complex diagnostic pathways, diagnostic delays, outpatient capacity and treatments delayed for medical reasons. Cancelled Ops - Programme Lead: Steve Flynn; Quality Lead: Wendy Hope Non-Achievement of Cancelled-ops not rebooked Target: 0 Current position: 06/2019 LTHTR 40 within 28 days Current Issues: Improvement Plans: These have occurred across a range of specialties. 1. Capacity issues continue creating inpatient pressures particularly in General Surgery The main reason for underperformance is due to and Neurosurgery. capacity across the Trust, which resulted in no bed 2. In Neurosurgery, a peer-review has taken place and an action plan has been being available on the ward in 50% (20) of the developed. breaches. Most significantly in General Surgery (10) 3. The Trust has an improvement plan in place to ease patient flow pressures, including and Neurosurgery (5). acute flow and system flow workstreams and escalation arrangements. 4. The CCG routinely request assurances that the affected patients are not waiting for Two of the 40 breached patients are still awaiting an cancer surgery and that no harm occurs as a result of the cancellations. appointment: 5. The CCG have ensured commencement of an Elective Care Delivery Board • 1 Neurosurgery patient (September 2019) with Executive leadership to address RTT issues on a broader • 1 Orthopaedic patient scale. It is hoped that this will have a positive impact upon the numbers of cancelled operations. EMSA – Programme Lead: Steve Flynn; Quality Lead: Jane Brenan/Wendy Hope Sleeping Accommodation Breach CSR CCG 15 Target: 0 Current position: 06/2019 GP CCG 24 ICS 108 No current issues: Improvement Plans: Partial The number of sleeping accommodation breaches rose 1. Trust flow and capacity issues remain problematic and a number of work streams are Estates Page 237 Page solution due Integrated Board Report NHS Chorley and South Ribble Governing Body

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from 69 in May to 78 in June. These were mainly in place to ease these pressures, including the new Critical Care facility under to the attributable to the critical care unit. In addition, there development. The Director of Nursing has asked for further work to be done to extension of critical care was one incidence in Endoscopy and a further support this work. (RPH) in incidence in Respiratory (NIV beds). 2. The CCG are in receipt of a report (dated 31.05.2019) that described the Trust’s addition The Trust has seen an increase in OPEL status and patient flow improvement programme. This is expected to have a positive impact. overarching this has been predominantly sustained at high OPEL 3. There is work ongoing with the patient flow team to ensure that the critical care trigger access and flow level 3 for several months. This is having an impact on prioritisation is an area of focus within the daily flow meetings. The critical care team improvement the ability to transfer patients out of the Critical care also review patients pre admission and are able accommodate patients in plans area in a timely manner due to the ongoing pressure to male/female areas however patient safety is the priority and this isn’t always possible. continue accommodate emergency admissions. The decision The team mitigate MSA breaches where possible and they are currently developing a about which patient is prioritised to be accommodated, Standard Operating Procure that documents all the actions and escalations to be is based on a risk based approach to ensure patient taken if a MSA breach is likely to occur. safety. 4. The Trust have agreed to include in the SOP a further escalation to the patient flow coordinator at 3 hours to see if this can apply traction. 5. Steps are taken to protect patient privacy and dignity when a breach occurs. Workstream: Mental Health Lead: Janet Ince First episode of psychosis treated with a NICE CSR CCG 50.0% approved care package with two weeks of referral Target: 56% Current position: 06/2019 GP CCG 20.0% ICS 44.83% Current Issues: Improvement Plans: March 2020 Both CCGs failed the target this month. Chorley & 1. NHSI IST team visited to review patient referral pathways and flow to increase South Ribble CCG’s position is at 50%, relating to 2 capacity – an action plan is now in place, including actions to: patients out of 4 treated outside of the target timescale. a. Review of RTT Standard Operating Procedure regarding clock start and stops. The Greater Preston position relates to 4 out of 5 b. Enhancing telephone triage patients treated outside of the target. This is in line c. Increase direct liaison activity between EIS and inpatient units to improve with the Trust position, which has been under target in timeliness of referrals. all months during 201920. d. Promote guidance for front facing teams to improve diagnosis and therefore timeliness of referrals Previously most delays were due to delays in the 2. The source of delayed referrals (i.e. which internal team) is now being routinely referral process, and increased demand across most monitored with action plans for high referrers of delayed patients. mental health services. However this month there has 3. There is an efficiency review to increase capacity within EIS services, including been a significant rise in delays due to patients being involvement of EIS regional lead. ‘complex’. This implies a change in reporting, which will be followed up at the contract meetings for

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The percentage prevalence of people who have CSR CCG TBC depression and/or anxiety disorder who receive Target: TBC Current position: 06/2019 psychological therapies GP CCG TBC Current Issues: Improvement Plans: March 2020 The CCG is currently unable to report against this Discussions are ongoing through contractual routes to resolve this issue. In the indicator because the lead commissioner and Provider meantime actions continue to improve the position: are still within contract discussions to agree the target • Redesign of the assessment stage to improve efficiency. level. National direction is that the target increases to • Improve communication between service and GPs, public and community. 22% this year; however, there is recognition that this • Capacity and demand modelling may be unachievable with the current levels of • Sub-contracting resource and staffing available. • Recruitment to vacancies and more pro-active recruitment strategy to predict the vacancies and act in a more timely fashion. • Recruit trainees. Quality (LTHTR) Quality Lead: Vicky Webster LTHTR Quality Lead: Wendy Hope Medication Errors (with harm) Target: 2 Current position: 06/2019 LTHTR 32

Current Issues: Improvement Plans: The Trust medicine safety report was not available at 1. A thematic review on anticoagulant incidents is ongoing at the Trust and the CCG the time of writing this report, but will be reviewed. have requested all findings and recommendations when available are shared. 2. The CCG continue to receive monthly medicine safety reports to ensure further details and assurances are received. This includes trends and themes of incidents reported. These reports are analysed and any queries are raised with the Trust directly. Serious Incidents Target: 0 Current position: 06/2019 LTHTR 3

Current Issues: Improvement Plans: Three Serious Incidents were reported in June: 1. Following the recent thematic review on Never Events, a further forensic analysis at • Medicine incident (1) specialty level for wrong site surgery, retained foreign objects and mis-placed naso- • Slips/trips/falls (1) gastric tubes is being undertaken by the Trust. This, along with an external review of • Surgical / invasive procedure (1) theatres will inform an overarching action plan, which will be presented by the Trust to the Central Lancashire Quality Improvement Board in September 2019. 2. Slips/trips/falls: The Trust is focusing on improving the management of lying and

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assessment) vision assessments and any medications which may increase the risk of falls. In addition, increased physiotherapist and occupational therapist involvement has supported the implementation of individualised mobility care plans and physiotherapy mobility assessments. This is supported by a national CQUIN scheme in 19/20. 3. The CCG request monthly updates from the Trust in relation to the associated actions in place to address the top five StEIS reported incident types and the recovery plan for outstanding investigations. 4. The CCG serious incident review panel continue to review all submitted StEIS reports monthly in order to ensure that the action plans submitted in the reports reflect the learning that has been identified from the incident. 5. The Trust continues to send lead clinicians to discuss their reports at the CCG serious incident panel. Quality (LCFT) Quality Lead: Jane Brenan LCFT Quality Lead: Heather Myers Pressure Ulcers Grade 3 and Grade 4 Grade 3: 3 Target: 0 Current position: 06/2019 LCFT Grade 4: 1 Current Issues: Improvement Plans: In June 2019, LCFT reported three grade 3 pressure . Although the prevalence of pressure ulcers within LCFT is lower than its comparable ulcers and one grade 4 pressure ulcer. organisations, the Trust is committed to reducing the occurrence of pressure ulcers further. The Trust has set an internal target to reduce the prevalence of pressure As a health economy, there is a targeted focus to ulcers by 25%. reduce the prevalence of pressure ulcers by increasing . The Pressure Ulcer Reduction Steering Group continues to meet monthly with awareness of pressure ulcers, to reduce harm by attendance from the CCG Chief Nurse. The Pressure Ulcer Improvement Plan is enabling preventative interventions to be implemented under review and will be presented at the Quality Committee. Reporting will be linked at an earlier stage. back to the pressure ulcer plan and strategy in order to establish the 25% reduction target is being met . All pressure ulcers continue to be reviewed and scrutinised by the LCFT Safety Senate to determine whether they were avoidable or unavoidable, and identify any learning to be shared and identify those that require STEIs reporting. . React to Red training continues to be delivered to support staff to prevent pressure ulcers developing and deteriorating. Care homes in the Pennine have signed up to the React to Red training. . Further work is to be undertaken led by the CCGs with the Community Trust and Acute trust in order to establish whether pressure ulcers are present on admission to hospital or acquired whilst at the hospital. This information will assist in identifying 240 Page Integrated Board Report NHS Chorley and South Ribble Governing Body

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improvements. . LCFT Tissue Viability Team have worked closely with the Care Home Enhanced Support Services and Care Homes to produce an initial guide for Nursing Homes on basic wound management and when to refer on. This will be trialed at a number of care homes. . A significant review of the Wound Care Formulary has been undertaken and positively received.

Serious Incidents Reported (Community contract only) Target: 0 Current position: 06/2019 LCFT 3 Current Issues: Improvement Plans: LCFT reported three serious incidents during June . Following a STEIS reportable incident LCFT will undertake a Rapid Review (within 72 2019. hours) and submit this to the CCG. The rapid reviews have been received. . A full RCA in relation to each incident will be submitted to the CCG within 60 days. Those incidents related to pressure ulcers found to be The investigative reports will then be duly reviewed by the CCG SI Review group to potentially avoidable. determine if the incidents have been thoroughly investigated and any lessons learnt cascaded across the health economy. . The CCG attends LCFT SI meetings where all SI cases are subject to a high level of scrutiny. Quality (Ramsay Health Care) Quality Lead: Vicky Webster Ramsay Quality Lead: Sam Riding Ramsay Health Care – Complaints Target: 0 Current position: 06/2019 Ramsay 4 Current Issues: Improvement Plans: Four complaints received in June Two complaints were in regards to post-operative symptoms, these are now closed. Two Two at Euxton Hall Hospital and Two at Fulwood Hall were around administrative issues. These have now been addressed and rectified. The Hospital. CCG continue to work with the provider to support resolution of the remaining open complaints and to work to reduce complaint numbers into the future.

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6. Improvement and Assessment Framework Dashboards

Integrated Board Report NHS Chorley and South Ribble Governing Body 25 September 2019 Page 242

Integrated Board Report NHS Chorley and South Ribble Governing Body 25 September 2019 Page 243 7. Improvement and Assessment Framework Performance Exceptions (Dashboard published July 2019)

Key: Rank: Lowest performing quartile Rank: Interquartile range Rank: Highest performing quartile Indicators with a target

Better Health 107a: Antimicrobial resistance: appropriate CSR: 0.997 GP: 1.086 Target: 0.965 Current position: 2019 02 England: 0.962 prescribing of antibiotics in primary care 105/195 155/195 Current Issues: Improvement Plan: The NHSE antibiotic volume target has been reduced from 1.161 An annual antibiotic prescribing audit was completed in all practices in Sept/Oct 2018; this will per STAR PU (Specific Therapeutic group Age-sex Related be repeated in Sept/Oct 2019. Individual feedback to practices ongoing. All practices written to Prescribing Units) to 0.965 per STAR PU. Prescribing volume with new targets and current position against targets. Antibiotic formulary reviewed and made across both CCGs continues to reduce but does not meet the available on net formulary. Antibiotic target is included in the quality contract. required targeted by NHSE. https://www.england.nhs.uk/ccg-out-tool/anti- dash/https://www.england.nhs.uk/ccg-out-tool/anti-dash/ 108a: The proportion of carers with long CSR: 0.58 GP: 0.60 term conditions who feel supported to Target: 1.000 Current position: 2018 England: 0.59 manage their condition 113/195 78/195 Current Issues: Improvement Plan: In comparison to the England average, CSR is just 0.1 below, and The following key performance indicator was added to the CCG’s General Practice Quality GP is 0.2 above. However, it is acknowledged that neither met Contract for 2019/20. ‘80% of carers on the register are to have been offered an annual health the target and further improvements are required. check’. This is with the aim of increasing the number of health checks carried out and in turn increasing the level of support offered to carers.

This is in addition to the following, already existing KPI within the contract: ‘Achieve or maintain 2% of list size on the carers register.’

We aim to build upon the proportion of carers identified and to ensure they feel supported by their practice. This is both in terms of the challenges they may experience in relation to this role, in addition to their overall mental and physical health, including any long-term conditions.

Page 244 Page There are a number of KPIs within the contract which encourage the supporting of patients (not Integrated Board Report NHS Chorley and South Ribble Governing Body

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solely, but including carers) to manage their long term conditions, such as inhaler technique checking for both COPD and asthma and referral for further support for pre-diabetic and diabetic patients including blood glucose monitoring. 121a: Provision of high quality care hospital CSR: 56 GP: 55 Target: N/A Current position: 18-19 Q3 England: N/A 175/195 180/195 Current Issues: Improvement Plan: Lancashire Teaching Hospitals received an overall rating of • The CCG continue to be active members at the Central Lancashire Quality Improvement ‘requires improvement’ at the last CQC inspection. Issues Board which was convened in response to the last CQC inspection. The unannounced part were highlighted in relation to patient flow, urgent and emergency of the CQC re inspection has taken place, prior to the Well Led re inspection. High care and a lack of strategy in the division of medicine. Mandatory level CQC feedback has been shared with the CCG. training compliance, safe management of medicines, staffing • Value stream analysis improvement work streams have been implemented and led by the levels and financial pressures were also areas of concern. CCG to assist with urgent care and flow challenges across the Trust. Priorities for 2019/20 are focused around extending provision of the Same Day Emergency Care service; review During 2019 the Trust have continued to encounter challenges in and enhance the intermediate care provision and further develop the neighbourhood relation to flow and capacity issues which are still impacting upon Networks to enable care closer to home. This work is expected to positively impact upon flow staff in the ED. Improvements have been made to the ED and capacity at the Trust. paediatric pathway at the Preston site, however challenges • The CCG instigated a single item QSG as a result of a high number of reported Never continue in relation to providing a sufficient number of qualified Events in 2018-19. The CCG have undertaken a review of these using Human Factors staff in the Chorley ED. methodology and presented the findings at the meeting. The Trust identified that in response to these events an external theatre review had been commissioned. Additionally Staffing levels continue to be challenging (in line with the rest of the Trust are undertaking their own forensic investigation of the Never Events (2018-19). The the country), however a number of safety mechanisms have been Trust will triangulate all of these reports and formulate one overarching action plan as a introduced in response to this. This includes the assessment of result. This will be discussed at the September Central Lancashire Quality Improvement patient acuity, increasing the establishment of qualified staff Board. where required and additional investment in staffing for ED, • The programme of CCG Quality Visits have continued throughout 2019 and are used to Paediatrics and Maternity. The Trust also undertake daily staffing sense check improvements against the CQC actions. reviews in order to manage any risks on a daily basis. Mandatory • The CCG have instigated an Elective Care Board and an ICP level Contract Executive training compliance has notably improved. meeting in order to progress any work in relation to meeting constitutional standards.

There have been some clear improvements in relation to the Trust Governance structure and reporting mechanisms. In addition an improved approach to medicines safety can be demonstrated following the recruitment of a medicines safety officer.

Financial pressures remain along with challenges meeting NHS Constitutional targets. 121c: Provision of high quality care: adult CSR: 64 GP: 59 Target: N/A Current position: 18-19 Q3 England: N/A social 245 Page care 26/195 177/195

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Current Issues: Improvement Plan: This indicator is based on an overall score indicative of the quality One home is subject to a phased admissions plan. The provider is proactively engaging with the of care in a CCG area as determined by CQC inspection ratings, support offered via the quality and safeguarding partnership but making limited progress with the and then rated against an England average. This overall score is improvement plan. High staff turnover and changes to the leadership team are factors impacting based on the ratings given at each site inspected in a CCG area on the improvement plan being embedded. The CQC have recently inspected and the report against the five key questions i.e. “Is it safe?”, “Is it effective?”, has been published. Quality monitoring and support visits provided by the CCG continue both and “Is it well-led?”, “is it caring?”, and “is it responsive?” The announced and unannounced. ratings for each question are scored as follows: outstanding = 3, Service Delivery: good = 2, requires improvement = 1, inadequate = 0. This is then • The safeguarding champion model continues to be a successful initiative with good added up into a total score for each CCG, and compared against engagement from care home providers. The next workshop will focus on sex and consent, the total maximum score available for each CCG to give a rating NHSE falls tools, PIPOT and updated safeguarding guidance. score out of 100. • The domiciliary safeguarding champion continues to be well attended and evaluated. The last workshop focused on Prevent, PIPOT and Hate Crime. 1. Themes across the regulated care sector identify areas of • A self-neglect framework and hoarding guidance has been launched via the Lancashire concern around medicines management, record keeping, and Safeguarding Adults Board (LSAB) in March 2019 to support a multiagency response for inconsistencies with leadership style across the care home services working with individuals who self-neglect where there is a risk of harm to individuals sector and the need to focus on an appreciative leadership or others. style. This is coupled with challenges due to retention of • The LSAB MCA sub group has introduced the Liberty Protection Safeguards (LPS) registered managers and the impact of inconsistency in implementation and planning group which aims to support agencies to understand the practice amongst staff teams. Areas for development also requirements LPS which will be replacing the Deprivation of Liberty Safeguards (DoLS) on 1 include the need to strengthen risk assessment and October 2020. management across the sector. The CCG safeguarding team • The care home collaborative continues to be successful, with a relaunch of the buddy continues to provide safeguarding leadership to those homes system (supported by AQUA). identified on Radar and the Quality, Performance • React to Red training continues, with the launch of e-learning. Improvement Plan (QPIP) process. • The care home newsletter remains well received with provider engagement in content. 2. One Intermediate care unit within a care home is being • Training continues to be offered by the CCG and the new timetable has been circulated. managed by the QPIP process and is subject to a phased • CCG chief nurse continues to Chair the ICS quality sub group. admission process. An action plan is in place and support is • Focused work underway to improve nutrition and hydration and oral health. provided by health and social care professionals to enable the homes to make the required improvements. One care home and one nursing home remain on staggered admissions following completion of the QPIP process with ongoing monitoring being provided by health and social care professionals. Once care home has been placed in special measures by CQC. 3. Seven homes remain on Radar and all have action plans in place and support visits planned. 4. Three domiciliary providers are on Radar, with a further three Page 246 Page being managed via the QPIP process. The CCG is not able to Integrated Board Report NHS Chorley and South Ribble Governing Body

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implement a suspension or contract warning notice due to lack of contractual arrangements in place with domiciliary care providers. A further provider is being supported to transfer all supported living contracts to other providers due to a closure of the service.

122c: One-year survival from all cancers Target: N/A Current position: 2016 England: 72.8% CSR: 73.6% GP: 72.7%

Current Issues: Improvement Plan: Chorley and South Ribble CCG are above the England average for the 1 year survival rate from cancer. The graph shows a steep increase in the survival rate in the last 15 years compared to the England average.

Greater Preston survival rate is just below the England rate and below the Chorley South Ribble. Greater Preston CCG has also reduced the gap with the England average figure.

123f: Mental health out of area placements CSR: 535 GP: 353 Target: N/A Current position: 2019 02 England: 124 188/195 179/195 Current Issues: Improvement Plan: The lack of in-patient beds and high mental health acuity • The ICS have established an IPA meeting (Michael Connell as lead and Rosemary Cowell continues to be a presenting problem, which has led to an from Central CCGs) looking at how many people are placed out of area and funded through increase in OAP which has led to a significant increase in bed MHCPOC (MH complex packages of care) money and who could be cared for more locally if days as per the target. This is a problem that is seen across the there was provision in the ICS or as LCFT say, they had rehab beds. ICS. Bed modelling previously undertaken indicated as previous • There are 123 people currently in locked and open rehab across the ICS- this is the group that there are enough acute beds in the system if there are other we think we can impact and bring back into planned beds more locally or if it included PDis, resources in place, which include, rehabilitation for individuals we could turn into community service provision. (there are also a significant number of with complex/enduring/long term mental health needs who require people in supported living and supported rehab that we will map next) detainment under the Mental Health Act/Treatment and • There are a total of 90 that are NHS only funded including LDis and the costs are huge. Assessment beds for LD. • This cohort needs to be analysed by required care type to identify what bed could work and The CCG further understand that Community Mental Health help- this would need to be done manually and MLCSU will organise. Teams in our area have been under significant pressure which • We discussed including locked rehab for ABI in this analysis because they are on MHA potentially has led to more individuals experiencing crisis situation sections and complex and could form part of a discussion about a bed in the ICS. around 247 Page their mental health with subsequently more individuals • there’s a piece of mapping for all providers in the ICS who offer rehab and complex care etc Integrated Board Report NHS Chorley and South Ribble Governing Body

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requiring admission to acute mental health beds. and much of this is complete, Generally, there has been an increase in individuals accessing • We are considering capturing the acute OOAs so that we could do something about them as mental health liaison teams. It is noted that some will require they are inappropriate OOA- this group are not in the TORs as they are meant to be admission to Acute mental health beds. For some individuals this impacted by the work we’re doing on MH pathways, community and admission avoidance, is a first presentation and they have not been previously known to so any funding released from reducing this type of OOA would be used to fund earlier mental health services. support and not a fixed bed. • We will capture data so that we have a complete understanding of what the need is if a person is in an OOA appropriately because the type of care isn’t available and they have ended up on an OOA pathway and not through IPA/IDT. • Central CCGs have opened a Crisis Haven (19 August). This will potentially prevent individuals going into Crisis and requiring acute mental health beds. • Mental Health housing officer - regular contact with inpatient wards to help improve capacity and flow. • Further staff have now been recruited into the Community Mental Health Teams to ensure robust service offer. • Primary care Mental Health Practitioners now allocated to Primary care networks to ensure more focus on early Intervention and prevention in mental health. • Community Prevention and Engagement Team (previously Community Restart) has been redesigned with a strong focus on keeping people well in the community and preventing ED admission. 123g: Proportion of people on GP severe CSR: 37.0% GP: 34.1% mental illness register receiving physical Target: 50% Current position: 18-19 Q4 England: 30.3% health checks 55/195 68/195 Current Issues: Improvement Plan: The delays in providing the physical health checks to the Due to the requirement for an ICT build to allow integration between the LCFT team undertaking proportion of people on the SMI register have been in the main the SMI physical health checks to directly exchange information with GP practices (as required due to the build of EMIS ICT system for the team as requested by by GPs) this has slowed down the roll out activity. The build is complete and will be live from 8 GPs. This will be in place 8 September and a roll out plan is September 2019. A roll out plan is in development and the provision of physical health checks being developed to commence further integration with GP will increase month on month (from October 2019) as the service is implemented across GPR practices thereafter. and CSR. 123j: Ensuring the quality of mental health CSR: 0.78 GP: 0.78 data submitted to NHS Digital is robust Target: N/A Current position: 2019 01 England: Null (DQMI) 157/195 157/195 Current Issues: Improvement Plan: The CCG are awaiting a response from the BI lead commissioner and will be provided in the next IBR. Page 248 Page

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124a: Reliance on specialist inpatient care CSR: 72 GP: 72 for people with learning disability and/or Target: N/A Current position: 18-19 Q4 England: N/A 188/195 188/195 autism Current Issues: Improvement Plan: • Aim is to support discharge back to the community for all • New community specification approved those individuals who are in hospital and prevent further • Collaborative approach with all providers to review pathway development opportunities admissions. Re-settlement programme monitored by NHSE • Position paper presented to CCB in August 2019 with an update on progress should result in discharges taking place in line with each • Learning disability and autism support risk register reviewed monthly individuals own plan, with specific effort to discharge the pre • Workforce developments – group continues to review the current actions 2014 cohort by 2019. • Regular service user engagement using pathways via targeted meetings • As at 4 September 2019 there were 11 patients in the Greater • Monthly community bed project board established Preston CCG who met the Winterbourne criteria and 8 • Learning process from care and treatment reviews and the review of admissions meetings patients within the Chorley and South Ribble CCG. continue • Of the total 19 patients, 3 (2 for Greater Preston and 1 for • Specialist support team fully mobilised and engaging with community teams for full Chorley & South Ribble) were from the original pre April 2014 collaborative approach cohort. • Enhanced focus on children and transition, parity of esteem, increasing annual health • Reflected within these figures, Greater Preston CCG has seen checks and screening uptake, quality assurance, prevention of admissions by the specialist 1 patient admitted and 3 patients discharged since the last support team and the crisis elements. reporting period. Chorley & South Ribble CCG has seen 2 patients admitted and 1 patient discharged during the same period. Better Care 125b: Women’s experience of maternity CSR: 81.1 GP: 79.5 Target: N/A Current position: 2018 England: 82.7 services 132/195 160/195 Current Issues: Improvement Plan: Latest National Maternity Survey for January 2019 shows Notably LTHTR achieved Beacon status for midwifery led services (one of 3 in England) and improved position. The survey now rates the Trust as 12th out of were shortlisted for RCM Excellence in Care award for participation in STRAWB study. 69 Trusts (previous position was 36th). Continuity of carer is expected to positively impact on patient experience and work is ongoing to Maternity Friends and Family for Antenatal Care for June 2019 achieve the NHSE targets, which involves women being assigned a named midwife to provide at was lower than expected, with 83.7% of patients surveyed (43) least 70% of their care. In March 2019, 26% of women were booked onto a continuity of carer recommending the service and 7.0% of participants not pathway and although this shows that good progress has been made on the path to reaching the recommending the service. 51% target by March 2021 the Trust has highlighted several challenges ahead, not least on- going staffing issues, the high proportion of part-time staff and the lack of an end-to-end digital Chorley Birthing Centre remained closed through June 2019, due maternity system. to on-going building maintenance work. This has had a knock-on effect on other Maternity services and a possible adverse effect Maternity Voices Partnership (MVP) on patient 249 Page experience. The CCG have requested additional The MVP continues to strengthen. Chaired by service users, the meetings are well attended by Integrated Board Report NHS Chorley and South Ribble Governing Body

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information in relation to the Antenatal scores at the August maternity services workforce; head of midwifery and consultant midwives as well as service contract operational meeting. users, with service user representation growing. Wider health and care representation includes Health Visitors, Dads net, Families and Babies (breastfeeding peer support), Infant Feeding Coordinator and perinatal mental health services.

Meetings have been themed to look at individual topics and feedback is instantly conveyed to providers and commissioners. Topics covered so far this year include:

• Neonatal • Multiple births and complex pregnancies

Key achievements: • A range of community locations secured to hold the MVP meetings that will facilitate a more diverse membership • Signposted numerous service users to various services, contacts and people to aid their informed decision making and also regarding birth afterthoughts and support services. • MVP chairs have presented patient stories at the CCG Governing Body meetings • Promoted the MVP at a recent maternity services open day, talking to over 100 women and family members • Promoted the MVP at a Mothercare family day event • The MVP Facebook page is growing which has enabled the MVP to reach out to more service users.

125d Maternal smoking at delivery CSR: 8.19% GP: 10.9% Target: 6% Current position: 18-19 Q3 England: 10.5% 60/195 93/195 Current Issues: Improvement Plan: The position in May 2019 (overall based upon LTHTR The CCG work closely with the acute Trust in order to monitor improvements against Saving submission) is 15.8% or women were smoking at the time of Babies Lives 2. The CCG receives a quarterly update on progress against the Maternity and booking and 10.8% at the time of delivery. In June 2019, women Neonatal Safety Improvement Plan. The Trust have an improvement plan for maternal smoking smoking at the time of delivery were recorded as 8.5%. as follows: The CCG monitor improvement updates via a quarterly report and the monthly performance via the maternity dashboard. To reduce the percentage of women at LTHTR smoking at time of birth from 10.5% to 9% by April 2020 (equates to a 14% reduction in smokers). In order to achieve this ambition the Maternity and Neonatal team have joined a collaborative 12 month programme, run by the North West Coast Innovation Agency’s coaching academy, focussing on ‘Coaching for a safe and continuously improving workplace culture’. This programme addresses organisational culture and its relationship to patient safety and service Page 250 Page improvement. The overarching aim of the programme is to reduce the percentage of women Integrated Board Report NHS Chorley and South Ribble Governing Body

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smoking at time of birth. Ongoing progress to date • Carbon Monoxide (CO) monitors have been bought and distributed to community midwives, to ensure all women are offered CO testing at booking. • Staff are being trained to use CO monitors and to reinforce the importance of CO monitoring and providing Very Brief Advice (VBA). The first month of the project demonstrated a baseline rate of 34.5% of pregnant women being tested at booking. The 2nd month 53% of women were tested at booking, the 3rd month of data is currently being collected • All women being admitted to the maternity unit as an inpatient should now have a smoking assessment on admission. This is completed on Quadramed, and if the woman is a smoker, VBA is provided and Nicotine Replacement Therapy (NRT) is offered (this started in June 2019) • The neonatal transitional care lead nurse has a meeting planned with the band 7 neonatal nurses to discuss the neonatal unit offer, consideration is being given to a regular weekly session where anyone visiting neonatal unit is offered a CO test. • Triage now have a CO monitor so they can offer a test to women attending with reduced fetal movements/growth issues • A Very Brief Advice e-learning package has been added to the Trust training site. • Smoking cessation champions have been identified in each clinical area. • Quit squad are currently attending some antenatal clinics to perform CO testing & smoke free home pledges. They are monitoring number of CO tests, referrals and pledges gained through this to see if this would feasible to implement on a more permanent basis. • Quit squad are now sending weekly reports to the specialist midwife for public health, regarding the previous week’s pregnancy referrals, so that the named midwife can be updated on whether the woman has made an appointment/set a quit date/declined support etc. 127e Delayed transfers of care per 100,000 CSR: 12.7 GP: 12.7 Target: N/A Current position: 2019 03 England: 10.2 population 150/195 149/195 Current Issues: Improvement Plan: Both CCGs are in the lowest quartile for this indicator. The On 14 June 2019, the A&E Delivery Board closed down the current Value Stream Analysis indicator is based on total length of Finished Consultant Episodes (VSA) workstreams. The Urgent and Emergency Care Improvement Group that governed following a Non-Elective admission, per 1000 population. Current delivery of the VSA workstreams was also stood down. length of stay is not at an optimal level. A review has taken place; the remaining work has been transferred into one of five areas in the 2019/20 A&E Delivery Board Plan. The workstreams and responsible groups are referenced below. Page 251 Page

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1. Alternatives to A&E – Aims to maximise the use of alternative pathways that avoid unnecessary attendance at A&E - Responsible Group: WHIN Board. 2. Same Day Emergency Care (SDEC) – Aims to embed clinical care which may include diagnosis, observation, treatment and rehabilitation not provided within the traditional hospital bed base or within the traditional outpatient services that can be provided across the primary/secondary care interface - Responsible Group: SDEC Board (to be established). 3. Acute Flow – Aims to maximise efficiency from admission to patients becoming clinically optimised and ready to leave hospital - Responsible Group: Urgent Care Steering Group (LTHTR). 4. System Flow – Aims to maximise efficiency from the point patients become clinically optimised and ready to leave hospital and return to the place they consider their home and are as independent as possible - Responsible Group: Community Flow Board. 5. System Escalation – Aims to implement an appropriate, timely and proportionate response to system pressure and efficient processes to manage escalation - Responsible Group: Winter Task and Finish Group. 127f: Population use of hospital beds CSR: 572 GP: 590 Target: N/A Current position: 18-19 Q2 England: 499 following emergency admission 170/195 178/195 Current Issues: Improvement Plan: As per above. As per above.

128e: Count of the total investment in primary care made by CCGs compared with Target: N/A Current position: 18-19 Q4 England: N/A CSR: Red GP: Red the £3 head commitment made in the General Practice Forward View Current Issues: Improvement Plan: Both CCGs spent £1 head in 2017/18 and although we didn’t Plans are in place to spend the remaining £2 head in 2019/20. spend the remaining £2 head in 2018/19 we accrued the funds and have plans in place to spend in 2019/20.

131a: Percentage of NHS Continuing CSR: 20% GP: 13.5% Healthcare full assessments taking place in Target: 15% Current position: 18-19 Q4 England: 6.91% an acute hospital setting 173/195 157/195 Current Issues: Improvement Plan: Greater Preston met this target at 13.5% as the expectation is that To increase our challenging bed and EMI bed base for individuals requiring this provision – less than 15% of DST’s should be completed in hospital. working with the lodge and looking at other provision in the area. Looking at a D2a/Assessment pathway for those individuals with challenging behaviour. Ensure that those individuals in hospital on a 1:1 have been reviewed and the 1:1 is removed as

Page 252 Page appropriate by the Mental Health team. – Meetings and discussions held with MH team and the

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RITT team to look into this further to help provide the CCG with assurances going forward. Attendance at the patient long length of stay meeting at RPH. Regular monthly clinical meetings with the Integrated discharge manager now held to discuss any issues. 145a: Expenditure in areas with identified Target: N/A Current position: 18-19 Q3 England: N/A CSR: Red GP: Red scope for improvement Current Issues: Improvement Plan: A number of the RightCare delivery plans submitted in 2018/19 Work is underway to review the expectations from the RightCare plans and demonstrate had significant outputs linked to the 2019/20 GP Quality Contract; effectiveness of these. therefore, will not yet be measured to demonstrate an impact.

164a: Effectiveness of working relationships CSR: 57.8 GP: 70.5 in the local system Target: N/A Current position: 18-19 England: N/A 181/195 84/195 Current Issues: Improvement Plan: Ipsos MORI 360 Stakeholder survey ICS level When compared to similar CCGs, and also CCGs regionally and The CCG’s Communication and Engagement (C&E) leads work closely with the Communication nationally, Chorley and South Ribble CCG’s results were on and Engagement leads at the Integrated Care System (ICS). They play an active part in the average either around the same or performed slightly worse than C&E steering group, and are currently working with system–wide partners to establish a its comparators. However, there was nothing significant of Community of Practice in respect of engagement that will facilitate better joined up working concern to note. There have been significant changes to the across the ICS. survey this year, notably the re-wording and re-ordering of the questions, the online format of the survey and the ability for Supported by the CCG, a multi-agency Maternity Voices Partnership is now well established. stakeholders to respond on behalf of multiple CCGs means that a The partnership contributes to effective working with our local maternity services, including the like for like comparison to the previous year is not possible. Head of Midwifery. Future meetings of the MVP have been scheduled to take place across Preston, Chorley and South Ribble to facilitate wider attendance by service users and partners It is encouraging to see that: at ICP level. • 79% of responders rated the effectiveness of their working The CCG is a key partner in the delivery of Better Births within the choice and personalisation relationship with the CCG very or fairly good strand of Better Births within the Local Maternity System (ISC). • 68% of responders rated the CCG’s effectiveness as a local system leader as part of an ICP/ICS CCG level plans to facilitate improve working relationships across the ICS/ICP • 74% of responders either strongly or tended to agree that Organisational Development - The CCG is an early adapter of the NHS Leadership Academy the CCG works collaboratively with other system partners Talent Management Diagnostic tool. The CCG will assess itself (at all levels) against a range of on the vision to improve the future health of the population indicators which includes: developing and mobilising talent and connecting to our local health across the whole system. and care system. It is envisaged that upon completion of the process, the CCG will be better placed to support and develop staff to build or improve their working relationships on a wider system level footprint. Page 253 Page

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360 Stakeholder Feedback As the Ipsos MORI 360 survey will no longer be commissioned by NHS England, the CCG is exploring other ways of gathering this valuable data. The CCG’s formal Patient Voice Committee will oversee this activity.

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8. Leadership

8.1 Workforce

CSR & GP CCG Integrated Board Report – HR – 31/07/2019

Expected Rate Actual Rate Sickness 3% 1.57% Mandatory Training 100% 91.00% 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 July should that the monthly sickness rate was 1.57%. This is a slight increase on 0.69% in May when this was last reported, however is below the national NHS expected rate. The CCG governance team continue 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 which are reported to the Governing Body on a bi- annual basis via the workforce report. In addition all CCG line managers have been offered a series of training sessions by the HR team on how to use policies such as Absence Management in a consistent manor.

Turnover The CCGs are currently reporting a monthly turnover rate of 0% for July 2019. This remains unchanged since last reported in May 2019.

Mandatory training The CCGs were below the 100% compliance rate for mandatory training in July 2019 at 91%; this is a slight reduction since this was last reported in May 2019 as 94%. From 1 April 2019 all staff and members of the CCG now complete their mandatory training on ESR which is a national system. The governance team will closely monitor training compliance to ensure that this change in system does not have a continual negative impact on training compliance.

8.2 Complaints

In July 2019, a total number of 18 complaints were received across both CCGs. This was 10 more than the previous month, as illustrated in table 1.

Table 1: Total number of complaints by CCG

CCG June 2019 July 2019 CSR 6 12 GP 2 6 Total 8 18

Graph 1 illustrates the number of complaints received for the period July 2018 to July 2019, broken down by CCG, to provide a full year view.

Integrated Board Report NHS Chorley and South Ribble Governing Body Page 255 25 September 2019 Graph 1 Complaints received by CCG (July 2018 to July 2019)

Of the complaints received in July 2019, four were transferred to other organisations (as highlighted in table 2), two were locally resolved by the customer care team, and 10 remained open but were within the 28 day timeframe for response. Two complaints were logged for information only as they were already being dealt with by the provider, or the complainant was given advice as to how to raise the complaint directly with the appropriate provider.

In July, five complaints related to issues the quality of care provided. Two complaints related to funding decisions. Other complaints related to issues such as concerns around referral pathways, difficulties obtaining appointments and poor communication.

Table 2: Complaints transferred to other organisations

Provider June 2019 July 2019 Lancashire Teaching Hospitals 1 0

Lancashire Care NHS Foundation Trust 0 1

Lancashire Care NHS Foundation Trust – 2 1 moving well service Ramsay 0 0

Out of area 0 1

Lancashire County Council 0 0

NHS England 1 0

North West Ambulance Service 0 0

GTD Healthcare 0 1

Other provider(s) 0 0

NHS 111 0 0

Integrated Board Report NHS Chorley and South Ribble Governing Body Page 256 25 September 2019 8.3 Freedom of Information (FOI) requests

A total number of 36 FOI requests were received in July 2019. This was five more than received in June 2019. Twelve requests remained open at the end of July. 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 June 2019.

• 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.

In July, across both CCGs, four exemptions were applied to part of a response. There are a number of exemptions that require 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. • The request repeats a previous request from the same person. • The information is accessible by other means.

Topics for information requested this month included information relating to mental health services, primary care networks, formularies and requests for information relating to diagnostics contracts.

Integrated Board Report NHS Chorley and South Ribble Governing Body Page 257 25 September 2019 9. Glossary

A&E Accident & Emergency NHSI National Health Service Improvement AHP's Allied Health Professionals NICE The National Institute for Health and Care Excellence AMD Acute Macular Degeneration NWAS North West Ambulance Service ASD Autism Spectrum Disorder OHOC Our Health Our Care BP PC Better Payment Practice Code OPFA Outpatient First Attendances CC Complications and Comorbidities OPFUP Outpatient Follow Up CCG Clinical Commissioning Group OPPROC Outpatients Procedures CHC Continuing Health Care PDSA Plan Do Study Act CI Consultant Initiated PLCV Procedures of Limited Clinical Value CITNS Children's Integrated Therapy Nursing POD Point of Delivery Services CL Cash Limit QI Quality Improvement CPA Care Programme Approach QIPP Quality for Innovation, Productivity and Prevention CPN Contract Performance Notice RAP Recovery Action Plan CQUIN Commissioning for Quality and Innovation RAT Rapid Assessment and Treatment CSR Chorley South Ribble RCAs Root Cause Analysis CT Computed Tomography RHC Ramsay Health Care CYP Children and Young People RRL Revenue Resource Limit DC Day Case RTT Referral to Treatment DPH Director of Public Health SALT Speech and Language Therapy DToC Delayed transfer of care SLAM Service Level Agreement Monitoring ECDS Emergency Care Dataset SoFP Summary Statement of Financial Position EHH Euxton Hall Hospital StEIS Strategic Executive Information System EL Elective STF Sustainability and Transformation Fund EMSA Eliminate Mixed Sex Accommodation SUS Secondary Uses Service ENT Ear Nose Throat TARN Trauma Audit & Research Network EPACCS Electronic Palliative Care Coordination TCI To Come In System FFT Friends and Family Test TICCS The Integrated Care Clinics FOI Freedom of Information VSA Value Stream Analysis GP Greater Preston WLIs Waiting List Initiatives HCAI - Health Care Associated Infections - YTD Year to date CDIFF Clostridium 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 MRC Medical Research Council MRSA Methicillin-resistant Staphylococcus aureus MSA Mixed Sex Accommodation MSK Musculoskeletal NEC Not Elsewhere Classified NELSD Non-elective same day NELST Non-elective short stay

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Agenda Item 11

Governing Body Meeting

Date of meeting 25 September 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 August 2019. 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 full-year breakeven position.

The year to date position highlights variances to plan for Acute, Mental Health and Community Services which are mitigated by utilisation of reserves. These are reflected in the net risk position as at the end of month 5 which remains at £4.4m.

Recommendations The Governing Body is asked to note the financial position of the CCGs at the end of August 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

Financial Performance Report NHS Chorley and South Ribble CCG Governing Body Meeting Page 307 25 September 2019

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 ☒ ☐ ☐ 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

Financial Performance Report NHS Chorley and South Ribble CCG Governing Body Meeting Page 308 25 September 2019

Financial Performance Report 2019/20 As at 31 August 2019 Forecast Outturn to 31 March 2020 Page 309 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 31st August 2019 the CCGs are forecasting to achieve the planned full-year breakeven position. The year to date position highlights the following variances against plan: Acute services Information is currently showing over-performance on Acute SLA's primarily for the main provider, Lancashire Teaching Hospitals. Activity is in accordance within plan but for non- elective activity, the activity is more complex and therefore the costs are higher than plan. We are also seeing a year to date over performance at Ramsay primarily due to Trauma and Orthopaedic procedures. Mental Health Services Additional costs in respect of Mental Health and Learning Disabilities packages of care. Community Health Services Over performance against plan within the independent sector. Reserves Contingency has been utilised to mitigate the above variances to plan and the under achievement of productivity and efficiency savings.

Full year impact of the above variances and mitigations are reported within the Main Risks sheet.

The CCG is continuing to work with its NHS partners, as part of the Integrated Care Partnership (ICP) to report the financial performance against the agreed ICP control total.

Page 310 Page

1

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 Efficiency and Productivity performance £0.0m variance to plan. - Efficiency and Productivity is under performing against plan by Running costs £0.9m. - Running costs are within budget. Main Provider Performance - LTH - Non-recurrent investments are in accordance with plan. - The CCGs are currently reporting a net risk position of £4.4m.

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2

Summary I&E - Joint

Annual Annual Annual Budget to Expenditure Variance to Annual Budget Forecast 2018/19 Outturn Date to Date Date Forecast Variance Outturn Variance Summary Income and Expenditure

as at 31st August 2019 £000 £000 £000 £000 £000 £000 £000 £000 Favourable / Favourable / Favourable / (Adverse) (Adverse) (Adverse)

In-year Revenue Resource Limit 250,075 250,075 0 598,648 598,648 0 574,308 24,340

Total Revenue Resource Limit 250,075 250,075 0 598,648 598,648 0 574,308 24,340

Acute services Lancashire Teaching Hospitals NHSFT 90,412 92,312 (1,900) 216,420 216,420 0 209,365 (7,056) NW Ambulance service NHST 5,693 5,716 (23) 13,663 13,663 0 12,064 (1,599) Wrightington Wigan & Leigh NHSFT 3,135 3,057 78 7,525 7,525 0 7,226 (299) Blackpool Teaching Hospitals NHSFT 2,247 2,213 33 5,392 5,392 0 5,154 (238) East Lancashire Hospitals NHST 1,443 1,372 72 3,464 3,464 0 3,360 (104) Ramsay 10,160 10,662 (502) 24,384 24,384 0 23,705 (679) Other Acute service providers 10,026 9,923 103 24,084 24,084 0 20,557 (3,527) Acute services 123,117 125,256 (2,139) 294,933 294,933 0 281,431 (13,502) Mental Health Services Lancashire Care NHSFT 18,218 18,218 0 43,723 43,723 0 40,824 (2,899) Other Mental Health providers 9,600 10,153 (553) 23,039 23,039 0 21,363 (1,676) Mental Health services 27,818 28,371 (553) 66,762 66,762 0 62,187 (4,575) Community Health Services Lancashire Care NHSFT 16,303 16,262 41 39,127 39,127 0 36,933 (2,194) Other Community providers 6,078 6,383 (305) 14,587 14,587 0 15,503 917 Community services 22,381 22,645 (264) 53,714 53,714 0 52,437 (1,277)

Other Programme: Continuing Care services 11,043 11,043 0 26,503 26,503 0 25,647 (856) Primary Care services 27,687 27,493 193 67,953 67,953 0 64,450 (3,503) Prescribing 22,409 22,409 0 53,903 53,903 0 56,146 2,243 Other Programme services 1,970 1,911 59 4,728 4,728 0 4,547 (181) Corporate 3,255 3,227 28 7,363 7,363 0 5,924 (1,439) Reserves 6,965 4,432 2,533 14,550 14,550 0 13,650 (899) Healthcare Sub Total 246,643 246,786 (143) 590,408 590,408 0 566,418 (23,989)

Running Costs 3,432 3,290 143 8,240 8,240 0 7,889 (351)

Total Expenditure 250,075 250,075 0 598,648 598,648 0 574,308 (24,340)

Surplus/(Deficit) 0 0 0 0 0 0 0 0

Of which: CSR CCG Surplus/(Deficit) 0 0 0 0 0 0 0 0 GPR CCG Surplus/(Deficit) 0 0 0 0 0 0 0 0

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3

Productivity and Efficiency (QIPP) - Joint

Target QIPP 14,032

YTD Risk Net QIPP QIPP overview Plan YTD Plan Actual (Shortfall) / Adjusted (Shortfall) / as at 31st August 2019 Benefit FOT Benefit £000 £000 £000 £000 £000 £000

Acute SLAs 3,165 1,710 1,710 - 3,165 - Mental Health SLAs 165 69 69 - 165 - Community SLAs 934 375 404 29 934 - IPA (Individual Patient Activity) 500 128 128 - 500 - Prescribing 4,688 1,986 2,060 74 4,688 - Primary Care (426) (194) (194) - (426) - Other Programme 217 (97) (97) - 217 - Running Costs 202 - - - 202 -

Sub total - assigned QIPP schemes 9,445 3,977 4,080 103 9,445 - Unidentified QIPP 4,587 1,019 - (1,020) - (3,569) Total QIPP 14,032 4,996 4,080 (917) 9,445 (3,569)

Month by month performance £000 3000

2000

1000

0 M01-3 M04 M05 M06 M07 M08 M09 M10 M11 M12

Planned QIPP Actual QIPP

Page 313 Page

4

Main Risks - Joint

Area of spend Current position Action Owners Net risk

£000 Programme costs Contracts and Activity Trajectories Growth in excess of plan. Based on activity and cost trajectories, the full year forecast outturn is expected Matt Gaunt to be £3.0m. The CCGs are working closely with Lancashire Teaching Hospitals NHSFT (LTH) to understand how this will impact on the financial performance of the system. (2,956) The finance team are reviewing the activity and cost data on a monthly basis and will update this risk position accordingly.

Mental Health Additional costs in respect of Mental Health and Learning Investment has been made to develop community based services, delivered by Disabilities packages of care. Lancashire Care NHSFT which will reduce spend on bespoke packages of care/out of area placements in the last six months of the financial year. Matt Gaunt (1,343)

QIPP Under-Delivery Integrated Business Plan Savings Delivery The Integrated Business Plan is underpinned by a detailed The Integrated Business Plan weekly meetings monitor actions and appropriate Jayne Mellor / productivity, efficiency and service redesign programme. support and measures in place to reduce the risk to delivery. Matt Gaunt / Achievement is required to support the CCG investment The CCG is currently reviewing the transformation cycle and working with NHS Helen Curtis plans for 19/20. England (QIPP 5) to advance the identification of further opportunities. (3,569) Contingency of £1.0m has been utilised to mitigate the A joint PMO has been established in partnership with LTH to address the gap unidentified QIPP year to date position and therefore the against the combined efficiency target. forecast gap is £3.6m.

Gross risk (before mitigations) (7,868)

Mitigations

Net Area Current position Action mitigation £000 Contingency Uncommitted programme contingency. 1,698 Uncommitted co-commissioning programme contingency. 259 Other mitigations Uncommitted budget and forecast underspends. Includes the robust scheme setting and monitoring of CQUIN performance. 1,426 Total mitigations 3,383

Net risk position

Total net risk (4,485)

Page 314 Page

5

Financial Performance Report 2019/20 As at 31 August 2019 Forecast Outturn to 31 March 2020 Page 315 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

Efficiency and Productivity performance £0.0m variance to plan. - Efficiency and Productivity is underperforming against plan by Running costs £0.4m.

Main Provider - Running costs are within budget. - The CCG is currently reporting a net risk position of £2.2m. Performance - LTH

Page 316 Page

Financial Performance Duties

Revenue Resource Limit (RRL) Total YTD Notes £000 Movements in allocations / funding totals £(393)k: Programme 289,104 Non recurrent Lancs & South Cumbria ICS hosted funding: £ 838k - Cancer Alliance Q2 system developmentfunding £ 50k - Cancer Alliance targeted lung health checks

£(1,281)k - Local Maternity Services - transferred to Blackpool CCG (host). Admin (running costs) 3,883

Cash Limit (CL) Cash Drawdown Total 300,000 £000 250,000 Plan (adjusted for in-year

200,000 allocations) Total 286,842 150,000 100,000 Notes YTD Actual cash 50,000 drawdown The Cash limit totals the RRL less the brought - (including NHS forward surplus of £6,145k (which must BSA payments) remain unspent in year).

Better Payment Practice Code (BPPC) Total invoices Year to Date Total invoices Target paid within performance YTD Trend Notes paid in year % target %

Volume 6,687 6,671 95.0% 99.8% The CCG is exceeding all BPPC target Non NHS levels. Value (£'000) 40,156 40,116 95.0% 99.9%

Volume 1,009 993 95.0% 98.4% NHS

Page 317 Page Value (£'000) 75,610 75,566 95.0% 99.9%

Financial Management

2018/19 Receivables past their 2018/19 Summary Statement of Financial Position (SoFP) YTD position as at 31 March YTD position 2019 due date as at 31 March 2019

£000 £000 £000 £000 Total non-current assets - - NHS 35 320

Non NHS 136 180 Current assets: Total 171 499 Inventories - -

Trade and other receivables 2,403 2,043 Comments Other financial assets 0 0 Cash - the balance on the SoFP is the total of anticipated Other current assets 0 0 payments/receipts for the CCG bank account (including uncleared BACS files). The month end cash target has been met. Receivables past their due Cash and cash equivalents (566) 58 date - NHS relate to balances owed by NHS England and East Lancashire Total current assets 1,837 2,101 CCG. Non NHS primarily relate to recharges owed by Lancashire County Council.

Total assets 1,837 2,101 Total receivables

NHS Non NHS Current liabilities: 3,000 Trade and other payables (12,420) (13,953) 2,000 Other financial liabilities 0 0 1,000 Other liabilities 0 0 0 Borrowings 0 0 Provisions (0) 0 Total current liabilities (12,420) (13,953) Cash - achieving 1.25% month end cash balance

Balance % Target %

Non-Current Assets plus/less Net Current Assets/(Liabilities) (10,583) (11,852) 1.40 1.20 1.00 Total non-current liabilities 0 0 0.80 0.60 0.40 0.20 Assets less Liabilities (10,583) (11,852) -

Total taxpayers' equity: (10,583) (11,852)

Page 318 Page

Summary I&E

Annual Annual Variance to Forecast 2018/19 Outturn Budget to Expenditure Date Annual Annual Variance Outturn Variance Summary Income and Expenditure Date to Date Budget Forecast

as at 31st August 2019 £000 £000 £000 £000 £000 £000 Favourable £000 £000 Favourable Favourable / (Adverse) / (Adverse) / (Adverse)

In-year Revenue Resource Limit 119,767 119,767 0 286,842 286,842 0 274,434 12,408

Total Revenue Resource Limit 119,767 119,767 0 286,842 286,842 0 274,434 12,408

Acute services Lancashire Teaching Hospitals NHSFT 43,254 44,654 (1,400) 104,115 104,115 0 97,991 (6,124) NW Ambulance service NHST 2,466 2,470 (5) 5,918 5,918 0 5,215 (703) Wrightington Wigan & Leigh NHSFT 2,632 2,556 76 6,317 6,317 0 6,023 (295) Blackpool Teaching Hospitals NHSFT 849 832 17 2,039 2,039 0 1,942 (97) East Lancashire Hospitals NHST 673 697 (24) 1,615 1,615 0 1,555 (60) Ramsay 4,828 5,004 (175) 11,588 11,588 0 11,397 (191) Other Acute service providers 3,944 4,009 (65) 9,474 9,474 0 8,786 (687) Total Acute services 58,647 60,224 (1,576) 141,065 141,065 0 132,909 (8,157) Mental Health Services Lancashire Care NHSFT 8,398 8,398 0 20,156 20,156 0 18,954 (1,202) Other Mental Health providers 5,013 5,314 (301) 12,031 12,031 0 11,103 (927) Total Mental Health services 13,411 13,712 (301) 32,187 32,187 0 30,057 (2,130) Community Health Services Lancashire Care NHSFT 7,832 7,814 18 18,797 18,797 0 17,697 (1,100) Other Community providers 3,010 3,136 (126) 7,224 7,224 0 7,753 528 Total Community services 10,842 10,949 (107) 26,021 26,021 0 25,450 (572) Other Programme: Continuing Care services 5,745 5,745 0 13,788 13,788 0 13,614 (174) Primary Care services 12,780 12,714 66 31,753 31,753 0 29,888 (1,864) Prescribing 10,835 10,835 0 26,126 26,126 0 26,943 816 Other Programme services 828 828 0 1,988 1,988 0 2,123 135 Corporate 1,113 1,113 1 2,472 2,472 0 1,835 (637) Reserves 3,948 2,085 1,863 7,558 7,558 0 7,921 362 Healthcare Sub Total 118,150 118,205 (56) 282,959 282,959 0 270,739 (12,220) Running Costs 1,617 1,562 55 3,883 3,883 0 3,695 (188) Total Expenditure 119,767 119,768 0 286,842 286,842 0 274,434 (12,408)

Surplus/(Deficit) 0 0 0 0 0 0 0 0 Page 319 Page

Productivity and Efficiency (QIPP)

YTD Risk Net QIPP QIPP overview as at 31st August 2019 Plan YTD Plan Actual (Shortfall)/ Adjusted (Shortfall) / Benefit FOT Benefit

£000 £000 £000 £000 £000 £000

Acute SLAs 1,106 467 467 0 1,106 0

Mental Health SLAs 165 69 69 0 165 0

Community SLAs 452 188 200 12 452 0

IPA (Individual Patient Activity) 225 57 57 0 225 0

Prescribing 2,236 945 889 (56) 2,236 0

Primary Care (176) (80) (80) 0 (176) 0

Other Programme 100 (42) (42) 0 100 0

Running Costs 91 0 0 0 91 0

Total QIPP 4,199 1,604 1,560 (44) 4,199 0 Unidentified QIPP 1,857 413 0 (413) 0 (1,445) Total QIPP 6,056 2,017 1,560 (457) 4,199 (1,445)

Current position £000

YTD Actual

Plan

- 1,000 2,000 3,000 4,000 5,000 6,000 Page 320 Page

Financial Performance Report 2019/20 As at 31 August 2019 Forecast Outturn to 31 March 2020 Page 321 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. Efficiency and Productivity performance - Efficiency and Productivity is under performing against plan by Running costs £0.5m. - 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 £2.2m.

Page 322 Page

Financial Performance Duties

Revenue Resource Limit (RRL) Total YTD Notes £000 There are no movements in allocations / funding since M03. Programme 312,555

Admin (running costs) 4,357

Cash Limit (CL) Total Cash Drawdown £000 350,000 Total 311,806 300,000 Plan (adjusted 250,000 for in-year allocations) 200,000 Notes YTD 150,000 100,000 Actual cash 50,000 drawdown The Cash limit totals the RRL less the brought - (including NHS forward surplus of £5,106k (which must BSA payments) remain unspent in year).

Better Payment Practice Code (BPPC) Total invoices Year to Date Total invoices Target paid within performance YTD Trend Notes paid in year % target %

Volume 6,310 6,307 95.0% 100.0% The CCG is exceeding all BPPC target

Non NHS levels. Value (£'000) 45,396 45,213 95.0% 99.6%

Volume 1,076 1,076 95.0% 100.0% NHS Value (£'000) 80,556 80,556 95.0% 100.0% Page 323 Page

Financial Management

2018/19 Receivables past their due 2018/19 Summary Statement of Financial Position (SoFP) YTD position as at 31 March YTD position date as at 31 March 2019 2019

£000 £000 £000 £000

Total non-current assets - - NHS (761) 341

Non NHS 1 (1) Current assets: Total (760) 340 Inventories - -

Trade and other receivables 3,274 1,690 Comments Other financial assets 0 0 Cash - the balance on the SoFP is the total of anticipated Other current assets 0 0 payments/receipts for the CCG bank account. The cash target has been met for the last twelve months. Receivables past their due date - NHS Cash and cash equivalents (289) 59 relates primarily to monies owed by NHS England, East Lancashire CCG Total current assets 2,985 1,749 and an outstanding urgent care centre recharge adjustment to Chorley and South Ribble CCG.

Total assets 2,985 1,749 Total receivables

nhs non nhs Current liabilities: 2,500 2,000 Trade and other payables (16,155) (15,217) 1,500 Other financial liabilities 0 0 1,000 500 Other liabilities 0 0 0 Borrowings 0 0 Provisions 0 0

Total current liabilities (16,155) (15,217) Cash - achieving 1.25% month end cash balance

Balance as a percentage Target Non-Current Assets plus/less Net Current Assets/(Liabilities) (13,170) (13,468) 1.40 1.20 1.00 Total non-current liabilities 0 0 0.80 0.60 0.40 0.20 Assets less Liabilities (13,170) (13,468) -

Total taxpayers' equity: (13,170) (13,468)

Page 324 Page

Summary I&E

Annual Annual Variance to Forecast 2018/19 Outturn Budget to Expenditure Date Annual Annual Variance Outturn Variance Summary Income and Expenditure Date to Date Budget Forecast

as at 31st August 2019 £000 £000 £000 £000 £000 £000 Favourable £000 £000 Favourable Favourable / (Adverse) / (Adverse) / (Adverse)

In-year Revenue Resource Limit 130,308 130,308 0 311,806 311,806 0 299,874 11,932

Total Revenue Resource Limit 130,308 130,308 0 311,806 311,806 0 299,874 11,932

Acute services Lancashire Teaching Hospitals NHSFT 47,158 47,658 (500) 112,305 112,305 0 111,374 (931) NW Ambulance service NHST 3,227 3,246 (18) 7,746 7,746 0 6,850 (896) Wrightington Wigan & Leigh NHSFT 503 501 2 1,208 1,208 0 1,203 (4) Blackpool Teaching Hospitals NHSFT 1,397 1,381 16 3,354 3,354 0 3,213 (141) East Lancashire Hospitals NHST 771 674 96 1,849 1,849 0 1,805 (44) Ramsay 5,332 5,659 (327) 12,796 12,796 0 12,308 (488) Other Acute service providers 6,082 5,914 168 14,610 14,610 0 11,770 (2,840) Total Acute services 64,470 65,032 (562) 153,867 153,867 0 148,522 (5,345) Mental Health Services Lancashire Care NHSFT 9,820 9,820 0 23,567 23,567 0 21,871 (1,696) Other Mental Health providers 4,587 4,839 (252) 11,009 11,009 0 10,260 (749) Total Mental Health services 14,406 14,659 (252) 34,576 34,576 0 32,130 (2,445) Community Health Services Lancashire Care NHSFT 8,471 8,449 22 20,330 20,330 0 19,237 (1,094) Other Community providers 3,067 3,247 (179) 7,362 7,362 0 7,751 388 Total Community services 11,539 11,695 (157) 27,693 27,693 0 26,987 (705) Other Programme: Continuing Care services 5,298 5,298 0 12,715 12,715 0 12,032 (682) Primary Care services 14,907 14,780 127 36,200 36,200 0 34,561 (1,639) Prescribing 11,574 11,574 0 27,776 27,776 0 29,203 1,426 Other Programme services 1,142 1,083 59 2,740 2,740 0 2,425 (316) Corporate 2,142 2,114 28 4,891 4,891 0 4,089 (802) Reserves 3,017 2,346 670 6,991 6,991 0 5,730 (1,261) Healthcare Sub Total 128,493 128,580 (87) 307,449 307,449 0 295,679 (11,770) Running Costs 1,815 1,728 87 4,357 4,357 0 4,194 (163) Total Expenditure 130,308 130,308 0 311,806 311,806 0 299,874 (11,932)

Surplus/(Deficit) 0 0 0 0 0 0 0 0

Page 325 Page

Productivity and Efficiency (QIPP)

YTD Risk Net QIPP QIPP overview as at 31st August 2019 Plan YTD Plan Actual (Shortfall) / Adjusted (Shortfall) / Benefit FOT Benefit

£000 £000 £000 £000 £000 £000

Acute SLAs 2,059 1,243 1,243 - 2,059 0

Mental Health SLAs - - - - 0 0

Community SLAs 482 187 204 17 482 0

IPA (Individual Patient Activity) 275 71 71 - 275 0

Prescribing 2,452 1,041 1,171 130 2,452 0

Primary Care (250) (114) (114) - (250) 0

Other Programme 117 (55) (55) - 117 0

Running Costs 111 - - - 111 0

Total QIPP 5,246 2,373 2,520 147 5,246 0 Unidentified QIPP 2,730 607 - (607) 0 (2,124) Total QIPP 7,976 2,979 2,520 (460) 5,246 (2,124)

Current position £000

YTD Actual

Plan

- 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 Page 326 Page

Agenda Item 12

Governing Body Meeting

Date of meeting 25 September 2019 Title of paper Joint Committee of CCGs Terms of Reference Presented by Mr Matt Gaunt, Chief Finance and Contracting Officer Author Mr Jerry Hawker – Accountable Officer, Morecambe Bay CCG Mr Andrew Bennett – LSC Executive Director of Commissioning Clinical lead N/A Confidential No

Purpose of the paper The Joint Committee of CCGs Terms of Reference.

Executive summary

The Terms of Reference of the Lancashire & South Cumbria Joint Committee of Clinical Commissioning Groups (TOR) were last reviewed and updated in November 2017. Under section 14 of the current TOR it is recommended that they are reviewed annually and this paper provides two revised options for the Committee to consider.

Two updated versions of the TOR’s were developed and presented to the Joint Committee on the 5th September 2019. Both versions were updated in-line with best practice observed in other joint committee TOR’s and take into account new guidance on Conflicts of Interest. The TOR’s had been aligned to the NHS Long Term Plan, the eight priorities established and agreed as part of the new Lancashire & South Cumbria Integrated Care System (LSC ICS) and specifically the ambition to develop more consolidated commissioning approaches across the ICS.

The main difference between the two proposed versions is that “version 2” was expanded to recognise and strengthen the full scope of commissioning responsibilities of the committee and to allow scope for the committee to provide a forum for agreeing future system changes including the development of Integrated Care Partnerships and consolidation of commissioning arrangements. The scope of decision making authority of the Committee had been directly linked to the work programme. Two levels of decision making had been incorporated in the TOR.

After careful consideration the Joint Committee supported the adoption of “version 2” of the new Terms of Reference, subject to some minor accuracy corrections and recommended that the new Terms of Reference be approved by each CCG Governing Body.

Recommendations

Joint Committee of CCGs Terms of Reference NHS Chorley and South Ribble CCG Governing Body Meeting Page 327 25 September 2019 For the Governing Body to endorse the need to deliver continued progress relating to the Our Health Our Care programme.

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

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

Joint Committee of CCGs Terms of Reference NHS Chorley and South Ribble CCG Governing Body Meeting Page 328 25 September 2019 Terms of Reference - Joint Committee of Clinical Commissioning Groups

1. Introduction

1.1 The Terms of Reference of the Lancashire & South Cumbria Joint Committee of Clinical Commissioning Groups (Appendix A) were last reviewed and updated in November 2017. Under section 14 of the current terms of reference (TOR) it is recommended that they are reviewed annually and this paper provides two revised options for the Committee to consider.

1.1 Since the last review of the Terms of Reference a number of important changes/events have taken place that have been considered and where appropriate incorporated into the proposed revised versions. These include:

• The publication of revised guidance on managing Conflicts of Interest in the NHS • The publication of the NHS Long Term Plan & Implementation framework • The development of the Lancashire & South Cumbria Integrated Care System (ICS) eight partnership priorities • The continued development of the Lancashire & South Cumbria CCG’s Commissioning framework and the progress to “place based” commissioning. • The development and approval of the Joint Committee work programme. • The refresh of the ICS Governance arrangements

1.2 Two versions of the Terms of Reference have been developed and presented to the Joint Committee. Both versions had also been presented to the Collaborative Commission Board for comment and all CCG Accountable Officers have been provided with copies for consideration and recommendations within their organisations.

1.3 In developing the proposed revisions a review of other joint committee termsof reference have been undertaken including those from Merseyside, Greater Manchester, London and Cheshire.

1.4 The Joint Committee of CCGs met on the 5th September 2019 and after careful consideration the Joint Committee supported the adoption of “version 2” of the new Terms of Reference, subject to some minor accuracy corrections and recommended that the new Terms of Reference be approved by each CCG Governing Body.

2.0 New Terms of Reference (Appendix B)

2.1 The new Terms of reference recommended by the Joint Committee of CCG’s is a more extensive rewrite and is intended to address all the issues/changes identified in section 1.1. In addition the new terms of reference provide additional clarity around the following:

Joint Committee of CCGs Terms of Reference NHS Chorley and South Ribble CCG Governing Body Meeting Page 329 25 September 2019 • Improved clarity over the extent of delegated authority based on a methodology currently adopted by a number of Joint Committees in England. • Aligned to the ICS priorities and the recent review of ICS governance arrangements, provides clarity on the role of the Joint Committee in supporting the continued establishment of the ICS and its governance arrangements; options for progressing towards “place based commissioning” aligned to the NHS Long Term Plan and the development of Integrated Care Partnerships (ICP’s)

2.2 Key changes are summarized as follows:

• General updating of terminology in-line with the NHS Long Term Plan.

• Section 1 provides a broader definition of the purpose of the Joint Committee encompassing its role in collectively supporting and progressing the strategy and priorities of the ICS including transformational change programmes, reducing unwarranted variation in the services and quality available to people across Lancashire & South Cumbria and providing commissioning leadership in developing new ways of working as set-out in the NHS plan.

• Section 4 provides greater clarity on the role and responsibilities of the Joint Committee including; additional clarity and definition regarding levels of delegated authority; increased clarity regarding the statutory responsibly of the committee with respect to the JCCCG work programme and the process by which the plan is agreed by CCG Governing Bodies; and provides a more robust definition of the role of the joint committee expanding its remit in-line with its statutory duties to cover both transformational change programmes and core commissioning duties including performance and financial management for relevant services delegated to the committee.

• Section 5 provides additional clarity on the decision making process and introduces two levels of delegated authority which would be agreed again each service/subject area identified and agreed within the JCCCG Work programme (schedule 3). The introduction of the two levels of decision making is consistent with best practice in other joint committees and allows clearer definition on where the Joint Committee has full delegated commissioning authority (Level 1) including all functions specified in Schedule 1 and where the Joint Committee acts as a body to exercise collective leadership in supporting recommendations to be made on areas in the work plan where delegated authority for the final decision remains with the eight individual CCG Governing Bodies (Level 2).

• Section 7.2 has been corrected to reflect that the vice chair is a voting member.

• Section 8.1 – the responsibility of CCGs to ensure voting representatives are present has been strengthened.

Joint Committee of CCGs Terms of Reference NHS Chorley and South Ribble CCG Governing Body Meeting Page 330 25 September 2019 • Section 14 has been introduced to comply with the 2017 guidance on managing Conflicts of Interest in the NHS.

• Schedule 3 – An example of a JCCCG work programme has been included as part of the terms of reference. The inclusion of level 1 and level 2 delegations has been included in the example for demonstration purposes only and to help the Governing Body in its understanding of the proposed approach. The Governing Body is asked to note that a further paper will be produced enabling the Governing Body to provide final approval of levels of decision making authority against the agreed work programme.

4.0 Conclusion 4.1 This report highlights the process and actions that have been taken to establish updated terms of reference for the Lancashire & Cumbria Joint Committee of CCGs. The approach has taken into account the guidance and requirementsas set-out in the NHS Long Term Plan and Implementation Framework together with the priorities developed and agreed by the Lancashire & South Cumbria ICS. 4.2 The proposed terms of reference are intended to support the ambitions agreed by the CCGs to progress the Commissioning Development framework and to ensure decisions are made effectively, transparently and in compliance with the delegations by CCGs to the Joint Committee

5.0 Recommendations

The Governing Body is asked to:

• Approve the adoption of the attached Terms of Reference (updated as Version 8) ratifying the recommendation of the Joint Committee • note that a further paper will be presented to the Joint Committee setting out levels of decision making authority against the agreed work programme.

Joint Committee of CCGs Terms of Reference NHS Chorley and South Ribble CCG Governing Body Meeting Page 331 25 September 2019

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JOINT COMMITTEE OF CLINICAL COMMISIONING GROUPS TERMS OF REFERENCE

Document Control Title Lancashire and South Cumbria Joint Committee of Clinical Commissioning Groups (JCCCGs) – Terms of Reference Responsible Person Independent Chair Date of Approval Approved By Joint Committee of Clinical Commissioning Groups Author JC CCG Accountable Officers Date Created 12th September 2019 Date Last Amended 24th October 2017 Version 8 Review Date October 2020 Publish on Public Website Yes No The version of the policy posted on the intranet must be a PDF copy of the approved version Constitutional Document Yes No Requires an Equality Impact Assessment Yes No

Amendment History Version Date Changes 4 31.12.16 Updated to standardise all TOR within HLSC 5 17.10.17 Outstanding amendments from Fylde and Wyre CCG incorporated. 6 24.10.17 Update of wording to bring in line with current environment. 7 28/08/2019 Update to bring in-line with current environment / NHS Long Term Plan 8 12/09/2019 Updated following JCCCG on the JCCCG on 05/09/2019

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1. The Purpose of the Joint Committee of the Clinical Commissioning Groups 1.1 The purpose of the Joint Committee is to bring together the leadership of the eight Lancashire & South Cumbria Clinical Commissioning Groups (JCCCG) who have collectively committed to improve and transform health and care services across the area, delivering the highest quality of care possible within the resources available.

The work of the Joint Committee is designed to deliver on the ambitions, commitments and priorities set-out in the NHS Long Term Plan and the Lancashire & South Cumbria ICS Strategy.

The leadership of the eight Lancashire & South Cumbria commissioning groups (CCGs) will through the Joint Committee aim to:

a. reduce unwarranted variation in the range and quality of services available to people living in different boroughs in Lancashire & South Cumbria by improving outcomes in areas that are below average and driving up outcomes overall; b. ensure key clinical standards are consistently met across the patch, so that all people receive the highest possible care and best outcomes. c. provide a joined-up approach to the commissioning of acute, community and mental health services, enabling the CCGs to work effectively with majorhealth and care providers to ultimately improve quality of outcomes for patients; d. Work collectively to ensure progress towards and ultimately delivery of financial sustainability (agreed control totals) at both ICP and ICSlevels. e. provide leadership in developing new ways of working as set-out in the NHS Plan including; a. supporting the continuing establishment of the Lancashire & South Cumbria ICS , b. options for moving towards “place based commissioning” c. development of integrated care partnerships

1.2 The primary purpose of the Joint Committee is to take collective commissioning decisions about services provided to the Lancashire & South Cumbria population.

1.3 Decisions will be taken by members of the joint committee in accordance with delegated authority from each CCG in-line with its Constitution, Scheme of Reservation & Delegation and the functions set-out in Schedule 1.

1.4 Guiding principles:

The Lancashire and South Cumbria Joint Committee will adhere to the following principles already adopted by the Healthy Lancashire & South Cumbria (HLSC)Programme: • People and patients come first – delivering parity of esteem and outcomes – fairness and timeliness of access to support. • Delivering a clinically and financially sustainable health and care system across HLSC. • Clinically-led, co-design and collaboration across HLSC health & care system, delivering integrated support. • Aligning priorities across local health and care systems and organisations –

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Page 334 managing sovereignty and risk. • Prioritised effort on greatest benefit – improving quality and outcomes efficiently and effectively. • Ensuring Value for Money. Getting it right first time. • Alignment of effort and resource across the system. • Built upon innovation, international evidence and proven best practice. • Subsidiarity with clear framework of mutual accountability.

1.5 The Joint Committee of CCGs will meet collaboratively with NHS England (NHSE) and NHS Improvement (NHSI)to make decisions in respect of those services within the Programme, which are directly commissioned by NHSE/NHSI.

2. Geographic Coverage 2.1 The Joint Committee shall comprise the eight Clinical Commissioning Groups who collectively cover the geographic footprint of the Lancashire & South Cumbria Integrated Care System (ICS) 2.2 The Joint Committee of Clinical Commissioning Groups (‘JCCCGs’) is a joint committee of: • NHS Blackburn with Darwen CCG; • NHS Blackpool CCG; • NHS Chorley & South Ribble CCG; • NHS East Lancashire CCG; • NHS Fylde & Wyre CCG; • NHS Greater Preston CCG; • NHS Morecambe Bay CCG; • NHS West Lancashire CCG.

2.3 Specialised services commissioned by NHS England for the population of Lancashire & South Cumbria whilst outside the delegated authority of the Committee will be involved through a collaborative commissioning arrangement. 2.4 Services commissioned by Local Authorities for the population of Lancashire & South Cumbria whilst outside the delegated authority of the Committee will be involved through, wherever appropriate, a collaborative commissioning arrangement.

3. Accountability & Responsibility - Statutory Framework 3.1 The NHS Act 2006 (as amended) was amended through the introduction of a Legislative Reform Order (LRO 2014/2436) to form joint committees. This means that two or more CCG’s exercising commissioning functions jointly may form a joint committee as a result of the LRO amendment to s.14Z3 of the NHS Act. Joint Committees are statutory mechanisms which enable CCG’s to undertake collective decision making. 3.2 The CCGs named in paragraph 1.5 above, have delegated the functions set out in Schedule 1 to the Joint Committee for commissioning services and functions as set-out and agreed within the Committee’s annual work programme.

3.3 Joint committees are a statutory mechanism, which gives CCGs an additional option for undertaking collective strategic decision making. Whilst NHSE/NHSI will make decisions on Commissioning Specialised services separate from the Joint Committee, it has been decided that decisions on those services will be undertaken on a collaborative basis. This will allow sequential decisions to be undertaken allowing clarity of responsibility, but also

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Page 335 recognising the linkage between the two decisions.

3.4 Individual CCGs and NHSE/NHSI will still always remain accountable for meeting their statutory duties. The aim of creating a joint committee is to encourage the development of strong collaborative and integrated relationships and decision-making between partners.

4. Role of the Joint Committee of CCGs 4.1 The overarching role of the Joint Committee is to take collective commissioning decisions about services provided for the Lancashire & South Cumbria population. Decisions will be taken by members of the Joint Committee in accordance with delegated authority from each CCG. Members will represent the whole Lancashire & South Cumbria population and make decisions in the interests of all patients.

4.2 Decisions will support the strategy, aims and objectives of the Lancashire & South Cumbria ICS and will contribute to the sustainability and transformation of local health and social care systems. The Joint Committee will at all times, act in accordance with all relevant laws and guidance applicable to the CCGs.

4.3 The role of the committee will be to exercise the collective functions of the Clinical Commissioning Groups with respect to:

a) Delegated decision making authority (level 1) on commissioning services across Lancashire & South Cumbria as agreed within the Committees Annual work programme and each member CCG Scheme of Reservation & Delegation. b) Making collective recommendations (level 2) to each member CCG Governing Body on commissioning services across Lancashire & South Cumbria which fall outside either the Annual work programme or member CCG Schemes of Reservation & Delegation. c) Making collective recommendations (level 2) to each member CCG Governing Body on developing new ways of working as set-out in the NHS Plan including; a. supporting the continuing establishment of the Lancashire & South Cumbria ICS b. future options for the configuration of Clinical Commissioning Groups c. development of integrated care partnerships 4.4 The Joint Committee will develop an annual work programme (Example in Schedule 3) which will be agreed and approved by the Governing Body of each member CCG.

It will be the responsibility of executive leads and the JCCCG to ensure clarity over the scope of decision making associated with the work plan (Level 1 or Level 2)

4.5 The role described in 4.3 includes, but is not limited to the following activities which are aligned to those set-out in Appendix 1. • Acting to secure continuous improvement in the quality of commissioned services, including outcomes for patients, safety and patientexperience. • Duty to promote the NHS Constitution • Due regard to the finance duties imposed on CCGs under the NHS Act 2006 including ensuring the means of meeting expenditure out of public funds.

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Page 336 • Duty to ensure that process and decisions comply with the NHS Guidance on Planning, assuring and delivering service change for patients (including but not limited to Case for changes, service models and decision making businesscases) • Statutory duties with respect to public engagement and consultation (including Local Authorities and associated committees) • Complying with public sector equality duty

5. Decision Making 5.1 The primary purpose of the Joint Committee is to take collective commissioning decisions about services provided to the Lancashire & South Cumbria population. 5.2 Joint Committee members will make decisions in the best interests of the whole Lancashire & South Cumbria population, rather than the population of the Governing Body they are drawn from. 5.3 At all times, the Joint Committee, through undertaking the decision making function of each member CCG, will act in accordance with the terms of their Constitutions , Scheme of Reservation & Delegation and the functions set-out in Schedule 1. 5.4 The decision of the Committee will be binding on all member CCGs 5.5 Decision making authority level definition: Level 1: where decision making authority is within the delegated authority of the Joint Committee as outlined within its Terms of Reference and where a decision(s) undertaken by the Joint Committee will be final and binding on all member CCGs Level 2: where health and social care commissioning areas and operational functions affect / impact on the population of Lancashire & South Cumbria(or wider) are considered by the Committee and any decision(s) undertaken by the Committee form the basis of endorsements and recommendations to the Governing Bodies of each member CCG, and other decision making bodies. 5.6 Any item or paper presented to the JCCCG which has not been previously agreed as part of the work programme will only be considered under Level 2 delegation.

6. Voting 6.1 The Joint Committee will aim to make decisions by consensus wherever possible. Where this is not achieved, a voting method will be used. The voting power of each individual present will be weighted so that each party (CCG) possesses 12.5% of total voting power.

6.2 It is proposed that recommendations can only be approved if there is approval by more than 75% of the voting membership.

7. Membership 7.1 Membership of the committee will combine both Voting and Non-voting members and will comprise of: -

7.2 Voting members: • The two individuals appointed to represent each of the member CCGs, subject to such voting being in compliance with paragraph 7 below on ‘Voting’. (Whilst the JCCCG does not require a clinical majority, the CCG members should ensure it consists of clinicians, lay members and executives).

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• A vice chairman to be elected from the membership of the JCCCGs by the members and who will retain their CCG voting rights;

7.3 Non-voting members:

• The Independent Chair of the Joint Committee

Non-voting attendees:

• The Lancashire & South Cumbria ICS Lead; • The Lancashire & South Cumbria ICS Medical Director; • The Lancashire & South Cumbria ICS Executive Director of Commissioning • NHS England Representatives • A Healthwatch representative nominated by the local Healthwatch groups; • Such representation from the Combined and/or Local Authorities as the JCCCG deems appropriate; • Other such representation as the JCCCG deems appropriate;

7.4 Committee members may nominate a suitable deputy when necessary and subject to the approval of the Chair of the Joint Committee. All deputies should be fully briefed and the secretariat informed of any agreement to deputise, so that quoracy can be maintained.

7.5 No person can act in more than one role on the Joint Committee, meaning that each deputy needs to be an additional person from outside the Joint Committee membership.

6. Meetings 6.1 The Joint Committee shall adopt the standing orders of Blackpool CCG, insofar as they relate to the:

a) notice of meetings b) handling of meetings c) agendas d) circulation of papers e) conflicts of interest

Notice of Meetings and the Business to be transacted (1) Before each meeting of the JCCCG, a clear agenda and supporting documentation, specifying the business proposed to be transacted shall be sent to every member of the JCCCG at least six clear days before the meeting. The agenda and papers will also be published on the Healthier Lancashire and South Cumbria website. (2) No business shall be transacted at the meeting, other than that specified on the agenda, or emergency motions allowed under Standing Order 3.8. (3) Before each public meeting of CCG Governing Body meetings, a public notice of the

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Page 338 time and place of the next Joint Committee meeting and the public part of the agenda shall be displayed on the CCG’s website, at least three clear days before the meeting.

8. Quorum 8.1 At least one voting member (or nominated deputy) from each CCG must be present for the meeting to be Quorate.

It is the responsibility of each CCG to ensure that they have at least one voting member present at all Committee meetings. In the exceptional circumstances that a CCG cannot field a representative, the CCG must communicate this information to the independent chair in advance of the meeting.

9. Frequency of Meetings 9.1 Frequency of meetings will usually be monthly, but as and when required, in line with priorities.

10. Meetings of the Joint Committee 10.1 Meetings of the Joint Committee shall be held in public, unless the Joint Committee considers that it would not be in the public interest to permit members of the public to attend a meeting or part of a meeting. Therefore, the Joint Committee may resolve to exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings), whenever publicity would be prejudicial to the public interest, by reason of the confidential nature of the business to be transacted, or for other special reasons stated in the resolution and arising from the nature of that business, or of the proceedings, or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time. 10.2 Members of the Joint Committee have a collective responsibility for the operation of the Joint Committee. They will participate in discussion, review evidence and provide objective expert input to the best of the knowledge and ability and endeavor to reach a collective view. 10.3 The Joint Committee may call additional experts to attend meetings on an ad hoc basis to inform discussions. 10.4 The Joint Committee has the power to establish sub groups and working groups and any such groups will be accountable directly to the Joint Committee. 10.5 Members of the Joint Committee shall respect confidentiality requirements as set out in the Standing Orders referred to above, unless separate confidentiality requirements are set out for the Joint Committee, in which event these shall be observed.

11. Secretariat Provisions 11.1 The agenda and supporting papers will be circulated by email, five working days prior to the meeting. The agenda and papers will be published on each member CCG website and the Healthier Lancashire and South Cumbria website.

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Page 339 11.2 Papers may not be tabled without the agreement of the Chair.

11.3 Minutes will be taken and distributed to the members within 14 working days after the meeting. 11.4 Minutes will be published in the public domain, unless there are discussions which need to be recorded confidentially - in which case there will be recorded separately and will not be made public.

11.5 Agenda and papers to be agreed with the Chairman seven working days before the meeting.

12. Reporting to CCGs and NHS England 12.1 The Joint Committee will hold annual engagement events to review aims, objectives, strategy and progress. The Joint Committee will also publish an annual report on progress made against objectives.

13. Decisions 13.1 The Joint Committee will make decisions within the bounds of the scope of the functions delegated.

13.2 The decisions of the Joint Committee shall be binding on all member CCGs, which are: Blackburn with Darwen CCG; Blackpool CCG; Chorley & South Ribble CCG; East Lancashire CCG; Fylde & Wyre CCG; Greater Preston CCG; Morecambe Bay CCG; and West Lancashire CCG. 13.3 All decisions undertaken by the Joint Committee will be published by the Clinical Commissioning Groups.

14. Conflicts of Interest 14.1 The Committee shall hold and publish a register of interests. Each member and attendee of the committee will be under a duty to declare any such interests. Any interest related to an agenda item should be brought to the attention of the Chair in advance of the meeting or notified as soon as the interest arises and recorded in the minutes. Any changes to these interests should be notified to the Chair. 14.2 All members of the Committee and participants in its meetings shall comply with, and are bound by, the requirements in the relevant CCG’s Constitutions, Policies, the Standards of Business Conduct for NHS staff and NHS Code of Conduct.

15 Review of Terms of Reference 15.1 These terms of reference will be formally reviewed by Clinical Commissioning Groups at least annually, taking the date of the first meeting, following the year in which the JCCCG is created and may be amended by mutual agreement between the CCGs at any time to reflect changes in circumstances as they may arise.

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16. Withdrawal from the Joint Committee 16.1 Should this joint commissioning arrangement prove to be unsatisfactory, the Governing Body of any of the member CCGs or NHS England can decide to withdraw from the arrangement, but has to give six months’ notice to partners, with new arrangements starting from the beginning of the next new financial year.

17. Signatures

Blackburn with Darwen CCG Blackpool CCG

Chorley & South Ribble CCG East Lancashire CCG

Fylde & Wyre CCG Greater Preston CCG

Morecambe Bay CCG West Lancashire CCG

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Page 341 Schedule 1 - Delegation by CCGs to Joint Committee

A. As required to achieve the purpose of the Joint Committee of CCG’s, the following CCG functions will be delegated to the Joint Committee of CCGs (‘the JCCCGs’) by the member CCGs in accordance with their statutory powers under s.14Z3 of the NHS Act 2006 (as amended). s.14Z3 allows CCGs to make arrangements in respect of the exercise of their functions and includes the ability for two or more CCGs to create a Joint Committee to exercise functions. The delegated functions relate to the health services provided to the member CCGs by all providers they commission services from in the exercise of their functions.

B. The Lancashire and South Cumbria ICS focuses on achieving clinical quality standards in the services listed below provided by the NHS Trusts (and other providers) within the ICS. As part of this work, it is necessary to consider interdependencies between these services and any other services that are affected. The relevant services are: a. All elements of the programme, including the Case for Change, evaluation criteria, options, communications plan and such like. b. Such other services not set out above, which the CCG members of the JCCCGs determine should be included in the programme of work.

C. Each member CCG shall also delegate the following functions to the JCCCGs, so that it can achieve the purpose set out in (A) above: a. Acting with a view to securing continuous improvement to the quality of commissioned services in so far as these services are included within the scope of the programme. This will include outcomes for patients with regard to clinical effectiveness, safety and patient experience to contribute to improved patient outcomes across the NHS Outcomes Framework. b. Promoting innovation, in so far as this affects the services included within the scope of the programme, seeking out and adopting best practice, by supporting research and adopting and diffusing transformative, innovative ideas, products, services and clinical practice within its commissioned services, which add value in relation to quality and productivity. c. The requirement to comply with various statutory obligations, including making arrangements for public involvement and consultation throughout the process. That includes any determination on the viability of models of care pre-consultation and during formal consultation processes, as set out in s.13Q, s.14Z2 and s.242 of the NHS Act 2006 (as amended) (‘the Act’).

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Page 342 d. The requirement to ensure process and decisions comply with the four key tests for service change introduced by the last Secretary of State for Health, which are: • Support from GP commissioners; • Strengthened public and patient engagement; • Clarity on the clinical evidence base; • Consistency with current and prospective patient choice. e. The requirement to comply with the statutory duty under s.149 of the Equality Act 2010 i.e. the public sector equality duty. f. The requirement to have regard to the other statutory obligations set out in the new sections 13 and 14 of the NHS Act. The following are relevant but this is not an exhaustive list: 13C and 14P - Duty to promote the NHS Constitution 13D and 14Q - Duty to exercise functions effectively, efficiently and economically 13E and 14R – Duty as to improvement in quality of services 13G and 14T - Duty as to reducing inequalities 13H and 14U – Duty to promote involvement of each patient 13I and 14V - Duty as to patient choice 13J and 14W – Duty to obtain appropriate advice 13K and 14X – Duty to promote innovation 13L and 14Y – Duty in respect of research 13M and 14Z - Duty as to promoting education and training 13N and 14Z1- Duty as to promoting integration 13Q and 14Z2 - Public involvement and consultation by NHS England/CCGs 13O - Duty to have regard to impact in certain areas 13P - Duty as respects variations in provision of health services 14O – Registers of Interests and management of conflicts of interest 14S – Duty in relation to quality of primary medical services g. The JCCCGs must also have regard to the financial duties imposed on CCGs under the NHS Act 2006 and as set out in: • 223G – Means of meeting expenditure of CCGs out of publicfunds • 223H – Financial duties of CCGs: expenditure • 223I - Financial duties of CCGs: use of resources • 223J - Financial duties of CCGs: additional controls of resource use h. Further, the JCCCGs must have regard to the Information Standards as set out in ss.250, 251, 251A, 251B and 251C of the Health & Social Care Act 2012 (as amended).

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Page 343 i. The expectation is that CCGs will ensure that clear governance arrangements are put in place, so that they can assure themselves that the exercise by the JCCCGs of their functions is compliant with statute. j. The JCCCGs will meet the requirement for CCGs to comply with the obligation to consult the relevant local authorities under s.244 of the NHS Act and the associated regulations. k. To continue to work in partnership with key partners e.g. the Local Authority and other commissioners and providers to take forward plans so that pathways of care are seamless and integrated within and across organisations. l. The Joint Committee will be delegated the capacity to propose, consult on and agree future service configurations that will shape the medium and long terms financial plans of the constituent organisations. The Joint Committee will have no contract negotiation powers meaning that it will not be the body for formal annual contract negotiation between commissioners and providers. These processes will continue to be the responsibility of Clinical Commissioning Groups and NHS England under national guidance, tariffs and contracts during the pre-consultation and consultation periods. D. The role of the JCCCGs shall be to carry out the functions relating to decision making on pertinent Lancashire and South Cumbria wide commissioning issues that arise from the programme. This includes, but is not limited to, the following activities: • Determine the options appraisal process; • Determine the method and scope of the engagement and consultation processes; • Act as the formal body in relation to consultation with the Joint Overview and Scrutiny Committees established for relevant consultation by the applicable Local Authorities; • Make any necessary decisions arising from a pre-consultation Business Case (and the decision to run a formal consultation process); • Approve relevant consultation plans; • Approve the text and issues on which the public’s views are sought in all documentation associated with the formal consultation process; • Take or arrange for all necessary steps to be taken to enable the CCG to comply with its public sector equality duties; • Approve the formal report on the outcome of the consultation that incorporates all of the representations received in response to the consultation document in order to reach a decision; • Make decisions about future service configuration and service change, taking into account all of the information collated and representations received in relation to

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Page 344 the consultation process. This should include consideration of any recommendations made by the ICS Board, or views expressed by the Joint Health Overview and Scrutiny Committee or any other relevant organisations and stakeholders.

At all times, the Joint Committee, through undertaking the decision making function of each member CCG will act in accordance with the terms of their constitutions. No decision outcome shall impede any organisation in the fulfillment of its statutory duties.

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Page 345 Schedule 2 - List of Members from each Constituent CCG

Clinical Commissioning Group Representative

Blackburn with Darwen CCG

Blackpool CCG

Chorley & South Ribble CCG

East Lancashire CCG

Fylde & Wyre CCG

Greater Preston CCG

Morecambe Bay CCG

West Lancashire CCG

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Page 346 Schedule 3: EXAMPLE OF A WORK PROGRAMME AND DELEGATION LEVELS

Service/ Executiv Description Key Output Level of Subject e Decision Sponsor making Urgent Care David Approve updated Urgent and Emergency Strategy Bonson Care strategy for Lancashire and South Document Level 1 Cumbria which will be developed in response to the national strategy. SEND Julie Collaborative work between CCGs and Higgins Lancashire County Council to deliver the Level 2 2019-2020 Lancashire SEND partnership improvement plan with specific delivery of a commissioning plan, evaluation and monitoring system, implementation of the neuro developmental diagnostic pathway; speech and language and occupation therapy service reviews; consistency in multiagency school readiness pathway

Mental Health Andrew Agree action plan for commissioners which Action Plan Bennett may arise from the external review of the Level 1 urgent care mental health system in Lancashire being undertaken by Northumberland Tyne and Wear NHS Foundation Trust Individual Jerry Agree a single commissioning and operating Proposed Patient Activity Hawker model across Lancashire & South Cumbria, Commission Level 1 (IPA) appropriately resourced, with the right ing Model staff, in the right place at the right time across the ICS, ICPs and neighbourhoods.

Agree a single governance, business Level 2 intelligence and delegated financial framework with accountability to the ICS and JCCCGs

Cancer Denis Agree recommendations for commissioners Set of Gizzi which arise from Cancer transformation Recommend Level 1 programme ations Cancer/ Denis Agree the Outline Business Case for Outline Workforce Gizzi Oncology Advanced Clinical Practitioners Business Level 2 Case Specialist Clare Approve a case for change for multi-agency Case for weight Thomas action in relation to obesity and specialist Change Level 1 management on weight management services Stroke Andrew Agree options for the configuration of Case for Level 1 Bennett Hyper Acute and Acute stroke services Change

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Page 347 Review and approve outline business case. Outline Level 1 Decide on requirement and readiness to Business consult. Case

Approve full business case Full Level 2 Review outcomes of consultation Business Consider and approve commissioning Case approach and approve delivery plan Commissioning Andrew Agree updated commissioning policies Policy Level 1 Policies Bennett developed collectively for all CCGs Documents Agree updated medicines management policies developed collectively for all CCGs Vascular Talib Agree operating model for vascular services Case for Level 1 Yaseen across Lancashire and South Cumbria. Change

Service (operating) model Commissioning Andrew Agree recommended operating models and Commission Level 1 development Bennett implementation plans arising from ing Commissioning Development Framework Framework programme Children and TBA Approve clinical model for CYP Mental Clinical Level 1 Young People’s Health services across Lancashire and South Model and Mental Health Cumbria implementa tion plan Approve transition and implementation plan for clinical model Children and Arif Approve case for change for paediatric Case For Level1 Maternity Rajpura services Change Primary Care Amanda Approval of ICS Strategy for Primary Care ICS Strategy Level 1 Doyle Planned Care Andrew Agree prioritised list of pathways and Clinical Level 1 Harrison timeline for development of outcome Pathways based consistent clinical pathways across Lancashire & South Cumbria

Learning Andrew Agree clinical model of non-secure, Clinical Level 1 Disability Bennett specialist inpatient provision for Learning Model Disabilities and Autism within the Lancashire and South Cumbria footprint

Integrated Julie Collaborative work between CCGs and Integrated Level 2 Commissioning Higgins Lancashire County Council to build a Commission (on LCC common platform for integrated ing platform footprint) commissioning at an ICP level: Initiation to proof of concept phase:- scope principles, commitment and approaches, for the integration agenda building on BCF; test two areas for “in view” budget

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Page 348 management leading to transformation for intermediate care and mental health section 117.

Decision making authority level definition:

Level 1: where decision making authority is within the delegated authority of the Joint Committee as outlined within its Terms of Reference and where a decision(s) undertaken by the Joint Committee will be final and binding on all member CCGs

Level 2: where health and social care commissioning areas and operational functions affect / impact on the population of Lancashire & South Cumbria(or wider) are considered by the Committee and any decision(s) undertaken by the Committee form the basis of endorsements and recommendations to the Governing Bodies of each member CCG, and other decision making bodies.

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JOINT COMMITTEE OF CLINICAL COMMISIONING GROUPS TERMS OF REFERENCE

Document Control Title Healthier Lancashire and South Cumbria (HLSC): Terms of Reference (TOR): Joint Committee of Clinical Commissioning Groups (JCCCGs) Responsible Person Independent Chair Date of Approval 2nd November 2017 Approved By Joint Committee of Clinical Commissioning Groups Author STP Corporate Office Date Created 18th April 2016 Date Last Amended 24th October 2017 Version 6 Review Date March 2018 Publish on Public Website Yes No The version of the policy posted on the intranet must be a PDF copy of the approved version Constitutional Document Yes No Requires an Equality Impact Assessment Yes No

Amendment History Version Date Changes 4 31.12.16 Updated to standardise all TOR within HLSC 5 17.10.17 Outstanding amendments from Fylde and Wyre CCG incorporated. 6 24.10.17 Update of wording to bring in line with current environment.

1. The Purpose of the Joint Committee of the Clinical Commissioning Groups 1.1 The NHS Act 2006 (as amended) (‘the NHS Act’), was amended through the introduction of a Legislative Reform Order (’LRO’), to allow Clinical Commissioning Groups (CCGs) to form joint committees. This means that two or more CCGs exercising commissioning functions jointly, may form a joint committee as a result of the LRO amendment to s.14Z3 (CCGs working together) of the NHS Act.

1.2 Joint committees are a statutory mechanism, which gives CCGs an additional option for undertaking collective strategic decision making. Whilst NHS England (NHSE) will make decisions on Specialised Commissioning separate from a joint committee, as such decisions cannot be delegated to a CCG or a joint committee of CCGs; they can still make such decisions collaboratively with CCGs.

1.3 Although the Healthier Lancashire and South Cumbria Programme (HLSC) will affect services commissioned by the Specialised Commissioning function of NHSE, it has been decided that decisions on those services will be undertaken on a collaborative basis. This will allow sequential decisions to be undertaken allowing clarity of responsibility, but also recognising the linkage between the two decisions.

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Page 351 1.4 Individual CCGs and NHSE will still always remain accountable for meeting their statutory duties. The aim of creating a joint committee is to encourage the development of strong collaborative and integrated relationships and decision-making between partners.

1.5 The Joint Committee of Clinical Commissioning Groups (‘JCCCGs’) is a joint committee of: • NHS Blackburn with Darwen CCG; • NHS Blackpool CCG; • NHS Chorley & South Ribble CCG; • NHS East Lancashire CCG; • NHS Fylde & Wyre CCG; • NHS Greater Preston CCG; • NHS Morecambe Bay CCG; • NHS West Lancashire CCG.

1.6 The primary purpose of the JCCCGs, is decision making on pertinent Lancashire and South Cumbria wide commissioning issues that arise from the programme.

1.7 In addition, the JCCCGs will meet collaboratively with NHSE to make integrated decisions in respect of those services within the Programme, which are directly commissioned by NHSE.

1.8 As set out in the Five Year Forward View, STP’s are required to accelerate progress to achieve the ‘triple aims’ of improved population health, quality of care and sustainable finances, in which our programme of work is built around. As such, health leaders across the Healthier Lancashire and South Cumbria area have collectively committed to improve and transform health and care services across the patch, delivering the highest quality of care possible within the resources available. The work of the programme is designed to deliver key clinical standards consistently across the patch, so that all people receive the highest possible care and best outcomes. Among the relevant work streams which the JCCCGs will consider under the programme are:

• Acute and Specialised • Urgent & Emergency Care • Mental Health (all ages) • Learning Disabilities • Prevention and Population Health

1.9 HLSC will establish an STP Board, informed by the Care Professionals Board, to oversee the development of agreed clinical quality standards, a feasibility analysis looking at the implications of implementing these standards, a clinical case for change, a financial case for change and new models of care.

1.10 Guiding principles:

The Healthier Lancashire and South Cumbria Programme is proposing to adhere to the following principles as a minimum: • People and patients come first – delivering parity of esteem and outcomes – fairness and timeliness of access to support. • Delivering a clinically and financially sustainable health and care system

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Page 352 across HLSC. • Clinically-led, co-design and collaboration across HLSC health & care system, delivering integrated support. • Aligning priorities across local health and care systems and organisations – managing sovereignty and risk. • Prioritised effort on greatest benefit – improving quality and outcomes efficiently and effectively. • Ensuring Value for Money. Getting it right first time. • Alignment of effort and resource across the system. • Built upon innovation, international evidence and proven best practice. • Subsidiarity with clear framework of mutual accountability.

2. Statutory Framework 2.1 The NHS Act which has been amended by LRO 2014/2436, provides at s.14Z3 that where two or more clinical commissioning groups are exercising their commissioning functions jointly, those functions may be exercised by a joint committee of the groups.

2.2 The CCGs named in paragraph 1.5 above, have delegated the functions set out in Schedule 1 to the JCCCGs.

3. Role of the JCCCGs 3.1 The role of the JCCCGs shall be to carry out the functions relating to decision making on pertinent Lancashire and South Cumbria wide commissioning issues that arise from the programme.

3.2 In relation to Acute and Specialised Services - The JCCCG will collaborate with NHSE, on services that they commission, in relation to aspects as yet to be agreed, but leading on the delivery on an agreed HLSC strategy aligned to national priorities.

3.3 In relation to Urgent and Emergency Care (UEC) – The JCCCG will ensure that national standards are delivered and that there is in place, an agreed UEC model, developed against these with all interdependencies mapped and considered.

3.4 Mental Health – The JCCCGs will recognise that this complex programme of work encompasses services for all ages, from Children’s and Young People’s Mental Health and emotional wellbeing, through to adult and older adult’s mental health. Decisions will relate to the development of parity of esteem and delivery of national strategies. This will be transacted through clarity of relevant pathways and understanding what the potential reconfiguration aspects are, to then agree JCCCG decisions and local decisions.

3.5 In relation to Prevention and Population Health – The JCCCG will provide strategic input into the delivery of a Prevention and Population Health Model to the member CCGs across the patch. This will enable the member CCGs to make local decisions, in alignment with the HLSC strategic objectives.

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Page 353 3.6 In relation to Learning Disabilities – The JCCCG will ensure that national standards and expectations outlined in the Transforming Care Programme, are delivered across all ages and that there is in place, an agreed Learning Disability model of care, developed against these with all interdependencies mapped and considered.

3.7 The role described in 3.1 includes, but is not limited to, the following activities:

• Determine the options appraisal process; • Determine the method and scope of the engagement and consultation processes; • Act as the formal body in relation to consultation with the Joint Overview and Scrutiny Committees established for relevant consultation by the applicable Local Authorities; • Make any necessary decisions arising from a pre-consultation Business Case (and the decision to run a formal consultation process); • Approve relevant consultation plans; • Approve the text and issues on which the public’s views are sought in all documentation associated with the formal consultation process; • Take or arrange for all necessary steps to be taken to enable the CCG’s as part of the JCCCG’s to comply with its public sector equality duties; • Approve the formal report on the outcome of consultation, that incorporates all of the representations received in response to the consultation document, in order to reach a decision; • Make decisions about future service configuration and service change, taking into account all of the information collated and representations received in relation to the consultation process. This should include consideration of any recommendations made by the STP Board, or views expressed by the Joint Health Overview and Scrutiny Committee or any other relevant organisations and stakeholders.

3.8 At all times, the Joint Committee, through undertaking the decision making function of each member CCG, will act in accordance with the terms of their constitutions. No decision outcome shall impede any organisation in the fulfillment of its statutory duties.

4. Geographical Coverage 4.1 The JCCCGs will comprise of those CCGs listed above in paragraph 1.5, covering Lancashire and South Cumbria.

4.2 NHS England Specialised Commissioning will also be involved through a collaborative commissioning arrangement.

4.3 The Joint Committee will have the primary purpose of decision making on pertinent Lancashire and South Cumbria wide commissioning issues that arise from the programme.

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Page 354 5. Membership 5.1 Membership of the committee will combine both Voting and Non-voting members and will comprise of: -

5.2 Voting members: • The two individuals appointed to represent each of the member CCGs, subject to such voting being in compliance with paragraph 7 below on ‘Voting’. (Whilst the JCCCG does not require a clinical majority, the CCG members should ensure it consists of clinicians, lay members and executives).

5.3 Non-voting members:

• The Independent Chair of the Joint Committee

Non-voting attendees:

• The STP Lead; • The STP Medical Director; • A vice chairman to be elected from the membership of the JCCCGs by the members and who will retain their voting rights; • The NHS England Specialised Commissioning Assistant Director will be invited to each meeting, in a non-voting capacity; • A Healthwatch representative nominated by the local Healthwatch groups; • Such representation from the Combined and/or Local Authorities as the JCCCG deems appropriate; • The Lead for the Prevention and Population Health Programme; • The Chair of the Finance and Investment Group

5.4 Committee members may nominate a suitable deputy when necessary and subject to the approval of the Chair of the Joint Committee. All deputies should be fully briefed and the secretariat informed of any agreement to deputise, so that quoracy can be maintained.

5.5 No person can act in more than one role on the Joint Committee, meaning that each deputy needs to be an additional person from outside the Joint Committee membership.

6. Meetings 6.1 The Joint Committee shall adopt the standing orders of Blackpool CCG, insofar as they relate to the:

a) notice of meetings b) handling of meetings c) agendas d) circulation of papers e) conflicts of interest

Notice of Meetings and the Business to be transacted (1) Before each meeting of the JCCCG, a clear agenda and supporting documentation, specifying the business proposed to be transacted shall be sent to every member of the JCCCG at least six clear days before the meeting.

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Page 355 The agenda and papers will also be published on the Healthier Lancashire and South Cumbria website. (2) No business shall be transacted at the meeting, other than that specified on the agenda, or emergency motions allowed under Standing Order 3.8. (3) Before each public meeting of CCG Governing Body meetings, a public notice of the time and place of the next Joint Committee meeting and the public part of the agenda shall be displayed on the CCG’s website, at least three clear days before the meeting.

7. Voting 7.1 The Joint Committee will aim to make decisions by consensus wherever possible. Where this is not achieved, a voting method will be used. The voting power of each individual present will be weighted so that each party (CCG) possesses 12.5% of total voting power.

7.2 It is proposed that recommendations can only be approved if there is approval by more than 75%.

8. Quorum 8.1 At least one voting member (or nominated deputy) from each CCG must be present for the meeting to be Quorate.

9. Frequency of Meetings 9.1 Frequency of meetings will usually be monthly, but as and when required, in line with priorities.

10. Meetings of the Joint Committee 10.1 Meetings of the Joint Committee shall be held in public, unless the Joint Committee considers that it would not be in the public interest to permit members of the public to attend a meeting or part of a meeting. Therefore, the Joint Committee may resolve to exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings), whenever publicity would be prejudicial to the public interest, by reason of the confidential nature of the business to be transacted, or for other special reasons stated in the resolution and arising from the nature of that business, or of the proceedings, or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time.

10.2 Members of the Joint Committee have a collective responsibility for the operation of the Joint Committee. They will participate in discussion, review evidence and provide objective expert input to the best of the knowledge and ability and endeavor to reach a collective view.

10.3 The Joint Committee may call additional experts to attend meetings on an ad hoc basis to inform discussions.

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Page 356 10.4 The Joint Committee has the power to establish sub groups and working groups and any such groups will be accountable directly to the Joint Committee.

10.5 Members of the Joint Committee shall respect confidentiality requirements as set out in the Standing Orders referred to above, unless separate confidentiality requirements are set out for the Joint Committee, in which event these shall be observed.

11. Secretariat Provisions 11.1 The agenda and supporting papers will be circulated by email, five working days prior to the meeting. The agenda and papers will also be published on the Healthier Lancashire and South Cumbria website.

11.2 Papers may not be tabled without the agreement of the Chair.

11.3 Minutes will be taken and distributed to the members within 14 working days after the meeting.

11.4 Minutes will be published in the public domain, unless there are discussions which need to be recorded confidentially - in which case there will be recorded separately and will not be made public.

11.5 Agenda and papers to be agreed with the Chairman seven working days before the meeting.

12. Reporting to CCGs and NHS England 12.1 The Joint Committee will hold annual engagement events to review aims, objectives, strategy and progress. The Joint Committee will also publish an annual report on progress made against objectives.

13. Decisions 13.1 The Joint Committee will make decisions within the bounds of the scope of the functions delegated.

13.2 The decisions of the Joint Committee shall be binding on all member CCGs, which are: Blackburn with Darwen CCG; Blackpool CCG; Chorley & South Ribble CCG; East Lancashire CCG; Fylde & Wyre CCG; Greater Preston CCG; Morecambe Bay CCG; and West Lancashire CCG.

13.3 All decisions undertaken by the Joint Committee will be published by the Clinical Commissioning Groups.

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Page 357 14 Review of Terms of Reference 14.1 These terms of reference will be formally reviewed by Clinical Commissioning Groups at least annually, taking the date of the first meeting, following the year in which the JCCCG is created and may be amended by mutual agreement between the CCGs at any time to reflect changes in circumstances as they may arise.

15. Withdrawal from the Joint Committee 15.1 Should this joint commissioning arrangement prove to be unsatisfactory, the Governing Body of any of the member CCGs or NHS England can decide to withdraw from the arrangement, but has to give six months’ notice to partners, with new arrangements starting from the beginning of the next new financial year.

16. Signatures

Blackburn with Darwen CCG Blackpool CCG

Chorley & South Ribble CCG East Lancashire CCG

Fylde & Wyre CCG Greater Preston CCG

Morecambe Bay CCG West Lancashire CCG

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Page 358 Schedule 1 - Delegation by CCGs to Joint Committee

A. As required to achieve the purpose of the Joint Committee of CCG’s, the following CCG functions will be delegated to the Joint Committee of CCGs (‘the JCCCGs’) by the member CCGs in accordance with their statutory powers under s.14Z3 of the NHS Act 2006 (as amended). s.14Z3 allows CCGs to make arrangements in respect of the exercise of their functions and includes the ability for two or more CCGs to create a Joint Committee to exercise functions. The delegated functions relate to the health services provided to the member CCGs by all providers they commission services from in the exercise of their functions.

B. The Lancashire and South Cumbria STP focuses on achieving clinical quality standards in the services listed below provided by the NHS Trusts within the STP. As part of this work, it is necessary to consider interdependencies between these services and any other services that are affected. The relevant services are: a. All elements of the programme, including the Case for Change, evaluation criteria, options, communications plan and such like. b. Such other services not set out above, which the CCG members of the JCCCGs determine should be included in the programme of work.

C. Each member CCG shall also delegate the following functions to the JCCCGs, so that it can achieve the purpose set out in (A) above: a. Acting with a view to securing continuous improvement to the quality of commissioned services in so far as these services are included within the scope of the programme. This will include outcomes for patients with regard to clinical effectiveness, safety and patient experience to contribute to improved patient outcomes across the NHS Outcomes Framework. b. Promoting innovation, in so far as this affects the services included within the scope of the programme, seeking out and adopting best practice, by supporting research and adopting and diffusing transformative, innovative ideas, products, services and clinical practice within its commissioned services, which add value in relation to quality and productivity. c. The requirement to comply with various statutory obligations, including making arrangements for public involvement and consultation throughout the process. That includes any determination on the viability of models of care pre-consultation and during formal consultation processes, as set out in s.13Q, s.14Z2 and s.242 of the NHS Act 2006 (as amended) (‘the Act’).

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Page 359 d. The requirement to ensure process and decisions comply with the four key tests for service change introduced by the last Secretary of State for Health, which are: • Support from GP commissioners; • Strengthened public and patient engagement; • Clarity on the clinical evidence base; • Consistency with current and prospective patient choice. e. The requirement to comply with the statutory duty under s.149 of the Equality Act 2010 i.e. the public sector equality duty. f. The requirement to have regard to the other statutory obligations set out in the new sections 13 and 14 of the NHS Act. The following are relevant but this is not an exhaustive list: 13C and 14P - Duty to promote the NHS Constitution 13D and 14Q - Duty to exercise functions effectively, efficiently and economically 13E and 14R – Duty as to improvement in quality of services 13G and 14T - Duty as to reducing inequalities 13H and 14U – Duty to promote involvement of each patient 13I and 14V - Duty as to patient choice 13J and 14W – Duty to obtain appropriate advice 13K and 14X – Duty to promote innovation 13L and 14Y – Duty in respect of research 13M and 14Z - Duty as to promoting education and training 13N and 14Z1- Duty as to promoting integration 13Q and 14Z2 - Public involvement and consultation by NHS England/CCGs 13O - Duty to have regard to impact in certain areas 13P - Duty as respects variations in provision of health services 14O – Registers of Interests and management of conflicts of interest 14S – Duty in relation to quality of primary medical services g. The JCCCGs must also have regard to the financial duties imposed on CCGs under the NHS Act 2006 and as set out in: • 223G – Means of meeting expenditure of CCGs out of publicfunds • 223H – Financial duties of CCGs: expenditure • 223I - Financial duties of CCGs: use of resources • 223J - Financial duties of CCGs: additional controls of resource use h. Further, the JCCCGs must have regard to the Information Standards as set out in ss.250, 251, 251A, 251B and 251C of the Health & Social Care Act 2012 (as amended).

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Page 360 i. The expectation is that CCGs will ensure that clear governance arrangements are put in place, so that they can assure themselves that the exercise by the JCCCGs of their functions is compliant with statute. j. The JCCCGs will meet the requirement for CCGs to comply with the obligation to consult the relevant local authorities under s.244 of the NHS Act and the associated regulations. k. To continue to work in partnership with key partners e.g. the Local Authority and other commissioners and providers to take forward plans so that pathways of care are seamless and integrated within and across organisations. l. The Joint Committee will be delegated the capacity to propose, consult on and agree future service configurations that will shape the medium and long terms financial plans of the constituent organisations. The Joint Committee will have no contract negotiation powers meaning that it will not be the body for formal annual contract negotiation between commissioners and providers. These processes will continue to be the responsibility of Clinical Commissioning Groups and NHS England under national guidance, tariffs and contracts during the pre-consultation and consultation periods. D. The role of the JCCCGs, shall be to carry out the functions relating to decision making on pertinent Lancashire and South Cumbria wide commissioning issues that arise from the programme. This includes, but is not limited to, the following activities: • Determine the options appraisal process; • Determine the method and scope of the engagement and consultation processes; • Act as the formal body in relation to consultation with the Joint Overview and Scrutiny Committees established for relevant consultation by the applicable Local Authorities; • Make any necessary decisions arising from a pre-consultation Business Case (and the decision to run a formal consultation process); • Approve relevant consultation plans; • Approve the text and issues on which the public’s views are sought in all documentation associated with the formal consultation process; • Take or arrange for all necessary steps to be taken to enable the CCG to comply with its public sector equality duties; • Approve the formal report on the outcome of the consultation that incorporates all of the representations received in response to the consultation document in order to reach a decision; • Make decisions about future service configuration and service change, taking into account all of the information collated and representations received in relation to

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Page 361 the consultation process. This should include consideration of any recommendations made by the STP Board, or views expressed by the Joint Health Overview and Scrutiny Committee or any other relevant organisations and stakeholders.

At all times, the Joint Committee, through undertaking the decision making function of each member CCG will act in accordance with the terms of their constitutions. No decision outcome shall impede any organisation in the fulfillment of its statutory duties.

Schedule 2 - List of Members from each Constituent CCG

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Page 362 Agenda Item 13

Governing Body Meeting

Date of meeting 25 September 2019 Title of paper Governance update Presented by Mr Matt Gaunt, Chief Finance and Contracting 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 paper is to provide the Governing Body with an update on two key governance areas as follows: - Terms of reference for approval to enable the Governing Body to meet in common with the Governing Body of NHS Greater Preston CCG - Elections update

Executive summary

Terms of reference – committee in common of the Governing Bodies

The Governing Bodies discussed at the last formal meeting that it was in support of the development of a joint meeting with the Governing Body of NHS Greater Preston CCG in order to receive items which were previously taken to individual Governing Body meetings but which are equally relevant to both CCGs. This will reduce the number of Governing Body meetings by 6 per year, freeing up some CCG resource, executive time, and administration time in reducing papers. A joint meeting also enables the views of both CCG to be heard together before decisions are taken in order to streamline decision making across the patch and enrich the debate for each CCG.

Actions agreed at the joint informal development session were as follows: - For a terms of reference to be brought to each Governing Body to approve at the September meetings. This is appended to this paper. - That the terms of reference capture the following points:  Vice Chair is listed separately in the membership from the other lay members and in quoracy  The Chair will be rotated between the Chair of each CCG  Each CCG will vote separately on decisions, therefore the meeting is to be constituted in common as opposed to joint  That all meetings will take place on a Wednesday at Chorley House

Governance update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 363

Elections update The Governing Body approved at its last meeting that all Governing Body vacancies should now be advertised to eligible clinicians. Expressions of interest opened on 25th July 2019 and closed on 19th August 2019 for the following roles:

- Chair - 2 GP Director posts (1 vacant and 1 tenure expiring)

The election has been handled externally by the Electoral Reform Service (ERS).

Chair The ERS received 2 expressions of interest for the role of Chair. Both candidates were submitted to an eligibility and suitability interview panel which met on 22 August 2019 and deemed that both candidates were eligible and suitable.

An election opened on 9th September and is due to close on 30th September at noon.

As per section 2.2.2 v of the constitution “The Governing Body shall recommend to NHS England that it should appoint its nominated candidate”. Therefore the Governing Body is asked to delegate this as a Vice Chairs action to recommend to NHS England that the CCG appoint the GP with the majority of votes to the role of Chair of the CCG.

GP Directors The ERS received 1 expression of interest for the 2 posts available for the role of GP Director. The expression of interest was submitted to an eligibility assessment panel which met on 21st August and deemed that the candidate was eligible.

An election opened on 9th September and is due to close on 30th September at noon.

As per section 2.2.4 v of the constitution “Each Member Representative shall be able to vote to ratify the recommendation in accordance with the number of votes set out at Clause 3.3.4 of the Constitution”. Therefore the membership will be given a 2 week timeframe to ratify the appointment.

As there was only 1 candidate who expressed an interest, it is known that a vacancy will still remain on the Governing Body after the elections conclude. There has been a vacancy on the Governing Body for over 12 months. The Governing Body must consider if it is comfortable to accept the vacancy or whether another expression of interest stage is opened.

Recommendations The Governing Body is asked to approve the terms of reference

The Governing Body is asked to approve that a Vice Chairs action is taken to recommend to NHS England that the CCG appoint the GP with the majority of votes to the role of Chair of the CCG.

The Governing Body is asked to consider if it is comfortable to accept the vacancy or

Governance update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 364 whether another expression of interest stage is opened.

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

NA

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

Governance update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 365

Assurance Each Governing Body will separately approve this terms of reference prior to meeting in common from November 2019 onwards.

Governance update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 366

TERMS OF REFERENCE

COMMITTEE IN COMMON OF THE GOVERNING BODIES

Document Reference: CSRGP/TOR/CICGB Document Title: Terms of Reference – Committee in common of the Governing Bodies Version: 1 Supersedes: N/A Authors: Sarah Mattocks Authors’ Designation: Corporate Affairs and Governance Manager Consultation Group: Governing Body Date Ratified: Review Date:

Committee in common of the Governing Bodies Terms of Reference Page 367 Version Control

Version Date Author Status Comment / Details of Amendments 0.1 29.08.19 Mrs S Mattocks Draft Document drafted 0.1 06.09.19 Mrs S Mattocks Draft Circulated to executive lead for governance, chief officer and chairs for feedback 0.1 25.09.19 Mrs S Mattocks Draft Submitted to the Governing Body for 26.09.19 approval

Circulation list

Prior to approval, the Terms of Reference are circulated to the following for consultation:

• CCG Governing Body members

Following approval these Terms of Reference will be circulated to:

• CCG Governing Body members

Committee in common of the Governing Bodies Terms of Reference

Page 368 1.0 Introduction

1.1 The Constitutions for NHS Chorley and South Ribble Clinical Commissioning Group (CCG) and NHS Greater Preston Clinical Commissioning Group (CCG) state in section 5.13.1 that:

“The Group may wish to work together with one or more Clinical Commissioning Groups, as it considers appropriate, in the exercise of its commissioning functions. The Group will describe and publish on its website any such arrangements in a ‘Statement of Collaborative Commissioning Arrangements”

this includes at 5.13.2:

“exercising jointly the commissioning functions of the Group and another CCG”

And at 5.13.4:

“Where the Group makes arrangements which involve all the Groups exercising any of their commissioning functions jointly, a joint committee may be established to exercise those functions”.

1.2 Such a committee allows the two central Lancashire CCGs to work more collaboratively and enables the views of both CCGs to be heard together before decisions are taken in order to streamline decision making across the patch and enrich the debate for each CCG.

1.3 To this end, the CCGs have agreed to establish a ‘Committee in common of the Governing Bodies’. The Committee is established as a committee in common of the two central Lancashire CCGs, which will receive items which were previously taken to individual Governing Body meetings but which are equally relevant to both CCGs. The meeting will hereafter be referred to as “the committee”.

2.0 Membership

2.1 The Committee will be chaired by the Clinical Chair and this will rotate between CCGs each meeting.

2.2 Membership of the Committee will be made up of all current members and attendees from both CCG Governing Bodies.

2.3 The Committee shall consist of:

• Chair and Clinical Leader of NHS Chorley South Ribble CCG (rotating Chair) • Chair and Clinical Leader of NHS Greater Preston CCG (rotating Chair) • Vice Chair (Lay Member Governance) of NHS Chorley South Ribble CCG and NHS Greater Preston CCG (Vice Chair) • Accountable Officer • Chief Finance and Contracting Officer • Director of Quality and Performance • GP Directors of both CCGs • Lay Members for Finance, Audit and Conflicts of Interest of both CCGs • Lay Members for Patient and Public Involvement of both CCGs

Committee in common of the Governing Bodies Terms of Reference

Page 369 • Governing Body Nurse • Secondary Care Doctor • Director of Transformation and Delivery (non-voting)

3.0 Decision making

3.1 Voting will take place separately between each CCG in succession. The CCG to vote first will be the CCG belonging to the Clinical Chair who is Chairing the given meeting.

3.2 Where possible decisions will be taken by consensus. Where there is a divide in opinion a vote will be taken and decisions made by simple majority.

3.3 Where items are only relevant to one CCG, the other CCG will not be involved in the decision making and discussion.

4.0 Attendance

4.1 Members would normally attend all meetings and it is expected that members will attend a minimum of 75% of meetings per annum barring any exceptional circumstances.

5.0 Quorum

5.1 A quorum shall comprise the following voting membership of each Governing Body:

i. the Chair or Vice-Chair; ii. either the Accountable Officer or the Chief Finance & Contracting Officer; iii. at least two GP Directors; iv. a Lay Member (not including the Vice Chair); and v. either the Secondary Care Doctor or the Governing Body Nurse.

6.0 Frequency and notice

6.1 The Committee shall meet on a bi-monthly basis. All meetings shall be held in public unless the Chair agreed that it would not be in the public interest to permit members of the public to attend a meeting or part of a meeting due to the confidential nature of the discussion. The Chair of the Committee may arrange extraordinary meetings at their discretion.

6.2 Unless otherwise agreed, not less than 1 months’ notice shall be given for a meeting.

6.3 The Chair of the Committee shall reserve the right to reconvene and rearrange ameeting should they feel this necessary.

6.4 In addition to public meetings, the Governing Bodies will meet at an informal development session approximately six times annually held jointly. The purpose for the development session is strategic development updates, facilitated training, education and the opportunity for open discussions between both Governing Bodies.

Committee in common of the Governing Bodies Terms of Reference

Page 370 7.0 Meeting papers

7.1 The agenda shall be developed by the Chair. Administration of meetings will be provided by the governance team, and papers will be circulated a minimum of five working days in advance of the meeting. There will be two separate ‘Chairs’ updates’ from the Chairs of each CCG.

8.0 Purpose and duties

8.1 The Committee has been established to bring together the business of both CCG Governing Body meetings. For further detail on the business of the Governing Body the constitution should be referred to at section 5.7.

9.0 Reporting

9.1 The minutes of the Committee meetings shall be formally recorded.

9.2 The business of the Committee will be reported in the Annual Governance Statement.

10.0 Conflicts of interest

10.1 All potential or perceived conflicts of interest must be declared. Where there are conflicts of interest these will be managed by the Chair in line with the CCG Policy (Managing Conflicts of Interest GOV07) and recorded in the minutes.

11.0 Review of Terms of Reference

11.1 The Terms of Reference of the Committee shall be reviewed by the Governing Body of each of the CCGs at least annually, or as needed. Any amendments must be approved by each CCG Governing Body.

Committee in common of the Governing Bodies Terms of Reference

Page 371

This page is intentionally left blank Agenda Item 14

Governing Body Meeting

Date of meeting 25 September 2019 Title of paper Organisational Development Update Presented by Helen Curtis, Director of Quality and Performance Author Glenis Tansey, Engagement and Patient Experience Lead Clinical lead N/A Confidential No

Purpose of the paper This paper is presented to the Governing Body to provide an update on the developments in respect of Organisational Development (OD) across the CCG. Areas for discussion include the results of the CCG staff survey (2019), the OD strategy and plan, staff wellbeing and training and development.

Executive summary The CCG has one workforce that supports both NHS Chorley and South Ribble CCG and NHS Greater Preston CCG.

The landscape for the NHS is changing rapidly with the emergence of the Integrated Care Partnership (ICP) and Integrated Care System (ICS). As set out in the NHS Long Term Plan (2019) and the Interim People Plan (2019), we need to strengthen leadership, and ensure that our workforce is making the most of their skills, and are better equipped for this ever- changing world and the opportunities that may follow.

The update presented to the Governing Body will focus on: • The results of the annual CCG staff survey 2019 • The OD plan and strategy • Training and Development: The NHS North West Leadership Academy Talent Management Diagnostic Tool

Staff survey results The survey was completed by CCG staff only. Embedded CSU members of staff have their own HR process.

There was an 88% response rate which was the same as last year. While a number of areas showed a slight decline in performance in relation to the previous year, within the context of an ever pressured and challenging environment, most of the changes were minimal.

OD plan and strategy Recognising that the best solutions come from staff themselves, the CCGs have established a staff OD working group to shape and implement the CCG’s OD plan. The plan contains

Organisational Development Update NHS Chorley and South Ribble CCG Governing Body Meeting Page 373 25 September 2019 several areas for action and is enclosed herewith. Behind this high-level OD plan sits a suite of more detailed action plans.

The areas for immediate focus are: • The refresh of the OD strategy • Staff well-being • Training and development • Review of internal communication.

Training and Development - NHS North West Leadership Academy Talent Management Diagnostic Tool The CCG has been successful in a bid to become an early adopter of the Talent Management Diagnostic Tool and is currently undertaking a self-assessment across the organisation against a number of areas relating to talent management: • Enabling a culture of talent management • Equality, diversity and inclusion in talent management • Identifying and retaining talent • Developing and mobilising talent • Connecting to our local health and care system

The CCGs will receive a report highlighting the strengths and areas for improvement, and will inform the refresh of the OD strategy.

The CCGs will further explore how the audit can be replicated on the ICP footprint.

Review of internal communication. We recognise that the staff survey results indicate that internal communication has declined and a review of all communications is a priority for the CCGs. This is currently underway.

Recommendations The Governing Body is asked to discuss the content of this report.

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 ☒

Organisational Development Update NHS Chorley and South Ribble CCG Governing Body Meeting Page 374 25 September 2019 Governance and reporting (list committees, groups or other bodies that have discussed this paper) Meeting Date Outcome

None 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 ☐ ☐ ☐ 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 findings of the NHS NW Leadership Diagnostic Tool audit and the refreshed Organisational Development strategy will be presented to the Board in due course.

Organisational Development Update NHS Chorley and South Ribble CCG Governing Body Meeting Page 375 25 September 2019

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Organisational Development Update September 2019 Page 377 Page

Updates • Annual staff survey results (2019) • Organisational Development Strategy and Plan • Training and Development: NHS NW Leadership Academy Talent Management Diagnostic Tool Page 378 Page

Annual CCG staff survey results 2019 Page 379 Page

How does it feel to work at the CCG at the moment?

Page 380 Page

% that agree or strongly agree 2015 2016 2017 2018 2019 A clear vision of the future direction of the CCGs and local 53% 55% health services has been communicated

I have enough opportunities to 71% 89% 75% 62% 59% contribute to the decision that affect me

My manager helps me to 63% 73% 77% 72% 71% understand how the corporate/business objectives relate to my role

I know what is expected of me in 90% 86% my role

I have the tools I need to do my 90% 89% 87% 86% 83% job effectively

I am given opportunitiesto 64% 76% develop and grow

My immediate managerinspires 62% 63% 74% 76% 76% me Page 381 Page

My manager cares aboutmy 86% 88% wellbeing

How much do (% of staff (% of staff (% of staff who (% of staff (% of staff you feel your who rated 7 who rated 7 rated 7 or more who rated 7 who rated 7 work is valued or more out of or more out of out of 10) or more out of or more out of by…….. 10) 10) 10) 10) 2017 2015 2016 2018 2019

Your manager 85% 86% 90% 83% 85%

Your team 98% 93% 92% 86% 86% colleagues

Members of the wider 70% 67% 71% 66% 44% organisation

External partners, 82% 79% 61% 59% 47% stakeholders and patients Page 382 Page

How (% of staff (% of staff (% of staff (% of staff (% of staff satisfied are who rated who rated who rated 7 who rated who rated you 7 or more 7 or more or more out 7 or more 7 or more with …….. out of 10) out of 10) of 10) out of 10 ) out of 10)

2015 2016 2017 2018 2019

Your working environment 60% 82% 80% 90% 87%

The weekly staff bulletin 90% 91% 83% 86% 86%

The monthly staff 77% 82% 87% 79 % 65% briefing The intranet 77% 79% 67% 67% 60%

Lunch and learn events 71% 79% 67% 67% 46%

Randomised coffee trials 55% 21%

Chief Officer P a open door 83% 71% 78% 62% 27% g

383 drop -ins e

What is going well and what can we improve on?

Page 384 Page

Annual staff survey results

Next steps

• Results have been aligned to the Organisation Development (OD) plan • Review of internal communication and engagement channels, including MET integration, lunch and learn etc. • Focus on communicating direction of travel wherever possible • Focus on staff well-being • Continued focus on talent management, individual development, training and career progression / opportunities

• 385 Page Refresh the OD strategy

OD plan

• High level OD plan enclosed • Key themes we are focussing on: . Refreshing the OD strategy . Staff well being . Early adopter of the NHS NW Leadership Academy Talent Management Diagnostic tool . Training and development . Internal communication Page 386 Page

Organisational Development plan 2019/20

Theme / Action Activity / initiative Timescales Assigned to Actions/notes and comments Status area

Strategy and planning Establish staff OD working group Oct-19 Glenis Tansey Staff OD working group established - representation from all business units and bands Initial meeting held TOR developed Key themes to commence: • Staff Well-being • Training, development and opportunities Two sub-groups (task and finish) established

Staff 'quick polls' on initiative ideas to ongoing OD working group Email or Survey Monkey based shape the OD plan Liaison with the CSU OD team Jul-19 Glenis Tansey On-going and as needed 44 days provision across two CCGs. Monthly update of activity agreed

OD strategy review Nov-19 Glenis Tansey Strategy due for review 2019 Use the findings from the NHSLA TM audit to shape Explore ICP/ICS wide strategy

Annual staff survey Sep-19 Glenis Tansey Survey questions agreed. MLCSU to undertake on behalf of CCGs. Survey closed report awaited Reports received Slides being produced for staff brief and GB's Staff survey presented to workforce at 31 July staff briefing. Slides produced for GB (Sept)

Early adopter Talent management Oct-19 Glenis Tansey Bid to NHS Leadership Academy successful diagnostic tool NHS Leadership Webinars to progress scheduled Academy Audit underway Apply for the Workplace Wellbeing Nov-19 Glenis Tansey Expression of interest Charter accreditation Undertake audit

Page 387 Page 1

Running costs Oct-19 Helen Curtis Close liaison with working groups established • Stand up Friday – becoming more focussed and inclusive • Values, Organisational Development and Culture • Workload priorities • Streamlining and duplication • Sharing information • ICS and ICP Keep staff informed

Keeping everyone Review all internal communications Oct-19 Jonathan Bridge Weekly bullet points post MET meetings informed Staff brief Lunch and Learn Randomised Coffee Trials Chief Officer Open Door Policy Away Days 2019/20 Intranet

Develop OD staff newsletter Oct-19 Glenis Tansey/ Staff Communicate the work of the OD group to the wider OD working group workforce

Listening, enabling Use of cross team working groups tbc tbc BELBIN project concept set - ask for volunteers from and empowering particular 'role types' (OD working group to Staff skills audit will support shape) Staff / team takeover of monthly staff tbc tbc Identify a team in every month as a plan for the full briefing sessions year ahead

Revamp staff suggestion scheme tbc tbc Use intranet Cross reference with internal comms Establish a coaching and mentoring hub tbc tbc Send CCG rep to be trained to access NHSLA portal

Commissioning/ transformation cycle tbc tbc Review cycle process for all CCG teams processes Keeping teams informed

Consideration and Meeting code of conduct Oct-19 Staff OD working group Part of staff wellbeing group behaviours (OD working group to shape) Office / behaviour code of conduct Oct-19 Staff OD working group Part of staff wellbeing group

Page 388 Page 2

Senior leadership Networking opportunities for MET tbc Helen Curtis/ Glenis Explore various options visibility Tansey Governing Body 360s tbc Helen Curtis/ Glenis Could be repeat of previous NHSLA process or a Tansey survey monkey process

Governing Body development session Oct-19 Helen Curtis OD session in conjunction with ICS OD leads

Governance review of Governing Body tbc Matt Gaunt Joint Governing Body meeting commences following merger vote November

JEM development tbc Glenis Tansey Development of JEM and Clinical Leaders within £2k grant in place and primary care networks option brief to be produced

Valuing people and Celebration event tbc tbc Could also include team showcases (see below), and celebrating successes be a mix of nominations and a staff panel choosing (OD working group to recipients shape) Team showcases tbc tbc Encourage teams to use lunch and learns to showcase achievements and use Our Week and intranet

Opportunity portal tbc tbc Intranet page showcasing local roles, secondments, projects and team help needed in the CCGs and across the ICS / ICP - could also link to staff profiles as online CVs

Apply for the Workplace Wellbeing Nov-19 Glenis Tansey Expression of interest given Charter Scoping telephone call made

Equality and Mandated line manager training Ongoing Sessions in place More may need to take place as mop-ups consistency Direct report 360s tbc Glenis Tansey Explore opportunities for 360 feedback Survey Monkey could be used

Consistent approach to Talent ongoing Executive Directors ED's to ensure consistency via PDRs, 1:1's Management (PDR, 1:1 appraisal) Glenis Tansey appraisals Line manager training

Page 389 Page

3

Audit PDR compliance Ongoing Glenis Tansey

Review and consider options for flexi Ongoing Staff Development sub- A working group have started discussions to take this time group forwards

Training and Development Ongoing Staff Development sub- Identify/ map training opportunities Develop clear routes and processes for group Undertake skills audit training opportunities. ID if there is an organisational wide budget Communicate findings of skills audit Bespoke training ongoing Glenis Tansey Explore Aristotle training for all CCG staff as identified in the IBP Friday meeting

Staff Wellbeing Establish staff well-being sub group and Ongoing Staff OD H&WB sub- Staff wellbeing room identified develop an action plan group Staff working group developing an action plan together with ideas gleaned from workforce Flexible working policy Produce OD newsletter

Key Not yet started In progress Completed Behind schedule

Updated 13.09 19 GT Page 390 Page

4

Agenda Item 16

Governing Body Meeting

Date of meeting 25 September 2019 Title of paper Policies for approval Presented by Mr Paul Richardson – Remuneration Committee Chair Mrs Linda Chivers – Audit Committee Chair Author Mrs Glenis Tansey, Engagement and Patient Experience Lead Mrs Anne Whittle, Corporate Business Manager Clinical lead N/A Confidential No

Purpose of the paper The updated Health and Safety and Freedom of Information policies are presented to the Governing Body today for approval.

Executive summary Health and Safety Policy The CCG’s Health and Safety policy has been updated to reflect changes in personnel and an updated Equality Impact Assessment.

An amendment was made to reflect that it is the organisation’s responsibility to monitor First Aider qualifications to avoid the potential for First Aid certificates to become out of date.

Freedom of Information Policy The CCG’s Freedom of Information policy has been refreshed in line with the CCG policy review process.

There have been no legislative changes that will impact on the policy.

The only changes to note are in respect of:

• Updated CCG email contact details: 2.8, 5.5 • The inclusion of previous FOI responses on the CCG websites:16.2 • Updated contact details: Appendix 2 • The name change of the CCG’s secure recording system: Appendix 3

Recommendations The Governing Body is asked to approve the updated Health and Safety policy and Freedom of Information policy.

Links to CCG Strategic Objectives SO1 Improve quality through more effective, safer services, which deliver a ☐

Policies for approval NHS Chorley and South Ribble CCG Governing Body Meeting Page 391 25 September 2019 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 The Committee agreed the Remuneration Committee 16 May 2019 policy subject to a change under the First Aid section.

The Committee agreed the 6 September Audit Committee policy subject to a minor 2019 change within appendix 3. 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 The Freedom of Information Policy will be reviewed as necessary in line with any changes in legislation, or at the specified review date.

Policies for approval NHS Chorley and South Ribble CCG Governing Body Meeting Page 392 25 September 2019

Freedom of Information Policy

Document Reference: CSR/IG/012 v3.0 Document Title: Freedom of Information Policy Version: 3.3 Supersedes: CSR/IG/012 v 3.0 Author: Glenis Tansey Authors Designation: Engagement and Patient Experience Lead Date Approved: XXX Review Date: September 2021

Page 393 Comment / details of Version Date Author Status amendments Policy drafted Engagement and Sent for comments to: 1.0 12.08.16 Patient Draft • Experience Lead CCG customer care team • Patient Advisory Group Comments received and incorporated from: Engagement and • CCG customer care team 1.1 16.08.16 Patient Draft Experience Lead • Patient Advisory Group Draft policy circulated to staff groups for review Suggestions and amendments incorporated and sent to Head Engagement and of Strategy and Corporate 1.2 17.08.16 Patient Draft Services and Head of Experience Lead Communications and Engagement for review and sign off All amendments incorporated Engagement and and final draft produced to 2.0 18.08.16 Patient Draft present to the Audit Committee Experience Lead for ratification

Engagement and Approved by Audit committee 2.1 02.09.16 Patient Draft subject to minor amendments Experience Lead Engagement and 3.0 02.09.16 Patient Final Final version Experience Lead 3.1 03.06.19 Engagement and Draft Policy reviewed and sent to Patient CCG customer care team for Experience Lead comments

3.2 12.06.19 Engagement and Draft Amendments made and sent to Patient PAG for comments Experience Lead 3.2 06.09.19 Engagement and Draft Version 3.2 submitted to the Patient Audit Committee for ratification Experience Lead 3.3 13.09.19 Engagement and Draft Policy agreed by the audit Patient Committee subject to a minor Experience Lead amendment.

Page 2 of 18 Page 410 Circulation list

Prior to approval, this policy was circulated to • CCG customer care team • Patient Advisory Group • Equality and Diversity Lead • Members of CCG and CSU embedded staff

Following Approval this Policy Document will be circulated to: • All CCG and CSU embedded staff • Patient Advisory Group

Equality impact assessment

This document has been impact assessed by the CCG. No issues have been identified in relation to equality, diversity and inclusion.

Page 3 of 18 Page 410 Table of Contents

1.0 Introduction ...... 5 2.0 Scope ...... 5 3.0 Principles ...... 6 4.0 Responsibilities ...... 7 The role of the Information Commissioner’s Office (ICO) ...... 7 CCG responsibilities ...... 7 5.0 Processing FOI requests ...... 8 6.0 Duty to provide advice and assistance...... 8 7.0 Requests which appear to be part of an organised campaign ...... 9 8.0 Multiple requests from one party...... 9 9.0 Transferring requests for information ...... 9 10.0 Seeking clarification ...... 9 11.0 Gathering information ...... 10 12.0 Applying exemptions and extensions ...... 10 13.0 The Public interest test ...... 11 14.0 Response letters ...... 11 15.0 FOI complaints procedure ...... 11 16.0 Publication scheme ...... 12 17.0 Charges and fees ...... 12 18.0 Re-use of information ...... 13 19.0 Equality and diversity...... 13 20.0 Records management ...... 13 21.0 Reporting on FOI data ...... 13 Appendix 1 Freedom of information exemptions ...... 14 Appendix 2 Useful contacts ...... 17 Appendix 3 Process Flowchart ...... 18

Page 4 of 18 Page 410 Policy Summary

This policy sets out the process for which NHS Chorley and South Ribble identifies, acknowledges and responds to requests made to the CCG under the Freedom of Information Act 2000, ensuring that all requests are processed in accordance with the Act and other relevant legislation.

1.0 Introduction

1.1 The Freedom of Information (FOI) Act 2000 sets out an obligation to all public authorities to be open and transparent with the information they hold. It enables members of the public to question the decisions of public authorities more closely and thereby ensure that the services provided are efficiently and properly delivered.

1.2 If a member of the public requests information, information will only be provided that is held in recorded form.

1.3 The FOI Act contains two main parts:

• The right of an individual to request information about, or held by a public authority in relation to any of its duties. • The legal obligation of a public authority to actively publish certain information within a publication scheme and provide a guide to this information.

1.4 This document:

• Sets out the FOI policy for NHS Chorley and South Ribble Clinical Commissioning Group (CCG). • Provides a framework to ensure that the CCG complies with the FOI Act 2000 and deals with all FOI requests in a timely and consistent manner. • Highlights to all CCG staff their responsibilities under the FOI Act.

2.0 Scope

2.1 This policy applies to all employees of NHS Chorley and South Ribble CCG including Governing Body members, employees on temporary contracts, agency staff, consultants, apprentices and students.

2.2 This policy provides a framework within which NHS Chorley and South Ribble CCG will ensure compliance with the requirements of the FOI Act 2000.

2.3 This policy does not cover requests for people to access their own personal data (information about themselves) such as their health records, or HR information. If a member of the public wishes to see information that a public authority holds about them, they should make a ‘subject access request’ under the Data Protection Act 1998. More information about subject access requests can be found on the Information Commissioner’s Office (ICO) website: https://ico.org.uk/for-the-public.

Page 5 of 18 Page 410 2.4 A guide to the FOI Act 2000 can be found on the ICO website: https://ico.org.uk/for-organisations/guide-to-freedom-of-information.

2.5 Anyone may request information under the Act. A valid request must be made in writing, stating; the name of the applicant, an address (postal or e-mail) for correspondence, a description of the information requested, and the format in which the information is to be supplied.

2.6 ‘In writing’ can be letter or e-mail.

2.7 A request for information made under the FOI Act 2000 does not need to state the Act within it.

2.8 Requests for information under the FOI Act 2000 should be made to the CCG in writing and sent to:

The Customer Care Team NHS Chorley and South Ribble Clinical Commissioning Group Chorley House Lancashire Business Park Centurion Way Leyland Lancashire PR26 6TT

Or by email to [email protected]

2.9 This policy should be read in conjunction with the CCG’s customer care policy which can be accessed via the CCG website: https://www.chorleysouthribbleccg.nhs.uk/how-to-make-a-complaint

2.10 A list of useful contacts and resources is illustrated within Appendix 2.

3.0 Principles

3.1 The main principle behind the FOI legislation is that people have a right to know about the activities of public authorities, unless there is a good reason for them not to. This means that:

• Everybody has a right to access official information unless there is a good reason not to share the information. There are a number of exemptions permitted under the Act that are set out in appendix 1.

• An applicant (known as the requester) is not required to give a reason for wanting the information.

• The information someone can obtain under the Act should not be affected by who they are. All requesters should be treated equally, whether they are journalists, local residents, public authority employees, or researchers.

• Any information released to a requester under the Act should be treated as if

Page 6 of 18 Page 410 it were being released into the public domain that is accessible to all.

4.0 Responsibilities

The role of the Information Commissioner’s Office (ICO)

4.1 The ICO is the UK’s independent authority established to uphold informationrights in the public interest, promoting openness by public bodies and data privacy for individuals. The ICO holds the power to enforce the rights created by the Act. This is done through ruling of complaints, providing information to individuals and organisations and taking the appropriate action when the law is broken.

4.2 In promoting good FOI practice, the ICO provides a number of guidelines, which can be used to help organisations to meet their obligations under the Act.

4.3 Full information regarding the role of the ICO can be found on its website at www.ico.gov.uk. CCG responsibilities

4.4 It is the responsibility of every staff member to be aware of the FOI Act 2000. Requests made under the Act do not have to mention the Act and can be given to any member of staff working for NHS Chorley and South Ribble CCG.

4.5 When creating information such as e-mails, documents or anything written down, members of staff should be aware that this can be requested under FOI. Marking an item as ‘confidential’ or submitting documents to ‘private meetings’ does not necessarily prevent its release.

4.6 The Chief Officer of NHS Chorley and South Ribble CCG has ultimate responsibility for the CCG’s compliance with the FOI Act 2000. The CCG has delegated day-to- day responsibility for implementing the Act to the Head of Strategy and Corporate Services.

4.7 The Director of Quality and Performance will have ultimate responsibility for the sign off of all FOI requests, which will also be delegated as needed.

4.8 The CCG will ensure that staff responding to FOI requests have received the appropriate training to do so.

4.9 The CCG will ensure that awareness of FOI is cascaded to all staff via the annual mandatory Information Governance (IG) training, and IG induction training.

4.10 Managers at all levels are responsible for ensuring that the staff for whom they are responsible are aware of, and adhere to, this policy. They are also responsible for ensuring that staff are updated in regard to any changes in this policy.

4.11 The CCG’s customer care team will be responsible for logging, investigating and responding to any requests for information made under the FOI Act2000.

Page 7 of 18 Page 410 4.12 Individual members of staff or teams regarded as ‘subject experts’ will be asked to supply information in a timely matter to the customer care team as part of their investigations.

4.13 Members of staff need to be aware that when they are asked to provide information for an FOI request, that there is a time limit involved (see 5.2).

4.14 If there are any queries from members of staff about releasing information under the exemption criteria, the customer care team will offer advice, but ultimately it is the responsibility of the Director of Quality and Performance to make final decisions relating to whether an exemption can be applied.

5.0 Processing FOI requests

5.1 The date of receipt of the FOI request is the day that the request is received by the organisation and not the date it is received by the individual who processes requests.

5.2 The timescale for the CCGs to respond to a request made under the FOI Act 2000 is within 20 working days of receipt, in accordance with section 10 of the Act.

5.3 The 20 day timeframe will commence the next working day after receipt of the request.

5.4 It may sometimes be necessary to extend this timeframe, for example to assess the public interest to release the information. In these circumstances, the response will be made within 40 working days, with notification given to the requester.

5.5 If a request for information under the FOI Act 2000 is received by a member of CCG staff who is not a member of the customer care team, it is important that they hand the request in person to a member of the customer care team, or email it directly to the team at: [email protected] as soon as they receive it.

5.6 Once an FOI request is received, the customer care team will: • Check that the request for information under the FOI Act 2000 is a valid request. • Log the request onto the CCG’s secure Pentana system. • Acknowledge the request to the requester, in writing, within three working days. • Respond to the requester within 20 working days.

5.7 A copy of the process flowchart is illustrated within Appendix 3.

6.0 Duty to provide advice and assistance

6.1 Under section 17 of the FOI Act 2000, the CCG has a duty to provide advice and assistance to anyone who has made, or wishes to make, requests for information.

6.2 The CCG will ensure that systems and processes are in place to meet this duty.

Page 8 of 18 Page 410 This will include making all staff aware of their responsibilities under FOI via the established staff communications methods and training programmes.

7.0 Requests which appear to be part of an organised campaign

7.1 Where a number of requests made by different people appear to form part of an organised campaign, the CCG may calculate the cost of complying with any of the requests as the cost of complying with them all. If this cumulative cost is estimated to exceed the appropriate limit that is set in the national regulations (18 hours), the CCG is not required to comply with the requests.

7.2 Where 7.1 is the case, the CCG will consider whether it is possible to publish the information on the FOI section of the CCG website and forward details of the link to each of the applicants.

8.0 Multiple requests from one party

8.1 Where a number of requests are made by one party, the CCG may calculate the cost of complying with the requests as the cost of complying with them all. If this cumulative cost is estimated to exceed the appropriate limit that is set in the national regulations (18 hours), the CCG is not required to comply with the requests.

8.2 Where 8.1 occurs, and the requests are received within a short space of each other, the requester will be asked to prioritise their requests. The CCG will then respond to as many requests as possible within the appropriate time limit.

9.0 Transferring requests for information

9.1 Where the CCG receives a request for information that it does not hold, but which is held by another public authority, the request for information may be transferred.

9.2 If a request is partly for information, which the CCG does hold, and partly for information which it does not, the transfer will only be made in respect of the information it does not hold. The CCG would then continue to process the request for the information that is held.

9.3 Wherever possible, the CCG will inform the requester which organisation may hold the information not held, and offer the requester contact details.

10.0 Seeking clarification

10.1 When processing requests, there may be times when the CCG may require the requester to provide clarification over all or part of the information requested.

10.2 When this occurs, the CCG will write to the requester expressing in detail what further information is required.

10.3 The CCG, wherever possible, will help the requester in clarifying the request.

Page 9 of 18 Page 410 10.4 Requests for clarification fall outside the 20 working days timescale to process requests. Therefore, requesters are encouraged to respond promptly to ensure that their request is processed as quickly as possible.

10.5 The 20 day timeframe will be paused until clarification is received.

10.6 Clarification may be discussed over the telephone in order to resolve clarification issues quickly.

10.7 Calls made to and from the customer care team are recorded for training and monitoring purposes.

11.0 Gathering information

11.1 In order to respond to an FOI request, the customer care team will seek information from CCG subject experts, teams or individual members of staff.

11.2 When requesting information, the customer care team will: • Clarify full details of the FOI request. • Ask the person they have contacted to confirm that they do hold the information, or clarify within five working days the person/ team who may hold the information if it is not them. • If the response internally is not received within five days it will be escalated to the department head. • Confirm timescales that the information is required by.

12.0 Applying exemptions and extensions

12.1 The CCG’s duty to provide information under the FOI Act 2000 is subject tocertain conditions or exemptions.

12.2 A list of exemptions is supplied in appendix 1 of this policy.

12.3 If the information requested is held, but meets one of the conditions outlined in the Act exempting it from disclosure, the requester will be issued with a refusal notice, which will inform them which exemption(s) has been applied, and the reasoning behind withholding the information.

12.4 All refusal notices provided by the CCG will contain details of how to appeal, both internally and to the ICO.

12.5 If the CCG holds some of the information, but some is exempt, the customer care team will provide the information that is not exempt.

12.6 If the CCG intends to withhold some information, there is a duty to explain the decision. This should be done within 20 working days, but if the CCG needs to consider the public interest test, they are entitled to a reasonable extended period.

12.7 If an extension is required, the CCG will estimate to the requester when they expect to reach a decision outside of the 20 working day period.

Page 10 of 18 Page 410 13.0 The Public interest test

13.1 Public interest will be considered in every case where a qualified exemption is applied.

13.2 Defining public interest may vary according to the information requested. It may involve decisions about accountability, transparent decision making and good management. When considering the public interest to reach a decision on an exemption, the CCG will seek appropriate advice. This may include legal advice.

14.0 Response letters

14.1 Once the information relating to the FOI has been gathered, the customer care team will generate a draft response letter.

14.2 The draft letter will be sent to the CCG’s FOI lead: Director of Quality and Performance for amendment, approval or sign off.

14.3 Any necessary amendments will be undertaken by the customer care team and sent back to the Director of Quality and Performance to amend, approve or sign off.

14.4 Once the final response has been signed off, the customer care team will send out the final response to the requester.

14.5 If the request was emailed to the CCG, a PDF copy of the final response will be emailed to the requester. The case will then be closed on the Pentana system.

14.6 If the request was made by post, the final response will be posted out to the requestor. The case will then be closed on the Pentana system.

15.0 FOI complaints procedure

15.1 If a requester is dissatisfied with the way that their request has been processed, they have a right to ask for an internal review to be conducted.

15.2 If an applicant is dissatisfied with the response they should contact the CCG’s customer care team via post or email at the addresses outlined in 3.7.

15.3 In conforming to section 45 of the FOI Act 2000, internal reviews will be conducted by a member of staff within the customer care team who has not been involved in responding to the original request, and therefore can give an impartial, independent opinion.

15.4 Wherever possible, internal reviews will be conducted within 20 working days.

15.5 On receiving an appeal, the customer care team will let the requester know promptly if they feel that the review will exceed 20 working days.

15.6 If a requester remains dissatisfied with the outcome of an appeal, they have the

Page 11 of 18 Page 410 right to make a complaint against the CCG to the ICO. This can be done in writing to:

Information Commissioner’s Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF

16.0 Publication scheme

16.1 It is a legal requirement of all public authorities to publish certain categories of information in the form of a publication scheme, showing commitment to routinely and proactively providing information to the public.

16.2 NHS Chorley and South Ribble CCG has developed a section on its website that provides information in relation to previous FOI requests, key documents such as the annual report and Governing Body papers and meeting schedules. It can be found at: http://www.chorleysouthribbleccg.nhs.uk/how-to-make-a-freedom-of- information-request. Previous FOI responses can be found on the CCG’s website at: https://www.chorleysouthribbleccg.nhs.uk/previous-freedom-of-information- requests

16.3 The content held on the CCG website is subject to regular reviews. As part of this, the CCG will identify where frequent requests have been made for the same information and aim to proactively publish this information, wherever possible.

17.0 Charges and fees

17.1 The FOI Act and associated Fees Regulations stipulate that the CCG cannot levy a fee for information unless there is a statutory basis for doing so, or the amount of time taken to locate the information takes longer than 18 hours.

17.2 Although the CCG does not generally charge for any information supplied under the FOI Act, or as part of its publication scheme, it is allowed to charge for disbursements related to the provision of information, and any reformatting requested by the requester of the information under the Act provided that the CCG makes the requester aware of the charges. This can also apply when multiple page hard copies are requested, or information is to be copied onto other media (e.g. disc).

17.3 Where charges are applicable, a fees notice will be issued to the requester as required under section 9 of the FOI Act.

17.4 Timescales for responding to an FOI may change if a charge or fee has occurred. The working days in the period between the requester’s receipt of the notice fee and the CCG receiving payment will not be included in the 20 working day calculation.

Page 12 of 18 Page 410 18.0 Re-use of information

18.1 NHS Chorley and South Ribble CCG allows all information held on its website and supplied under the FOI Act to be re-used free of charge with the following conditions:

• Information supplied freely by the CCG should not be re- used for commercial profit or gain. • Information should be re-used in the context to which it was originally supplied, and not altered without the express permission of NHS Chorley and South Ribble CCG.

19.0 Equality and diversity

19.1 The CCG will consider all requests for information to be translated or provided in an alternative format and will make every effort to supply this where possible. These requests should be made with the initial FOI request.

19.2 The CCG website has been tested by its Patient Advisory Group for accessibility. Information held on the CCG website in relation to FOIs can be can be translated, using Google Translate. The website also contains accessibility tools for alternating text size and background shade, and also for use within screen readers.

20.0 Records management

20.1 All records created, used and held in implementing the FOI Act 2000 are done so in accordance with related CCG policies, information governance standards and relevant legislation listed below:

• The Equality Act 2010. • The NHS Confidentiality Code of Practice 2003. • The Freedom of Information Act 2000. • The Human Rights Act 1998. • The Data Protection Act 1998. • Access to Health Records Act 1990. • The Public Records Act 1958.

21.0 Reporting on FOI data

21.1 Activity relating to requests for information under the FOI Act 2000 will be reported to the Joint Patient Voice Committee and the Joint Quality and Performance Committee via a quarterly customer care activity report. Information reported to the Committees will include the number of requests, themes and the number of breaches. No personal data will be reported.

21.2 The activity report will also be shared with the CCG’s Joint Patient Advisory Group.

Page 13 of 18 Page 410 Appendix 1 Freedom of information exemptions In response to a request for information under the FOI Act, the CCG may refuse to supply some or all of the information, or may be unable to process a request for another reason. In such situations, the requester will be advised of the reasons why.

The following provides further information about some of the reasons why the CCG may not supply the information requesters have asked for; it is not a comprehensive legal guide, but is intended to provide general information.

Please note that the FOI Act does contain other exemptions to disclosure that are not included below, but which may apply to a request.

Full details of exemptions can be found on the Information Commissioners Office (ICO): https://ico.org.uk/for-organisations/guide-to-freedom-of-information/refusing-a- request. Common exemptions

• Section 1(3) - interpreting and clarifying requests • Section 12 - it will cost too much to find the information you want • Section 14 (1) - the request is vexatious • Section 14 (2) - you have already asked for this information • Section 21- the information you want is already available • Section 22 - the information you want is going to be published in the future • Section 22a- the information is part of research information • Section 30 - the information you want is held for investigative purposes • Section 31- disclosing the information would prejudice law enforcement • Section 32 - the information has been filed with, or created by, a court • Section 38 - somebody’s health or safety may be endangered • Section 40 - you are asking for personal information • Section 41- the information was provided in confidence • Section 42 - the information is legally privileged • Section 43 - the information is commercially sensitive • Section 44 - we are not allowed to give you the information • The public interest test

Section 1(3) - interpreting and clarifying requests This exemption means that the CCG does not have to comply with a request in situations where it needs more information from you in order to do so. However, when refusing to deal with the request for this reason, the CCG must ask the requester for more details so that we can deal with the request.

Section 12 - it will cost too much to find the information you want This exemption means that the CCG does not have to comply with a request if the cost of doing so exceeds the ‘appropriate limit’. The appropriate limit is, effectively, 18 hours, and applies to time spent locating and collating the requested information. In such circumstances, the CCG has a duty to advise the requester how, if possible, the scope of the request could be narrowed to bring it within the limit.

Page 14 of 18 Page 410

Section 14(1) - The request is vexatious The CCG does not have to comply with a request if it is vexatious. The definition of vexatious is not straightforward, but the following would be taken into consideration: • Can the request fairly be seen as obsessive? • Is the request harassing the authority or causing distress to staff? • Would complying with the request impose a significant burden in terms of expense and distraction? • Is the request designed to cause disruption or annoyance? • Does the request lack any serious purpose or value?

Section 14(2) - You have already asked for this information The CCG does not have to comply with repeated requests. This only applies to requests from the same person, submitted without a ‘reasonable’ interval in between, and where we have already responded to the first request. Although the FOI is officially ‘applicant blind’, this is one of a few circumstances where the CCG can consider the specific application. A ‘reasonable’ interval depends upon the nature of the request; if the requested information changes or is updated frequently a reasonable interval may only be a couple of months. However, if the information is obviously never going to change, or only changes once a year, then a reasonable interval may be a year or longer.

Section 21 - The information you want is already available If the information you have requested is already available elsewhere, your request can be refused. The CCG will signpost the requester to how the information can be found.

Section 22 - The information you want is going to be published in the future If a request is for information that is due to be published in the future, the request might be refused. There must be a genuine intention to publish the information at a future date (even if a date of publication has not been set) at the time the request is received, and it must be reasonable in all the circumstances to withhold the information until the planned publication.

Section 22A - The information is held as part of research information This exemption applies if, the requested information is held as part of on an ongoing programme of research and there is an intention by someone, whether an individual or organisation, private or public sector, to publish a report of the research; and where disclosure of the information would or would be likely to prejudice the research programme, the interests of participants in the programme, or a public authority holding or intending to publish a report of the research. So long as the research programme is continuing, the exemption may apply to a wide range of information relating to the research project. There does not have to be any intention to publish the particular information that has been requested, nor does there need to be an identified publication date.

Section 30 - The information you want is held for investigative purposes The CCG can withhold information that has been held at any time for the purposes of investigations and proceedings conducted by the CCG to determine whether somebody should be charged with an offence. It also applies to information that was obtained or recorded for these purposes.

Page 15 of 18 Page 410

Section 31 - Disclosing the information would prejudice law enforcement If disclosure of the information you want would, or would be likely to, prejudice the prevention or detection of crime, or the apprehension or prosecution of offenders, then the CCG can refuse to disclose it.

Section 32 - The information has been filed with, or created by, a court If the information you want is in a document that has been filed with a court, or is in a document that has been created by a court, it is exempt from disclosure.

Section 38 - Somebody’s health or safety may be endangered If disclosure of the information you want would, or would be likely to, endanger the physical or mental health of anybody the CCG can refuse to disclose it.

Section 40 - You’re asking for personal information If you are asking for personal information about yourself it will be refused. However, your request will automatically be considered as a subject access request under the Data Protection Act. If you are asking for personal information about somebody else, your request can be refused if disclosure of the information would breach one of the data protection principles, or if the individual concerned has specifically asked that the information is not disclosed (and they have provided suitable reasons as to why).

Section 41 - The information was provided in confidence If the information requested was provided to the CCG in confidence, the request may be refused, but only if disclosure would constitute a breach of confidence that could result in legal action being taken against the CCG. This only applies to information received from outside the CCG.

Section 42 - The information is legally privileged The exemption exists to protect the confidentiality of communications between a client and their legal adviser. If the information requested constitutes legal advice, or a request for legal advice, then it might not be disclosed.

Section 43 - The information is commercially sensitive If the information requested is a trade secret, or will prejudice somebody’s commercial interests, the request may be refused.

Section 44 - We’re not allowed to give you the information The FOI Act does not over-rule other legislation. Disclosure of the information requested may be prohibited by another Act, and so we are legally prevented from providing it.

The public interest test Some of the exemptions in the FOI Act have a ‘public interest test’ associated with them. This means that, even if the exemption applies, we must consider whether the public interest favours disclosing the information, or whether the public interest favours withholding it.

Page 16 of 18 Page 410 Appendix 2 Useful contacts

CCG customer care service contact details

Telephone 01772 214601 or 01772 214602

Calls to these numbers are recorded for training and monitoring purposes

Fax 01772 214051

Email [email protected]

Freedom of Information Csrccg.FOI@ nhs.net (FOI) email General enquiries [email protected]

FOI website page https://www.chorleysouthribbleccg.nhs.uk/how-to-make- a-freedomof-information-request

Customer care website www.chorleysouthribbleccg.nhs.uk/contact-us page External links

Information Commissioner’s https://ico.org.uk Office

Page 17 of 18 Page 410 Appendix 3 Process Flowchart

Request received by the CCG under the Freedom of Information (FOI) Act 2000

CCG customer care team to log the request on the secure Pentana system

CCG customer care team to validate if the request is a genuine FOI request for information and then acknowledge receipt of the request to the requester within 3 working days

YES Is the FOI request valid? NO

CCG customer care team to CCG customer care team to gather information from the write to the requester to appropriate subject matter explain why expert, individual or team Close on system Extension needed YES Agree timescale

with requester

Information received by customer care Follow process team

CCG customer care team to draft a response letter from the information received.

CCG customer care team to send the draft letter to the Respond to requester Director of Quality and within 20 working days

Performance and make any amends

Customer care team CCG customer care team to commence investigation send out final response to with team member not requester within 20 working involved in the original days process. Requester not happy with Close on system the response Page 18 of 18 Page 410

Health and Safety Policy

Document Reference: HS01 Document Title: Health and Safety Policy Version: 3.0 Supersedes: 2.0 Author: Midlands and Lancashire CSU Health and Safety Team Authors Designation: Midlands and Lancashire CSU Health and Safety Team Consultation Group: Remuneration Committee Date Ratified: TBC Review Date: 19 May 2020

Page 411 Version Control

Comment / Details of Version Date Author Status Amendments Lisa Featherstone, Corporate affairs and Policy ratified by Audit 1.0 01.03.2013 Final Governance Committee Manager Midlands and Lancashire CSU 1.1 08.12.2015 Draft First draft of updated policy Health and Safety Team Midlands and Further updates following Lancashire CSU feedback provided by 1.2 21.12.2015 Draft Health and Safety Operational Governance Team Group Midlands and Lancashire CSU Approved by Remuneration 2.0 19.01.2016 Final Health and Safety Committee Team 2.1 15.05.2018 Midlands and Draft Inclusion of Section 9.0 Lancashire CSU relating to First Aid Health and Safety Team 3.0 16.05.2019 Geoff Lavery, Final Updated to reflect changes Estates FM, in personnel, Equality Impact Operations Lead Assessment updated

Circulation List Prior to Approval, this Policy was circulated to the following for consultation: • Corporate Affairs and Governance Manager • Estates FM, Operations Manager • Equality and Diversity Lead • MET • Chorley and South Ribble CCG Remuneration Committee • Greater Preston CCG Remuneration Committee

Following Approval this Policy Document will be circulated to: • All CCG staff

Equality Impact Assessment

This document has been impact assessed by the CCG. No issues have been identified in relation to Equality, Diversity and Inclusion.

Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 2 of 24 Page 412 Contents

1.0 Introduction...... 4 2.0 Scope ...... 4 3.0 The CCG’s Health and Safety Management System ...... 4 4.0 Objectives ...... 5 5.0 Roles and Responsibilities ...... 6 6.0 General Arrangements for Health and Safety...... 7 7.0 Training ...... 9 8.0 Dissemination and Implementation ...... 9 9.0 First Aid ...... 9 10.0 Measuring Performance ...... 10 11.0 Equality Analysis Assessment ...... 10 12.0 References ...... 11 Appendix 1: General Statement of Health and Safety Policy ...... 12 Appendix 2: Equality Impact Assessment (EIA): Non-Clinical Policy ...... 13

Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 3 of 24 Page 413 1.0 Introduction 1.1 NHS Chorley and South Ribble Clinical Commissioning Group (CCG) as the employing body for NHS Chorley and South Ribble CCG and NHS Greater Preston CCG, attaches great importance to the health, safety and welfare of its entire staff, and recognises its legal obligations under the Health and Safety at Work etc Act 1974, to ensure the health, safety and welfare of its staff, so far as is reasonably practicable. The CCG also accepts such responsibility for other persons who may be affected by its activities whilst on any site.

1.2 Work can make a positive or negative contribution to an individual’s health. Organisations that successfully manage health and safety recognise the relationship between the control of risks and the core business objectives, plus the important contribution which employees and their representatives can make to improve health and safety.

1.3 The CCG in adopting a positive pro-active stance on health and safety aims to promote an accountable culture which is just and fair to its employees, and enables the CCG to learn from incident reports and risk assessments in order to continuously improve its health and safety management and where necessary, change policy/procedure to enable this to happen.

1.4 This policy will set out the CCG’s arrangements for health and safety, and follow the recognised standard of HSG65 for all health and safety related policies, this safety model includes Plan, Do, Check and Act.

2.0 Scope 2.1 This policy applies to all employees of the CCG including bank, locum, agency, and sub-contracted staff. Managers at all levels are expected to take an active lead to ensure that health and safety and systems of internal controls are of the highest standard and integral to the operation of the organisation.

2.2 The CCG will ensure that adequate resources are provided to meet legal health and safety standards and provide sufficient information, instruction and training to enable employees, independent contractors, bank, agency and locum staff to carry out their work safely.

3.0 The CCG’s Health and Safety Management System 3.1 The Health and Safety Management System (HSMS) forms part of the CCG’s overall management system. It provides structure arrangements to reduce health and safety risks associated with the CCG’s activities, thereby meeting the requirements of the Health and Safety at Work etc Act 1974 and associated legislation.

3.2 The HSMS has been designed primarily to be appropriate to the scope and scale of risk associated with our activities. The framework of documents comprises: Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 4 of 24 Page 414 • Our Health and Safety Policy which confirms the CCG Governing Body’s commitment in relation to health and safety. • Organisational responsibilities which state the group and individual responsibilities for delivering the Policy commitment. • A suite of health and safety procedures that specify the standards and requirements that must be implemented in order that the commitment in the Health and Safety Policy is met.

3.3 The main elements of our Health and Safety Management System are:

• Strong and effective leadership at every level of the organisation. • A detailed understanding of the risks facing our business and those arising from our activities. • Implementation of proportionate control measures to eliminate risks so far as is reasonably practicable. • Checking and measurement of the effectiveness of risk controls. • Learning from our and others’ experiences, as well as new research, so that we improve our understanding of risk.

4.0 Objectives 4.1 The CCG’s Health and Safety objectives are to:

• Comply with all relevant health and safety legislation, approved codes of practices (ACOP), guidance notes, Secretary of State directives, and other relevant standards. • Integrate health and safety principles into servicedelivery, management and decision making processes. • Consult and communicate with employees and trade union representatives to ensure they are all aware of their health and safety responsibilities. • Strive for continuous improvement in health and safety standards. • Recognise the different demands that the CCG faces and work to deliver a consistent approach to managing health and safety.

4.2 To achieve these objectives the CCG will:

• Develop and maintain a documented and consistently applied Health and Safety Management System including clear roles, responsibilities and clear reporting lines. • So far as is reasonably practicable, provide and maintain healthyand safe work places, equipment and methods of working. • Provide sufficient resources to meet our commitment to health and safety. • Appoint competent persons to support us in meeting our statutory duties. • Provide employees at all levels with suitable and sufficient information, instruction, training and supervision to enable them to work safely and

Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 5 of 24 Page 415 avoid any actions that may adversely affect the health and safety of themselves or others. • Work with partners, stakeholders, external contractors and other agencies to develop awareness, a common understanding and promote good standards of health and safety. • Undertake continuous monitoring of our health and safety performance.

5.0 Roles and Responsibilities Structure for Health and Safety Management 5.1 In order to ensure that health and safety is successfully managed within the CCG, clear lines of responsibility and accountability are required to ensure a positive health and safety culture is fostered by the visible and active leadership of senior management.

The CCG Governing Body 5.2 The overall responsibility for health and safety performance, and legal compliance lies with the Governing Body. It has delegated responsibility for ensuring the CCG’s Health and Safety Policy is implemented to the Chief Officer and will receive and review regular reports on progress.

The Chief Officer 5.3 The Chief Officer has overall accountability and responsibility for all matters involving health, safety, welfare and fire, appertaining to the CCG. It is also the responsibility of all departmental heads and managers to manage health and safety issues within their functional area.

5.4 The Chief Officer in turn, nominates the Estates FM, Operations Manager as the nominated manager with responsibility for the day to day management of all health, safety, welfare, fire and security matters within the CCG.

The Estates FM, Operations Manager 5.5 The responsibility of the Estates FM, Operations Manager is to provide a safe and secure environment for all the CCG staff, visitors and contractors by adopting a holistic approach in managing health and safety risks of all types which the CCG may be subjected to. They will:

• Ensure competent people are appointed to provide advice and guidance on health and safety. • Ensure arrangements are in place to monitor, inspect, audit and review health and safety activities. • Ensure there are effective arrangements for consulting with employees on health, safety and welfare issues and promoting collaborative working with Trade Union appointed Health and Safety Representatives.

All Managers 5.6 All managers are responsible for ensuring that health and safety is an integral part of the management process within their area of responsibility. Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 6 of 24 Page 416 5.7 All managers have the responsibility to:

• Ensure that the CCG’s Health and Safety Policy, procedures and safe system of works are communicated and implemented to all employees. • Ensure all employees have induction and instruction emphasising health, safety, and welfare aspects of all operations. • Promote a positive and proactive approach to health andsafety. • Ensure risk assessments are undertaken for work activities they control, in consultation with their employees. This includes identifying the hazards, those at risk, and how they could be harmed. • Develop, implement and review safe working practices to satisfy themselves that appropriate and sufficient control measures are in place to remove or reduce the risks to as low asis reasonably practicable. • Ensure that they and their employees have adequate levels of training, instruction and supervision to work safely with minimal risk to themselves or others. • Ensure that emergency and evacuation procedures, especially means of escape in the event of fire, are known to all staff, contractors, volunteers, visitors and customers and that escape routes are kept free from obstruction. • Ensure employees report all accidents and incidents and that methods to prevent a recurrence are implemented through investigation.

Employee Duties and Responsibilities 5.8 All employees employed and contracted by the CCG have a statutory duty to take reasonable care of their own safety and the safety of others who may be affected by their acts or omissions.

5.9 Employees and contracted staff must comply with all relevant legislation, CCG policies and procedures, attend mandatory and statutory training, and report untoward incidents or unsafe occurrences.

5.10 Employees and contracted staff have a responsibility for bringing to the immediate attention of their manager any failings that could be detrimental to themselves and others, including visitors.

6.0 General Arrangements for Health and Safety Health and Safety Policies / Procedures 6.1 The overall corporate Health and Safety Policy is supported by a number of other operational policies/procedures that provide more detailed guidance on certain aspects of health and safety. These documents do not supersede this policy, but should be read in conjunction with it.

6.2 Further policies/procedures and guidance will be produced as required by changes in legislation or in line with best practice.

Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 7 of 24 Page 417 6.3 All health and safety policies will be reviewed by the Estates FM, Operations Manager who will, where appropriate, ensure that any management approval is obtained, prior to publication.

Risk Assessments 6.4 The Management of Health and Safety at Work Regulations 1999 make more explicit the general duties placed on the CCG under the Health and Safety at Work etc Act 1974. In order to meet with the regulatory requirements, the CCG will ensure:

• Risk assessments are carried out in order to evaluate and adequately control hazards, so to ensure the health, safety and welfare of employees, and others who may be affected by work activities of the CCG. • Risk assessments are recorded in writing, on the appropriate form, in accordance with the CCG Risk Management Strategy and Policy. • Arrangements will be made for putting into practice the preventative and protective measures that follow from the risk assessment. • Risk assessments will be regularly monitored and reviewed to ensure they remain ‘live’ documents. They will be updated in accordance with legislative requirements, standards, codes of practice etc. • The outcomes of risk assessments will be readily available and communicated to staff. Staff will receive instructions and/or training associated with the level of risk identified and the control measures taken to prevent or control risks.

Accident and Incident Reporting 6.5 In the event of an accident/incident staff will ensure that a detailed entry of the event is recorded on an accident form and will notify their line manager who will subsequently determine, in conjunction with the Midlands and Lancashire CSU Health and Safety Team, if notification is required under The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013.

6.6 Where an accident/incident has occurred, it is necessary to carry out a review of the risk assessment of the task being undertaken at the time, to ascertain if additional precautions, an alteration of the method of work or additional control measures are necessary. This must be written down and the conclusions clearly defined and acted upon.

6.7 As a learning organisation we will use the information to prevent re- occurrences, where reasonably practicable, to the same events.

Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 8 of 24 Page 418 7.0 Training 7.1 Health and safety training is a statutory requirement of legislation and therefore mandatory for all staff of the CCG. Provision will be made to ensure staff receive adequate information, instruction and training with respect to health and safety where appropriate.

7.2 All new permanent employees must receive an Induction to include health, safety, welfare, fire and security procedures and arrangements.

8.0 Dissemination and Implementation 8.1 For health and safety management to be effective within the CCG, this policy has to become a living document and a natural “part of everyday working practice”.

8.2 A structured and supportive approach for the implementation of this policy will demonstrate the CCG’s commitment that all staff are taking positive steps and working in partnership with each other and stakeholders to provide a positive health and safety culture within the CCG.

8.3 To achieve this, the Health and Safety Policy will be;

• Reviewed and approved by MLCSU Health and Safety Team. • Reviewed and ratified by the CCG’s Remuneration Committee. • Circulated to all managers, with specific responsibilities detailed in the document. • Available to all employees and contract staff electronically on the CCG staff intranet. • Available to all stakeholders on request (in an appropriate format).

8.4 It is a legal requirement that a health and safety poster (Health and Safety Law “What you need to know” HSE (2008)) is displayed in every workplace area that employees have access to that outlines British health and safety law.

9.0 First Aid 9.1 All first aiders must have the necessary training and qualifications, as evidenced by a current first aid certificate. It is the responsibility of all first aiders to maintain a valid certificate of competence and to advise their manager when it is due to expire. The first aider will also keep a record of training and qualifications. The list of first aiders and their locations are displayed on notice boards. It is the responsibility of the CCG to monitor First Aider qualifications to avoid the potential for First Aid certificates to become out of date.

9.2 All information of a personal nature obtained in the course of first aid duties will be treated as confidential.

9.3 First aiders will:

a) Act in accordance with their training at all times; Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 9 of 24 Page 419 b) Summon further medical help where necessary; c) Look after the casualty until recovery has taken place or further medical assistance has arrived; d) Ensure their own safety at all times; e) Record all treatments for which they are responsible, with specific details of the injury or other reason for treatment; f) Encourage the injured party to complete an Incident Report Form; g) Provide witness statements for the treatment provided where appropriate; h) Ensure that the first aid box for which they are responsible is appropriately stocked and maintained in a clean, tidy condition, obtaining replacement items as necessary; i) Keep their manager informed of annual leave dates, to ensure cover is provided.

Further Guidance on First Aid can be found on the HSE website: http://www.hse.gov.uk/firstaid/ and the Midlands and Lancashire CSU Health and Safety Team.

10.0 Measuring Performance

10.1 Health and safety performance will be measured by the Midlands and Lancashire CSU Health and Safety Team and reported back to the CCG by:

• Monitoring corporate performance standards; • Regular auditing and undertaking inspections; • Accident/incident reporting and investigation; • Liaising with Human Resources and Occupational Health to check the effectiveness of health surveillance and detect early signs of risks to health.

11.0 Equality Analysis Assessment 11.1 The CCG aims to design and implement procedural documents that meet the diverse needs of our service and workforce, ensuring that no one is placed at a disadvantage over others, in accordance with the Equality Act 2010.

11.2 An Equality Impact Assessment (EIA) has been completed, and can be found at Appendix 2. This was used to determine the potential impact this policy might have with respect to individual protected characteristics.

12.0 References • The Health and Safety at Work etc Act 1974 • The Management of Health and Safety at Work Regulations 1999 The Workplace (Health, Safety and Welfare) Regulations 1992 The Reporting of Incidents, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) • Health and Safety (First Aid) Regulations 1981 (as amended) • The Health and Safety Information for Employees Regulations 1989

Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 10 of 24 Page 420 • The Safety Representatives and Safety Committees Regulations 1977 (as amended) • The Health and Safety (Consultation with Employees) Regulations 1996 (as amended) • Disability Discrimination Act 1

Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 11 of 24 Page 421 Appendix 1: General Statement of Health and Safety Policy Philosophy NHS Chorley and South Ribble Clinical Commissioning Group (CCG) is committed to providing a safe and healthy working environment for all its employees, and regards health and safety as a matter of the utmost importance. An effective policy enhances business performance, reduces injuries and ill health, protects the environment and reduces unnecessary losses and liability. It follows that minimising risk to employees, visitors, and property is inseparable from all other business objectives.

General Statement of Policy The CCG, as an employer, is committed to ensuring the health, safety and welfare of its employees, so far as is reasonably practicable. The CCG also fully accepts its responsibility for other persons who may be affected by its activities and will take steps to ensure that its statutory duties are met at all times. The Governing Body expects all staff, visitors, contractors and other employers who work at the CCG to share this commitment by complying with the CCG policies and procedures, and to understand that they too have legal and moral obligations to themselves and to one another.

The CCG intends to ensure the health and safety of all persons who may be affected by its activities is maintained by ensuring that, in so far as is reasonably practicable:

• A safe working environment is provided, along with adequate welfare arrangements and facilities. • Identifying hazards and conducting formal risk assessments when appropriate in order to minimise the risk for all activities undertaken by the CCG. • All systems of work are safe and without unnecessary risks to health and safety. • Providing, managing and maintaining plant and equipment so that it is, so far as reasonably practicable, safe and that risks to health are controlled. • Ensuring that control measures and emergency procedures are in place, effective, properly used, monitored and maintained. • Provide suitable and sufficient information, instruction, training and supervision at all levels necessary to ensure that staff are competent to undertake their work activities. • Consulting with and involving our staff in matters relating to their own health and safety. • Keeping up to date with best practice in relation to health and safety and complying with all relevant legislation and authoritative guidance. • Contractors and providers undertaking work on behalf of the CCG are competent to do so.

The CCG will undertake to continually review and develop its safety management systems, with the overarching aim of conducting its activities in a manner which does not affect the health and safety of any staff, contractors, visitors or members of the public.

Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 12 of 24 Page 422 I and the other members of the Governing Body are committed to this Policy and to the implementation and maintenance of the highest standards of health, safety and welfare within the CCG. We expect every member of the CCG to share this commitment and to work together to achieve it.

Signature of Accountable Officer:

……………………………………………………………………………………………….

Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 13 of 24 Page 423

Appendix 2: Equality Impact Assessment (EIA): Non-Clinical Policy

☒ NHS Chorley and South Ribble CCG ☒ NHS Greater Preston CCG

Name of Reference Health and Safety Policy HS01 (v2.1) Policy Number This Policy Health and Safety Policy v1.0 replaces EIA Date 9th May 2019 Review Date 12 months after policy ratification Geoff Lavery, Estates FM, [email protected] 01772 214371 Author Contact details Operations Lead [email protected] 01772 214143 Lead Director Jayne Melloe Contact details EIA Approved by NHS Chorley and South Dawn Clarke Signed off by Ribble Remuneration Equality and Diversity Lead Committee

Signature and Signature and

date 09.05.2019 date

Risk Score Page 424 Page

The equality impact assessment tool for non-clinical policies has been developed in 4 sections:

Section 1: CCG policy development to be completed by the policy author. Section 2: Engagement and consultation Section 3: CCG actions on consultation feedback to be completed by the policy author. Section 4: The risk assessment to be completed by the policy author and assured by the Equality and Diversity Lead.

The policy and equality impact assessment will be signed off by the Operational Governance Group Group and then go to the Remuneration Committee for ratification.

Page 425 Page Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 14 of 24

Section 1: CCG policy development

Relevant documents Original policy Health and Safety Policy v1.0 National Health and Safety at Work etc Guidance Act 1974 The Management of Health and Safety at Work Regulations 1999 Midlands and Lancashire Reviewed other CCGs health Local CSU Health and Safety Team Other relevant and safety policies. Intelligence documentation

Research Research Changes in legislation, NHS England guidance. Resource Briefly describe any factors that could have an influence on this policy CCG additional criteria Additional information

Page 426 Page Factors for consideration of inclusion in

the policy or

as an exception

Is there any public No concern?

Who will this

policy directly

affect? Age Belief Race / / Race Carers Sexual Sexual Gender Ethnicity Disability Maternity Religion / Orientation Partnership Pregnancy / / Pregnancy Married / Civil Reassignment Sex (gender) Sex

Please tick the

appropriate ☒ ☒ ☒ ☒ ☒ ☒ ☒ ☒ ☒ ☒

column Comments The health and safety policy will affect all staff, visitors and contractors within Chorley House.

Page 427 Page Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 16 of 24

Safeguarding Are there any safeguarding concerns from this policy? ☐ Yes, for the following reasons: ☒ No, for the following reasons: N/A

Page 428 Page Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 17 of 24

Section 2: Engagement and consultation

The CCGs are involving people who may experience an impact due to the proposed policy. Where possible, the CCGs will be inclusive of any other vulnerable group who may be impacted in the future by this policy.

Engagement and consultation Internal External • Equality and Diversity Lead • Midlands and Lancashire CSU Health and • Corporate Affairs and Governance Safety Manager Manager • Estates FM, Operations Manager • MET • CSR CCG Remuneration Committee • GP CCG Remuneration Committee

Protected Groups Negative Impacts informed by Patient Advisory Committee Age

Disability

Gender

Gender Reassignment

Marriage / civil partnership

Page 429 Page Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 18 of 24

Pregnancy / maternity

Race/ethnicity

Religion / belief

Sexual orientation

Additional Comments

Page 430 Page Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 19 of 24

Section 3: CCG actions on consultation feedback

Engagement undertaken and actions taken Date Group Identified concerns Policy Reason for amended exclusion 09/05/19 None N/A N/A

Objective justifications Are there any objective justifications for NOT taking any action to improve the negative impacts that have been identified? ☐ Yes, please state: ☒ No, not applicable

Does this policy show due regard to the people in the local community? Due regard: This means to give a fair consideration to and give sufficient attention to all of the facts (Law Dictionary: Black's Law Dictionary, 2014) ☐ Yes, please state: ☒ No, please state: Policy only applies to CCG staff, visitors and contractors.

Page 431 Page Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 20 of 24

Section 4: Risk assessment Please identify any possible risk for staff, visitors, contractors and / or the Clinical Commissioning Group if the policy is implemented without amendment. All risks will be monitored for trends and provided to the policy author when the policy is due to be reviewed.

Implementation risk: consequence score Domain Insignificant Minor Moderate Major Catastrophic Impact on the Minimal injury Minor injury Moderate injury Major injury leading Incident leading to safety of staff or requiring or illness, requiring to long-term death public no/minimal requiring professional incapacity/disability An event which (physical/psychol intervention or minor intervention Mismanagement of impacts on a large ogical harm) treatment. intervention RIDDOR/agency patient care with number of patients reportable incident long-term effects An event which impacts on a small number of patients Complaints/audit Informal Formal Formal complaint Multiple complaints/ Inquest/ombudsman complaint/inquiry complaint (stage 2) complaint independent review inquiry (stage 1) Local resolution Low performance Gross failure to Local (with potential to rating meet national resolution go to independent Critical report standards Single failure review) Severely critical to meet Repeated failure to report internal meet internal standards standards Reduced performance rating if unresolved Statutory duty/ No or minimal Breech of Single breech in Multiple breeches in Multiple breeches in inspections impact or breech statutory statutory duty statutory duty statutory duty

Page 432 Page Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 21 of 24

of guidance/ legislation Challenging Enforcement action Prosecution statutory duty. Reduced external Low performance Zero performance performance recommendations/ rating rating For example: rating if improvement Critical report. Severely critical unsatisfactory unresolved. notice. report. patient For example: a experience which For example: For example: a major impact on For example: a is not directly a minor moderate impact people with a catastrophic impact related to patient impact on on people with a protected on people with a care. people with a protected characteristic has protected protected characteristic has been identified. characteristic has No action characteristic been identified. Consideration been identified that required. has been should be given to may lead to litigation identified that This can be remove the policy or impact on patient was agreed resolved by from the website safety. to be making and review it accepted amendments to immediately. The policy should within the the policy or Q. Can we make be removed from scope of the providing an amendments to the the website and policy. objective policy or provide reviewed justification for not objective immediately. No action amending the justifications? required. policy (This must If yes, this must be be published with published with the the policy and policy and EIA. EIA). If no, the policy should be removed from the website and reviewed immediately. Adverse Rumours Local media Local media National media National media publicity/ Potential for coverage coverage coverage <3 days coverage >3 days

Page 433 Page Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 22 of 24

reputation public concern short-term Long-term service well below MP concerned reduction in reduction in public reasonable public (questions in the public confidence expectation House) confidence Total loss of public Elements of confidence public expectation not being met Business Insignificant cost <5 per cent 5–10 per cent over Non-compliance Incident leading >25 objectives/ increase over project project budget with national 10–25 per cent over project projects No impact on budget per cent over project budget objectives Minor impact budget Failure of strategic on delivery of Major impact on objectives impacting objectives delivery of strategic on delivery of objectives business plan Finance Small loss Risk of Loss of 0.1– Loss of 0.25–0.5 Loss of 0.5–1.0 per Loss of >1 per cent including claims claim remote 0.25 per cent per cent of budget cent of budget of budget of budget Claim(s) between Claim(s) between Claim(s) >£1 million Claim less £10,000 and £100,000 and £1 than £10,000 £100,000 million

Page 434 Page Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 23 of 24

Implementation risk: likelihood score Rare Almost Unlikely Possible Likely Certain Frequency: Not expected Expected to Expected to Expected to Expected to How often to occur for occur occur monthly occur weekly occur daily might it/does it years annually happen? Probability <1% 1-5% 6-20% 21-50% >50% Will only occur Unlikely to Reasonable Likely to More likely to in exceptional occur chance of occur occur than not circumstances occurring occur

Risk matrix Rare Unlikely Possible Likely Almost certain Negligible 1 2 3 4 5 Minor 2 4 6 8 10 Moderate 3 6 9 12 15 Major 4 8 12 16 20 Catastrophic 5 10 15 20 25

Risk score on draft policy Risk score on finalised policy Score = 6 Score = What are the key reasons for the change in the risk score?

Page 435 Page Health and Safety Policy NHS Chorley and South Ribble CCG May 2019 Page 24 of 24

This page is intentionally left blank Agenda Item 17

Governing Body Meeting

Date of meeting 25 September 2019 Title of paper Audit Committee Update Presented by Mrs Linda Chivers, Audit Committee Chair Author Mrs Linda Chivers, 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 6 September 2019 and on any work undertaken by committee members outside of the meeting.

Executive summary The minutes of the meeting held on 28 June 2019 are attached for information. The key points from the meeting on 28 June were presented to the Governing Body on 24 July 2019.

The report on the meeting held on 6 September outlines the key decisions made, the assurances sought and any key risks that were identified.

The Audit Committee recommends the revised Freedom of Information Policy to the Governing Body for approval.

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 Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 437 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 ☐ ☐ ☒ register? Yes No N/A 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 Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 438 1.0 Introduction

1.1 The Governing Body papers include the approved minutes of the meeting held on 28 June 2019. The key points from the meeting on 28 June were reported on at the Governing Body meeting on 24 July 2019. This report covers the meeting held on 6 September 2019.

1.2 Governing Body members are asked to note that the Chorley and South Ribble CCG Audit Committee meeting on 6 September was not quorate from item 7 (GBAF and Corporate Risk Register) onwards. The Chorley and South Ribble Audit Chair would share collective views of both Chorley and South Ribble and Greater Preston CCG Audit Committees on those items which required a decision.

2.0 Decisions

2.1 The Committee reviewed the Freedom of Information Policy, which has been refreshed in line with the CCG policy review process. There were no legislation changes that impact the policy. The changes reflected updated CCG contact details and the inclusion of previous FOI responses on the CCG website under the Publication Scheme which helps the CCG in signposting requests to previous FOIs where appropriate. The committee received assurances that the Patient Voice Committee looks at the volume of the requests and any trends and receives assurance that we use exemptions and exceptions properly. The Committee recommends the Freedom of Information Policy for approval.

2.2 The Committee reviewed the Whistleblowing Policy and agreed to defer recommendation of the policy until November 2019 to allow for further detail to be included following executive support including whether information about Caldecott arrangements should be included in the policy.

2.3 The Committee approved the proactive exercise which is to be undertaken by Counter Fraud Services. A decision was made to use Personal Health Budgets for the proactive exercise.

3.0 Assurances

3.1 The Committee received a presentation from the Director of Transformation and Delivery on a deep dive into GBAF04 – Integrated Care Partnership (ICP) delivery and accountability. The presentation included the current status and long term plan for ICP delivery and accountability, including progress against the Five Year Forward View and the governance arrangements in place to oversee the delivery of transformation. This risk was not included on the Corporate Risk Register as the CCG was confident that the risks concerned can be mitigated. The risk had been reframed to reflect all of our system partners and the links between the CCG, ICP and ICS in delivering our strategic responsibilities.

3.2 With regard to the deep dive into GBAF04, the Committee sought assurances around capacity including drawing sufficient capacity from our partners and

Audit Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 439 ensuring that all partners understand and share with staff the strategic and operational priorities of the ICP. The committee also sought assurances in relation to how the Joint Strategic Needs Assessment informs plans and how the Memorandum of Understanding links to the Integrated Care System. Governing Body Members may wish to consider the challenge posed to the Director of Transformation and Delivery in her role as SIRP for the WHIN platform whilst not being a member of the ICP Board.

3.3 The Committee continues to seek assurances that the risks relating to the prescribing of opioids are being mitigated. This risk relates to potential for patient harm and financial risk to the organisation if we do nothing to address the issue, and would be kept open on the GBAF and updated following a discussion between the Director of Finance and Contracting and the Director of Quality and Performance. Although assurance was given at the Clinical Effectiveness Committee that the risk is being mitigated, there would be no evidence of this until the internal audit by the Medicines Management Team is repeated. It was suggested by the committee that the CCG should identify and address the outliers first, and to look at benchmarking across other organisations and what alternative medicines are available. There was a further concern that this risk was not picked up until the Audit Committee identified the risk. The Governing Body will wish to note that there is conflict for GPs who prescribe the opioids. The committee noted that MLCSU has oversight of prescribing issues through the Medicine Management Team.

3.4 The Committee discussed the recruitment to GP Director vacancy under GBAF03 – Well Led as Chorley and South Ribble CCG has an ongoing vacancy and has not received enough Expressions of Interest. Audit Committee members noted that the CCG will be able to quantify the issue and challenge any issues once the election process has closed.

3.5 The Committee received a verbal update from Grant Thornton, External Audit colleagues who are leading the audit for the CCG on the Mental Health Investment Standard (MHIS). The work is split across two levels. These are a walkthrough of MHIS including sampling of specific areas, and conclusion of this work if there are any issues. Grant Thornton have access to a moderation process through a national panel to take any issues. Grant Thornton confirmed that there are currently no issues. The final report would be presented to Audit Chairs for approval under Chairs Action prior to submission to the Governing Body in September 2019.

3.6 The committee received assurance from Grant Thornton in the delivery of external audit services. External Audit colleagues provide health sector updates which Grant Thornton feel are relevant to CCGs and that they are being considered and addressed by the CCG.

3.7 The Committee received a report on the annual review of the effectiveness of external audit services. The survey asked those respondents to consider how assured they are with the external audit service. Overall the survey showed that the majority of respondents have a mostly ‘very high’ level of satisfaction with the external audit service. There were no negative comments received.

3.8 The Committee received an update report on progress against the Internal Audit Plan for 2019/20. KPMG have recommended a framework to improve recruitment

Audit Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 440 and selection processes for Governing Body members, Clinical Advisors and Apprentices. KPMG gave an update on the Quality Assurance and Performance Monitoring audit, which had received an assurance rating of Significant Assurance, and have identified good practice across the quality assurance system. The recommendation relates to working towards an ICP approach for quality assurance, including that systems and functionality processes such as the Integrated Board Report and Aristotle which will need to be compatible for wider ICS partnership working.

3.9 The Committee received an update from KPMG on developments in the health sector. Where actions are required by the CCGs these were highlighted.

4.0 Information

4.1 As the Counter Fraud Specialist was unable to attend the meeting due to bereavement, the Committee received the Anti-Fraud Progress Report and agreed to defer the discussion on this item. A report on the annual review of the effectiveness of counter fraud services was also received and deferred until November 2019.

4.2 The Committee received the Corporate Registers, noting that there have been no new entries on the Hospitality, Sponsorship and Gifts Register, the Procurement Decisions Register and the Losses, Write-offs and Special Payments Register. There were two new entries on the Tender Waivers Register. The Committee received assurances with regard to the process and decision to award contracts under single tender waiver procedure with regard to Weight Management Service and Dermatology Service.

5.0 Audit Committee Chair Update

5.1 The Audit Committee Chairs reported on their recent activities. Mrs Chivers has been involved in the GP Director and Chair recruitment processes for Chorley and South Ribble CCG. There had been a number of concerns regarding conflicts of interest and processes which Mrs Chivers has fed back to CCG managers. All concerns raised had been reviewed, investigated and responded to.

5.2 Mr Cherry, Greater Preston CCG Audit Chair continues to attend ICS Board meetings. He reported on difficulty in decision making and a genuine concern about where finances should sit within the ICS.

5.3 Committee members met informally after the Audit Committee meeting to consider the outcomes and decisions made.

Mrs Linda Chivers, Audit Committee Chair Chorley and South Ribble CCG September 2019

Audit Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 441

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Chorley and South Ribble CCG Audit Committee Minutes Friday, 28 June 2019, Board Room 1 - Chorley House, Lancashire Business Park, Centurion Way, Leyland PR26 6TT at 9.30 am

Present Mrs Linda Chivers, Audit Committee Chair (Chair) Mr Paul Richardson, Lay Member Governance (representing Chorley and South Ribble and Greater Preston CCGs)

In Attendance Mr Ian Cherry, Audit Committee Chair, Greater Preston CCG Mrs Debbie Corcoran, Lay Member Patient and Public Involvement, Greater Preston CCG Mr Tim Cutler, Partner, KPMG Mr Matt Gaunt, Director of Finance and Contracting Mrs Lynne Johnstone, Audit Manager, Grant Thornton Mrs Sarah Mattocks, Corporate Affairs and Governance Manager Mrs Anne Whittle, Corporate Business Manager (minutes)

1 Introduction Mrs Chivers welcomed everyone to the meeting. The committee expressed condolences to Mr Gizzi who was unable to attend the meeting due to a family bereavement.

2 Apologies for Absence Apologies for absence were received from Mr Geoffrey O'Donoghue, Lay Member Patient and Public Involvement and Mr Denis Gizzi, Chief Officer.

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. Audit Chairs expressed thanks to Mr Cutler for submitting his declaration. Although not a requirement this was helpful for the committee. There were no other declarations of interest.

4 Minutes of Previous Meeting Both Audit Committees reviewed the minutes of the Audit Committee meetings held on 3 and 21 May 2019.

Minutes 3 May 2019 Chorley and South Ribble and Greater Preston CCGs Item 6 - GBAF and Corporate Risk Register Page 11 of ModGov papers, last bullet point should read “… received relating to Procedures with Low clinical Value …”.

Item 9 – Responses from Management and those charged with Governance Second sentence should read “The letters to Grant Thornton provided a response to a series of questions from External Auditors to the Chief Finance and

Page 443 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting held on 28 June 2019 Contracting Officer and the Audit Chairs …”.

Item 13 – Information Governance Annual Report and Toolkit Third paragraph, last sentence should read “… following a meeting with the Chorley and South Ribble CCG Audit Chair …”.

Minutes 21 May 2019 Chorley and South Ribble CCG The minutes were accepted as an accurate record.

Minutes 21 May 2019 Greater Preston CCG The minutes were accepted as an accurate record.

Resolved That the minutes from the meetings held on 3 May 2019 for both CCGs were accepted as a correct record, subject to the above corrections, and the minutes from meetings held on 21 May 2019 for each CCG were accepted as a correct record.

5 Matters Arising Audit Committee members accepted those items which were identified as complete and updates where actions were not complete. The committee accepted the following additional updates:

CSR & GP AC190301-13 Anti-Fraud Work Plan for 2019/20 Mr Gaunt has put a number of suggestions for the next anti-fraud proactive exercise to be undertaken to Mr Bell, Counter Fraud Specialist who would provide an update on those suggestions to the Audit Committee meeting on 6 September 2019, when the committee would be asked to make a decision as to which exercise to take forward.

CSR & GP AC 190503-11 Internal Audit Progress Report The first two actions were complete. The CHC Lead has been recruited to the CCG. The third action related to invoices received before purchase orders raised and would be picked up under the Internal Audit update.

CSR&GP AC 190521-03 External Audit Report Mrs Johnstone confirmed that Grant Thornton will provide an update report on the Mental Health Investment Standard to the Audit Committee on 6 September, and a final report to Audit Chairs by 12 September for sign off under Chairs Action by 13 September, prior to submitting to the Governing Body meetings at the end of September. Audit Committee members noted the tight timeframe and that there is a requirement to include the document in the CCG’s Annual Report. This action was now completed.

Resolved That the Committee noted the updates provided and approved the closing of all actions assessed as complete.

6 Single Tender Waiver Process Mr Gaunt presented a report which provided details to support the Single Tender Waivers that were presented at the Audit Committee on the 3 May 2019 to demonstrate that they were approved in line with the Single Tender Waiver procedure. The paper focused on the aspects discussed at the meeting on 3 May,

Page 444 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting held on 28 June 2019 to offer assurance to the committee around compliance with procurement regulations and making a judgement based on balancing the procurement risks against the operational risks and the interest of the patients, that the approval of the recent waivers was based on sound judgement and reasonable grounds.

Mr Gaunt drew attention to Appendix 1 of the report, which was the Single Tender Waiver process checklist, which has been developed to ensure a high level of disclosure in future and provide assurance that process has been followed. Mr Cutler gave additional assurance as Internal Auditors that the checklist was robust and that how it is used was key.

In reply to a comment that the evidence and efficacy shown around the current contract in the document was weak, Mr Gaunt offered to provide an addendum which includes details for the current provider and how performance reflects against those measures. For example “Referral To Treatment the CCG expects that the service will be …”.

Mr Gaunt explained that he had asked the Procurement Manager to establish a planned approach to procurement of services. Audit Committee members noted that the decision to procure is prior to the stage of submitting the Single Tender Waiver to the Audit Committee.

In reply to a concern about the timescale for this particular contract which was due at the end of March i.e. financial year end, Mr Gaunt gave assurance for future Single Tender Waivers that the process has been strengthened by using a trigger system when a contract is due to expire to give assurance regarding future Single Tender Waivers. The committee expressed thanks to KPMG colleagues for looking at the process checklist.

Resolved That the Committee noted the additional details provided in relation to the Single Tender Waivers; and noted that for any future Single Tender Waivers the checklist will be used as part of the sign off process to ensure all required details are covered within the Single Tender Waiver report.

7 Governing Body Assurance Framework and Corporate Risk Register Mrs Mattocks presented an update report to the Audit Committee on the Governing Body Assurance Framework (GBAF) and Corporate Risk Register (CRR). The report also provided an update on the development of a risk register for the Integrated Care Partnership. The following comments were received.

GBAF • With regard to risks 1 and 3, which relate to Quality, Safe and Effective Services and Well Led, and the proposal to merge the two CCGs, should the votes decide against a merger, might a risk assessment be worthwhile to look at the implications of the other options available to make the 20% reduction in administration costs? Mr Gaunt confirmed that the risk would be for the next financial year as this is when the result would come to fruition. • Mr Cherry commented on a report which he had received in his role on the ICS Board that Blackpool hospital has over 40 CQC Inspectors currently on site. Given that cardiac patients from Greater Preston, Chorley and South Ribble were referred to the hospital it was felt this should be identified as a

Page 445 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting held on 28 June 2019 risk. Mr Gaunt would ask the Head of Quality and Performance how our CCGs are sighted on other providers in the wider area. Mr Cherry added that this is a system wide matter. • That the references to CQC currently undergoing an unannounced visit needs to be re-worded to reflect that LTH is undergoing the assessment and CQC undertaking it.

Corporate Risk Register There were three ongoing risks on the Corporate Risk Register with changes to these risks highlighted in the document since last reported to the Audit Committee. The risks related to RTT and 52 week trajectory, Continuing Health Care (CHC) patients in receipt of domiciliary healthcare, and a risk that the CCG is not in a position to meet NHS England’s requirement to be able to offer Personal Health Budgets to all new Homecare packages from 1 April 2019.

Mr Cherry advised the committee that he has received a report following questions raised at Greater Preston Governing Body meeting confirmed that more than 62% of our GPs are prescribing more than twice the recommended amount of opioids than other GPs in the wider footprint. He asked whether this was a risk that should be included on the CCG Corporate Risk Register. Mr Gaunt would discuss this matter with the Head of Quality and Performance. Mr Cherry was concerned that there were conflicting reports around the CCG practices prescribing of opioids. Mr Gaunt confirmed that he will look into the reporting of the Medicines Management Committee and Clinical Effectiveness Committee into the Governing Body. It was also agreed that this item would be discussed at the next Quality and Performance Committee meeting.

In reply to a question about whether the CCG is satisfied with the level of coverage on the risk register from those programmes of work that GP directors are involved in Mrs Mattocks confirmed that there is a scheme risk register whereby the risks are discussed at Stand Up Friday meetings, and that if a GP Director is working on a particular piece of work this is likely to be captured from this. Mr Cherry referred to the Greater Preston Governing Body having been given assurance around prescribing but then a contradiction through the Commissioning and Support Unit Case Study through Medicines Management and Optimisation team reporting with regard to prescribing of opiates. Aspects of those risks included patient safety and quality as well as liability for the CCG for those patients wrongly prescribed opiates and who are now addicted. There was potentially reputational and financial risk to the CCG. The Quality and Performance Committee would be asked to look into this from a quality perspective, and the Clinical Effectiveness Committee would be asked to look at in terms of compliance against clinical standards and report back to the Audit Committee. Mr Cutler commented that this was about being seen corporately to progress the action and CCG concern that the risk should be added to the Corporate Risk Register.

As the committee has identified that there may be issues around prescribing and process, it directed the Quality and Performance Committee to consider the quality aspects and the Clinical Effectiveness Committee to consider process to make sure that the Governing Body is sighted of any risks.

Audit Committee members noted that the Primary Care Commissioning Committee should also be sighted of the outcomes of discussions as the

Page 446 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting held on 28 June 2019 committee which holds GPs to account.

Mr Cherry sought assurance around any potential risks resulting from the NTW review of mental health services as this was not featured on the Corporate Risk Register. Mr Gaunt would discuss this matter with the Head of Quality and Performance. It was also agreed that this item would be discussed at the next Quality and Performance Committee.

Mrs Chivers sought assurance that more grip is applied where deadlines are passed or where extended and that reasons provided.

Integrated Care Partnership Risk Register Mrs Mattocks gave an update following the ICP Shadow Board, which engaged with Mersey Internal Audit Agency (MIAA) to support it in delivering a risk programme to members at a development session on 23 May. It was highlighted at this session that further engagement needed to be undertaken with members on a risk register before this could be developed, agreed and then utilised by the Board.

The governance leads from each ICP organisation are scheduled to meet to develop some engagement tools to be distributed to members in order that risk themes and mitigation can be identified. A full risk register will then be presented for the ICP Board to approve in the autumn.

On review of discussions at ICP Board development sessions to date the key themes that will be explored in its risk register were included in the report. As the risk register is developed this will be shared with the Audit Committee. There is also an Our Health Our Care programme risk register in place, which will be presented at the next Our Health Our Care Joint Committee meeting. The OHOC risk register will be incorporated into the ICP risk register and brought to the Audit Committee. The following comments were received.

• That the Audit Committee looks at process and wished to consider what is the level of risk that the CCG is not sighted on. • With regard to the ICP risk register, the committee considered how the CCGs hold providers / risk leads to account with the first ICP performance meeting in July.

Resolved That the Committee: 1) noted the progress with the GBAF for 2019/20; 2) noted the process used to manage the CRR; and 3) noted the process used to develop an ICP Risk Register

8 Risk Management Strategy Mrs Mattocks presented an updated Risk Management Strategy for review and recommendation to the Governing Body for approval. The strategy was updated following a risk management audit in March 2019 which was completed by KPMG and reported ‘significant assurance’ with one recommendation which was to add in a timescale for when lower scoring risks should be reviewed. Section 9.12 of the strategy has been updated to this effect. Section 3.1 has also been updated following a recommendation from an internal audit of partnership working, to include within the scope that the strategy is relevant to all matters that affect the

Page 447 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting held on 28 June 2019 CCG including transformation programmes with other organisations and hosted arrangements.

Mrs Chivers would meet outside the meeting with Mrs Mattocks to discuss some formatting changes. Mrs Chivers referred to section 7 about monitoring risks at ICP level. It was agreed to allow the development of the ICP Risk Register before suggesting or making any changes.

Audit Committee members discussed the remit of the Quality and Performance Committee under paragraph 7.5. It was agreed to add a fourth bullet point under paragraph 7.5 to include any other issues which give concern that patient safety is at risk. The monitoring and review of the strategy under paragraph 12 would be extended to include “or when good practice is identified”. The Risk Management Strategy is a rolling two year document.

Resolved That the Committee recommended the updated Risk Management Strategy for approval by the Governing Body, subject to the above amendments.

9 Information Governance and IG Handbook Updates Mrs Mattocks presented an update to the committee on key areas of the Information Governance agenda. The Data Security and Protection (DSP) Toolkit was released on 18 June and work was underway to set the delivery plan for this year. A report with the detail will be presented to the Audit Committee as the toolkit evidence progresses.

The report highlighted the work that the CSU IG team are undertaking to support the CCGs to meet their statutory requirements and combines all the elements that the DSP Toolkit requires to be routinely documented and reviewed.

The Information Governance Handbook has been reviewed and an amendment has been made to the change in name of the Data Protection Officer, which is now provided by the CSU IG Team.

Resolved That the Committee noted the amendment to the IG Handbook and the work underway on the recent submission of the DSP Toolkit update report.

10 Audit Committee Review of Effectiveness Mrs Mattocks presented the outcome of a recent survey which has been undertaken to support the review of the effectiveness of the Audit Committee, as required in the Audit Committee’s terms of reference. The survey has been circulated for completion by members of the Audit Committee, Internal and External Auditors, Counter Fraud service providers and officers who attend Audit Committee meetings and asked those respondents to consider how assured they are with the effectiveness of the Audit Committee.

Analysis of the survey results has been reviewed and was summarised in the report. The results of the survey were appended to the report for information. Audit Committee members considered the scores and focused on the low scoring areas, providing comments. The following actions were agreed.

Question 6 related to equal prominence given to both quality and financial

Page 448 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting held on 28 June 2019 assurance. It was agreed that when the Audit Committee Terms of Reference are next reviewed they should be updated to reflect the risk profile of the organisation.

Question 23 related to the Audit Committee at the end of each meeting discussing the outcomes and reflecting back on the decisions made and what worked well or not so well. It was noted that attendees may not be aware of the meeting between Audit Committee members after each meeting and it was agreed to add to the agenda that a closed session will follow the meeting to reflect back on decisions made.

Question 25 referred to whether the Governing Body challenges and understands the reporting from this committee. Audit Committee members considered whether the clinical members of the Governing Body provide enough challenge to the reporting from the Audit Committee. An action has been noted to review the committee reporting into the Governing Body. This question would be split into two for the next committee review as it was agreed that ‘understanding’ was different to ‘challenging’.

Question 36 related to whether respondents felt that the committee Chairs allow debate to flow freely and do not assert their own views too strongly. There was one score of 1 with no comment provided, even though the average score was 3.55 for this question. Committee members felt this was about style and as long as style does not hinder discussion this was acceptable.

Audit Committee members noted that some of the questions were not relevant for all respondents to answer and the questions for next year’s survey would be amended to reflect the participants, with some of the questions directed to committee members only.

Mrs Chivers asked external colleagues how they felt about their participation at committee meetings. Mr Gaunt added that our professional partners should feel able to contribute to the discussions. Both internal and external audit colleagues confirmed there were no issues and took on board the comments received.

It was noted that most of the responses throughout the survey scored a highlevel of agreement to the statements and that less than 5% of responses were negative.

It was agreed to add an additional option for future questions for ‘no opportunity to observe’.

Resolved That the Committee noted the content of the review and the comments received and agreed to the above changes to questions for next year’s survey.

11 External Audit Progress Report and Sector Update Mrs Johnstone presented a report on progress in delivering external audit responsibilities. The audit of the 2018/19 financial statements was now complete and the audit findings report was discussed at the Audit Committees on 21 May 2019. The Audit Opinions were signed off on 28 May 2019. Grant Thornton will begin work on the planning process for the 2019/20 financial year audit.

The report included a summary of emerging national issues and developments

Page 449 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting held on 28 June 2019 that may be relevant to the CCG and a number of challenge questions in respect of those emerging issues which the committee may wish to consider. Mrs Johnstone added that it is key to recognise financial pressures to focus on delivering with technology. She drew attention to articles on Medicine in Health and Social Care findings from the CQC.

Audit Committee members considered the earlier discussion with regard to ICP and ICS wide matters. A mechanism for sharing reports from health sector updates would be developed and brought back to the committee.

The committee considered the possibilities of a no deal Brexit and whether there are any models to support the practical implications of a no deal Brexit. Mr Gaunt confirmed that he receives updates via email from Professor Keith Willett, Director for Acute Care, NHS England, and informed the committee that implications will be assessed during August. Issues raised included workforce and medical supply chains. Mr Cutler added that one of the risks is around IT supplies and local risk analysis has identified potential issues around supply chain.

Resolved That the Committee noted the content of the report.

12 Internal Audit Progress Report and Sector Update Mr Cutler presented a report on progress against the internal audit plan for 2019/20. The main areas of note were the completion of follow up of previous internal audit recommendations and information in relation to soft controls which KPMG are introducing to their internal audit approach going forward. Mr Cutler drew attention to the timeframe for audits and confirmed that much of the work for Quarter 1 audits will be completed and reported on in September. Scoping for the audits in Quarter 2 will also be completed by the September meeting. There were no issues at this point in the plan.

Mr Cutler asked for the committee’s view on treatment resulting from the additional Payroll Controls review which would require an additional 8 days of audit work. Audit Chairs were mindful that the plan was already full and reviews taken out that the Audit Committee would have liked to have kept. The Committee was of the view that, if necessary, additional days would need to be added to the plan rather than remove agreed reviews. It was agreed that Mr Gaunt and Mr Cutler would discuss how the additional days would be incorporated into the plan.

Mr Cutler referred to the recommendations tracking under section two of the report, that the follow up work has been completed and of the 22 recommendations there were nine recommendations outstanding, all of which were non priority. Mr Cutler will keep the timeframe under review to make sure that deadlines are met taking into account those deadlines which have been extended.

With regard to Appendix 2 of the report which referred to KPMG looking to test some of the soft controls to be used in audits, Mr Cutler explained that this might include whether the team was under a lot of pressure, for example when purchase orders have been raised after invoices received.

The committee noted the sector update which highlighted the main technical

Page 450 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting held on 28 June 2019 issues which are currently having an impact on the health sector. The articles were flagged where KPMG believe will have an impact on the CCG with KPMG’s perspective given on the issues.

Resolved That the Committee noted the content of the report.

17 Corporate Registers Mrs Mattocks presented an update on each of the following corporate registers:

• Hospitality, Sponsorship and Gifts Register; • Tender Waivers Register; • Procurement Decisions Register; and • Losses, Write-offs and Special Payments Register.

Resolved That the Committee: 1) noted there have been 0 new entries on the Hospitality, Sponsorship and Gifts Register; 2) noted there have been 0 new entries on the Tender Waivers Register; 3) noted there have been 0 new entries on the Procurement Decisions Register; and 4) noted there have been 0 new entries on the Losses, Write-offs and Special Payments Register.

19 Chairs Update The Audit Committee Chairs reported on their activities since last reported to the Audit Committee. Mrs Chivers attended the Chorley and South Ribble CCG Membership Council meeting on 19 June when GPs were asked to consider questions about a potential merger between Chorley and South Ribble and Greater Preston CCGs. GPs also shared their views on the GP Quality Contract at the meeting.

Resolved That the Committee noted the update provided.

19 Any Other Business There was no further business to discuss.

20 Outcomes from the Meeting After the meeting Audit Committee members met informally to consider the outcomes and the decisions made at the meeting.

Date of next meeting: Friday 6 September 2019, 9.30am in Board Room 1, Chorley House

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

Page 451 Ratified Minutes of NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Audit Committee Meeting held on 28 June 2019

This page is intentionally left blank Agenda Item 18

Governing Body Meeting

Date of meeting 25 September 2019 Title of paper Joint Quality and Performance Committee Update Presented by Paul Richardson, Vice Chair Author Mrs Helen Curtis, Director 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 meetings held on 7 August and 11 September. The minutes of the July and August meetings are attached.

Executive summary

The August meeting was themed and the Committee received a presentation from the Special Educational Needs and Disability (SEND) Team. They talked the Committee through the process on how agencies co worked and details of the improvements which had been put in to place. Acknowledgement was given by the Designated Clinical Officer and Senior SEND Officer that the service needed to improve. Inspections were jointly carried out with CQC but services are not rated as CQC ratings and they receive an outcome letter. Due to the size of the geographical area changes where were necessary were underestimated and although improvements had been put in place further work was required to evidence this.

Patient Safety Strategy highlights were presented to the Committee which were launched at the Patient Safety Congress earlier in July. There is to be an annual refresh of priorities and the strategy will go to the ICP Board in October.

A presentation focussing on the Winter Pressure Deep Dive included charts and information on current performance levels, impact of winter schemes, analysis by Clinical Analysis Review Team (CART), the Oak Group report, Quality and Safety issues and the Emergency Care plan on a page. Discussion took place around possible reasons for spikes in A&E attendances, increases in numbers of, causes of and clarification of sepsis. This deep dive will be repeated at the November meeting to ensure that the ‘so what’ question is addressed more thoroughly with providers invited to attend.

The September meeting was a full business meeting. Reassurance was given that if a discharge to assess unit based in the Greater Preston area was to close there would be capacity in the community for patients being discharged. RADAR and

Joint Quality and Performance Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 453 Care Home Collaborative were reported to be improving service engagement.

Admissions to hospital in August for people with a learning disability or autism totalled 10; this is against guidelines of 2. This is despite Local Area Emergency Protocol meetings taking place in an attempt to avoid admission. Currently there are no local assessment and treatment beds available so patients are being placed out of area although four beds are currently being secured in the Macclesfield area in the interim. The Integrated Board Report detailed performance information across key national healthcare standards along with progress against the CCGs Integrated Business Plan.

Both meetings remained non quorate due to the vacant GP Director post.

Recommendations

The Governing Body is asked to note the content of the report and to approve the revised Terms of Reference for the Committee.

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 Quality and Performance 07/08/2019 A number of actions were Committee and 11/09/19 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.

Joint Quality and Performance Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 454

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 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 Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 455

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Quality and Performance Committee Minutes Wednesday, 14th August 2019, Board Room 1 - Chorley House, Lancashire Business Park, Centurion Way, Leyland PR26 6TT at 10.30am

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 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 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 (Chair) Mr Ian Cherry, Lay Member – NHS Greater Preston CCG

In Attendance Mrs Ruth Bond, Personal Assistant - Quality and Performance Team - NHS Chorley and South Ribble CCG Ms Diane Booth, Senior SEND Officer, SEND Miss Jane Brennan, Chief Nurse - NHS Chorley and South Ribble CCG and Greater Preston CCG Mrs Kate Burgess, Commissioning Delivery Manager, Urgent Care - NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mr Steve Flynn, Commissioning Delivery Manager - NHS Chorley and South Ribble CCG and Greater Preston CCG Ms Anne Hardman, Designated Clinical Officer, SEND Mr Glenn Mather, Associate Director for Performance and Effectiveness – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mrs Ruth Trevena, Locality Information Lead, Business Intelligence – NHS Midlands and Lancashire Commissioning Support Unit

1 Welcome and Apologies for Absence

Mr Richardson welcomed the Committee Members. It was acknowledged the Committee was not quorate. No decisions were to be voted on.

Apologies were received from Mr Matt Gaunt, Chief Finance Officer - NHS Chorley and South Ribble CCG and NHS Greater Preston CCG

Minutes of Quality and Performance Committee Quality and Performance Committee 11 September 2019 Page 457

2 Declarations of Interests

There were no conflicts of interest outside those noted in the routine submission. Mrs Curtis advised her daughter is a Manager at Lancashire Teaching Hospital Trust, no decisions or voting were required at this meeting.

3 Minutes of previous meeting

Amendment required to the Opioid section, to better reflect the robust discussion by the Committee. Minutes of the previous meeting otherwise were agreed as accurate and correct.

4 Matters arising

Follow-up audit regarding Opioid prescribing to be added. There were no other outstanding matters arising.

5 Special Educational Needs and Disability (SEND)

The Committee received a presentation on Special Educational Needs and Disability from Ms Anne Hardman, Designated Clinical Officer and Ms Diane Booth, Senior SEND Officer. Explanation was given on how agencies co worked and improvements that had been put in to place.

The Committee raised concern regarding the significant issues discovered on their last inspection. It was explained that the inspection report was accurate and the service needed to improve. Inspections, although jointly carried out with CQC, are not rated as CQC ratings and services receive a letter with the outcome. A new Act was introduced in 2014 and although processes should have been reviewed at that time they had actually remained the same. Due to the size of the geographical area changes had been underestimated. Although improvements had been put in place, further work was needed to evidence this.

The Committee thanked Ms Hardman and Ms Booth for the presentation and they left the meeting.

Action: Presentation to be distributed to Committee members – Mrs Bond

6 Patient Safety Strategy

The Patient Safety Strategy highlights were presented to the Committee. These were launched at the Patient Safety Congress earlier in 2019. Confirmation was given that a draft ICP Continuous Improvement Strategy was in development although this had been paused and rephrased to Patient Safety Strategy – ICP. There is to be an annual refresh of priorities and the strategy will go to the ICP Board in October.

Minutes of Quality and Performance Committee Quality and Performance Committee 11 September 2019 Page 458 Question was raised in relation to Primary Care reporting of safety and quality issues and whether there were plans to support Primary Care colleagues where clinical or patient safety issues were identified. Mr Cherry raised a query that some areas of patient safety had not been highlighted or mentioned for example risk tolerance and stratification of priorities across organisations responsible for patient safety. It was agreed that a further paper would be brought back to the next thematic QPC meeting in October outlining the implications for our health economy at ICS, ICP & CCG levels.

Action: Presentation and link to Patient Safety Strategy to be distributed to Committee members – Mrs Bond

Action: Further paper to be presented at October QPC meeting – Mrs Curtis

7 A&E Winter Pressure Deep Dive

Mr Mather presented the A&E Winter Pressure Deep Dive. This included charts and information on current performance levels, impact of winter schemes, analysis by Clinical Analysis Review Team (CART), the Oak Group report, Quality and Safety issues and the Emergency Care plan on a page.

A discussion took place around possible reasons for spikes in A&E attendances, increases in numbers of, causes of and clarification of sepsis.

Mr Cherry enquired if A&E admissions correlated with four hour breaches. It was confirmed the CART process was beginning to look in to this. Mr Cherry also questioned if data was available as to why people attended A&E, how many received no treatment and how many could have been treated elsewhere. It was agreed that it would be of greater value to the committee if the copious data presented could be analysed and interpreted further to provide more succinct business information.

Action: Presentation to be distributed to Committee members – Mrs Bond

8 Any other business

None.

Date of next meeting: Wednesday, 9th October 2019

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

Minutes of Quality and Performance Committee Quality and Performance Committee 11 September 2019 Page 459

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Quality and Performance Committee Minutes Wednesday, 10th July 2019, Board Room 1 - Chorley House, Lancashire Business Park, Centurion Way, Leyland PR26 6TT at 10.30am

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 Mr Matt Gaunt, Chief Finance Officer - 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 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 (Chair) Mr Ian Cherry, Lay Member – NHS Greater Preston CCG

In Attendance Mrs Ruth Bond, Personal Assistant - Quality and Performance Team - NHS Chorley and South Ribble CCG Miss Jane Brennan, Chief Nurse - NHS Chorley and South Ribble CCG and Greater Preston CCG Miss Wendy Hope, Effectiveness and Innovation Specialist (Clinical) - NHS Midlands and Lancashire Commissioning Support Unit Mr Glenn Mather, Associate Director for Performance and Effectiveness – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mrs Clare Moss, Head of Medicines Optimisation, NHS Midlands and Lancashire Commissioning Support Unit Mrs Heather Myers, Quality and Performance Specialist - NHS Midlands and Lancashire Commissioning Support Unit Mrs Emma Orton, Continuing Healthcare and Individual Patient Activity Clinical Lead - NHS Chorley and South Ribble CCG and Greater Preston CCG

1 Welcome and Apologies for Absence

Mr Richardson welcomed the Committee Members. It was acknowledged the Committee was not quorate. No decisions were to be voted on.

Apologies were received from Mrs Tricia Hamilton, Governing Body Nurse - NHS Chorley

Minutes of Quality and Performance Committee Quality and Performance Committee 14 August 2019 Page 461 and South Ribble CCG and NHS Greater Preston CCG

2 Declarations of Interests

There were no conflicts of interest outside those noted in the routine submission. Mrs Curtis advised her daughter is a Manager at Lancashire Teaching Hospital Trust, no decisions or voting were required at this meeting.

3 Minutes of previous meeting

Minutes of the previous meeting were agreed as accurate and correct. They could not be formally ratified as the Committee was not quorate.

4 Matters arising

There were no outstanding matters arising.

5 Quality Visit Reports – Ramsay Healthcare and Lancashire Care Foundation Trust

Miss Hope and Mrs Myers joined the meeting and presented quality visit reports for Ramsay Healthcare and Lancashire Care Foundation Trust.

Euxton Hall Hospital was the focus of the quality visit with Ramsay Healthcare. There has been a recent appointment of a Head of Clinical Services which replaced the Matron role. Areas covered included theatres, ward, diagnostics and out patients. The visit was very positive and they received good patient experience stories. Out patients was very busy with five clinics running smoothly. The team found that theatres had improved and were running at full capacity. Staff were willing to talk to the team and felt well supported by managers.

The Lancashire Care Foundation Trust report covered District Nurse services in Clayton Brook and Leyland area and the Buckshaw Team who were covering out of hours. The quality visit was jointly undertaken with Lancashire Care Foundation Trust and this particular service was chosen due to staffing levels and incidents that have been reported. Staff took the opportunity to discuss adverse discharges and a review of documentation identified gaps, these are being addressed jointly between Lancashire Teaching Hospitals Trust, North West Ambulance Service, Local Authority and Lancashire Care Foundation Trust. A question was raised whether the increase in adverse discharges had a connection with the rise in numbers of readmissions. Miss Brennan to supply adverse discharge figures to Mrs Mellor.

There was a concern for safety for evening staff as they did not have the facilities to use as a base often leaving them to wait in their vehicles. Consideration is being given for out of hours staff to co-locate with out of hours GP’s. Issues were also raised regarding IT and connectivity which has caused some members of staff giving their own personal numbers to end of life patients in order to reduce

Minutes of Quality and Performance Committee Quality and Performance Committee 14 August 2019 Page 462 their stress of trying to contact them.

Miss Hope and Mrs Myers left the meeting.

Action: Miss Brennan to forward adverse discharge figures to Mrs Mellor.

6 Opioid Prescribing

Mrs Moss joined the meeting to present an Opioid Prescribing paper. This was a two year case study started in 2017 focussing on Opioid prescribing across the Greater Preston and Chorley and South Ribble GP footprint. The case study looked at prescribing of Opioids within and above national guidance parameters.

Guidance indicates that Opioids prescribed at 120mg and above per dose was not clinically effective against pain. Practices found prescribing above these levels were visited by a member of the Medicines Optimisation Team and training was given. A recent re-audit showed a small decrease in prescribing at the higher end (180mg – 240mg) and there is plan this year for this to reduce.

A robust discussion took place within the Committee and whilst an improvement was noted in some areas and the national contact indicates that this is an issue in other areas, the committee nonetheless raised concerns about the level of overprescribing which clearly still existed in our CCGs’ areas and agreed that this should be included in the relevant risk registers.

A request was made to include opioid reduction in the GP quality contracts and this will be considered.

A further re-audit will be taking place to monitor prescribing.

Action: Re-audit to monitor opioid prescribing – Mrs Moss

7 Transforming Care

The report indicated that although discharges have been going ahead it has not been possible to prevent admissions. Lancashire and South Cumbria are presently meeting targets and timescales in relation to holding Care Treatment Reviews (CTRs). Due to issues at Whorlton Hall, it has been reported that NHSE will be requesting CTRs to be carried out every three months rather than every 6 months, which will require twice the resources to deliver. NHSE have also requested regular quality reviews for all individuals placed out of area.

8 Care Homes

The report confirmed the position of care homes. Springfield Manor Gardens has now had the suspension lifted and is open to staggered admissions. Swansea Terrace has recently had a CQC rating of good. Withy Grove is now closed and a review of the residents who have moved has been requested to ensure they are

Minutes of Quality and Performance Committee Quality and Performance Committee 14 August 2019 Page 463 safe. 67% of care homes within Lancashire are rated good, there has been a reduction in reported pressure ulcers due to the ongoing react to red training and there is a new campaign being launched around nutrition which is also a campaign recognised by NHSE.

9 Serious Incidents

A single item QSG for Lancashire Teaching Hospitals Trust has taken place due to the number of reported Never Events. Attendees to the first part of the meeting included NHSE/I, Spec Com, CQC and CCG. Lancashire Teaching Hospital Trust attended the second part although it was noted the Medical Director was not present. A review of neuro theatres by Royal Colleges has found nothing in relation to culture. Issues relating to general theatres will be raised at the September Improvement Board.

Lancashire Teaching Hospital have completed a deep dive in to all reported never events over the previous two years. A report and action plan has been produced although further work is required along with the offer of support from Bolton Hospital NHS Foundation Trust to facilitate shared learning and improvement. A forensic investigation has been commissioned by the Trust to review all Never events and the Executive Team have appointed a chair to lead on the progress of the review and findings.

The CCG undertook a review of the reported never events utilising human factors methodology and the findings were shared with NHSE/I at the Serious Incident Quality Surveillance Group.

The Committee discussed the omission in the report of an issue at Blackpool Victoria Hospital where a number of patients from our areas attend for treatment. It was agreed that future reports will include reference to a wider context if issues exist in other Trusts where any of our patients were receiving care.

Action: Miss Brennan to circulate LTHTr paper

10 Continuing Healthcare and Individual Patient Activity update

Mrs Emma Orton delivered detailed report on Continuing Healthcare (CHC) and Individual Patient Activity (IPA) to the Committee at local level and also at ICS level. Fast tracks (evidence of rapid deterioration and affect/prognosis by clinician) within mental health have been on the increase. Discussion is needed around EMI Nursing Homes and the level of care required when accepting patients. It has been found that some homes are more willing to take bedbound patients with challenging behaviour on intervention rather than mobile patients with challenging behaviour and who are at risk of falls. A neighbouring CCG is demonstrating better performance; this is potentially due to them having an in- house team and a different population and historic relationship with the local authority.

Minutes of Quality and Performance Committee Quality and Performance Committee 14 August 2019 Page 464

11 Integrated Board Report

A revised version of the Integrated Board Report was presented to the Committee. The new version continues to ensure the reporting against constitutional standards and the Improvement and Assessment Framework but streamlines the report to assist with reducing the workload on teams. Dashboards are included along with the incorporation of the exception report. Appendix one attached to the report is a dashboard from Aristotle which is the information the ICP is receiving and is developed from assurance.

The Committee requested a possible review of the order of the IBR contents.

12 GBAF

GBAF01 to be revised to include Opioid Prescribing and the current inspection / investigation at Blackpool Victoria hospital

Action: Mrs Curtis to redraft.

13 Any other business

None.

Date of next meeting: Wednesday, 14th August 2019

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

Minutes of Quality and Performance Committee Quality and Performance Committee 14 August 2019 Page 465

This page is intentionally left blank Agenda Item 19

Governing Body Meeting

Date of meeting 25 September 2019 Title of paper Primary Care Commissioning Committee Update Presented by Mr Paul Richardson, Lay Member Author Mrs Jill Truby, Committee Secretary Clinical lead Dr Lindsey Dickinson, GP Director Confidential No

Purpose of the paper This paper is intended to provide the Governing Body with a summary of key decision made by the Delegated Commissioning Committee.

Executive summary The Delegated Commissioning Committee met in September 2019. The meetings were held in public. The minutes of that meeting have not yet been ratified.

The items considered at the meeting included:- • Quarterly Contractual Changes • GP Quality Contract: Performance 2018/19 • Station Surgery • Application for merger Adlington Medical Centre

The ratified minutes of the meeting held on 5 June 2019 are attached.

Recommendations The Governing Body/Committee is asked to receive the minutes and update.

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

Delegated Commissioning Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 467

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: 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 N/A description and reference number

Assurance Delegated Commissioning Committee

Delegated Commissioning Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 468

Chorley and South Ribble CCG Primary Care Commissioning Committee Minutes Wednesday, 5 June 2019, Board Room - Chorley House, Lancashire Business Park, Centurion Way, Leyland PR26 6TT at 2.30 pm

Present Mr Paul Richardson, Lay Member Governance (Chair) Dr Eamonn McKiernan, Secondary Care Doctor Mrs Tricia Hamilton, Governing Body Nurse Mrs Linda Chivers, Lay Member, Chorley and South Ribble CCG Mr Matt Gaunt, Chief Finance and Contracting Officer Mr Denis Gizzi, Chief Officer

In Attendance Dr Gora Bangi, Chair of NHS Chorley and South RIbble CCG Dr LIndsey Dickinson, GP Director Dr Sumantra Mukerji, Chair of NHS Greater Preston CCG Dr Hari Nair, GP Director Mrs Debbi Corcoran, Lay Member, Greater Presotn (arrived 2:45 pm) Mrs Jayne Mellor, Director of Transformation Planning and Delivery Mrs Donna Roberts, Head of Primary and Elective Care Ms Lysa Hasler, NHS England Mrs Jill Truby, Committee Secretary

Members of the Public There were 4 members of the public present

1 Welcome and apologies for absence As Chairman of the meeting, Mr Paul Richardson welcomed everyone to the meeting in common of the Primary Care Commissioning Committees of Chorley and South Ribble CCG and Greater Preston CCG.

Apologies for absence were received from Mr Ian Cherry, Mr Geoffrey O’Donoghue and Ms Helen Curtis.

Quorum The meeting was quorate.

2 Declarations and Register of Interests Mr Richardson 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 members of the Primary Care Commissioning Committee are listed in the CCGs’ Register of Interests. The Register is available either via the secretary

Minutes of Chorley and South Ribble CCG Primary Care Commissioning Committee 5 June 2019 Page 469 to the governing body or the CCGs’ websites at the following link: http://chorleysouthribbleccg.nhs.uk/about-chorleysouthribbleccg/who-we-are/our- governing-body/

GP directors made the usual GP declaration as providers of services.

Chorley and South Ribble CCG Primary Care Commissioning Committee resolved: • Declarations of Interests were noted

3 Minutes of previous meeting The minutes of the meeting held on 3 April 2019 were agreed as an accurate record subject to the following amendment:

Item 9 Primary Care Financial Budget 2019/20 – paragraph 6 should read……… “A question was raised in regards to the care home model and how this supports practices with specialised care homes where patients with complex medical issues live such as a hostel served by the Berry Lane practice.”

The minutes of the meeting held on 16 May 2019 were agreed as an accurate record.

4 Matters arising April minutes – Item 5 Memorandum of Understanding Helen Curtis to confirm the mechanism to report and review complaints.

5 Network DES Registration confirmation

Mrs Donna Roberts presented the report which summarised the Networks across both CCGs and detailed the next steps which are being taken by the Networks to ensure their registration is confirmed.

A Primary Care Network consists of groups of general practices working together with a range of local providers, including across primary care, community services, social care and the voluntary sector, to offer more personalised, co-ordinated health and social care to their local populations.

Primary Care Networks were required to submit an initial Network Agreement by 15 May 2019, as part of the registration process for the Network Contract Directed Enhanced Service. By the specified date the CCGs received initial registration from nine Primary Care networks which cover 100% of practices across both CCGs.

Mrs Roberts explained that the geographic coverage of the Primary Care Network is up to the member practices to decide through discussions with their colleagues and neighbours. The only involvement of the CCG in this process should be when there are gaps in the total Primary Care Network coverage of their area. The Network area must cover a boundary that makes sense to its: (a) constituent members (b) other community based providers who configure their teams accordingly and (c) the local community, and would normally cover a geographically contiguous area.

In response to a question Mrs Roberts confirmed that patients would normally expect to travel for specialised services.

A question was raised as to the process of engaging with patients on how services were developed and was there a mechanism in place to ensure networks were delivering a quality of service. Mrs Roberts confirmed that feedback would be sought through activity

Minutes of Chorley and South Ribble CCG Primary Care Commissioning Committee 5 June 2019 Page 479 reports and via the practices Patient Participation Groups.

Chorley and South Ribble CCG Primary Care Commissioning Committee: • Noted the report and the CCG’s decision to approve the Primary Care Networks.

6 Quarterly Contractual Changes Ms Lysa Hasler presented the paper which provided the committee with a summary of the contractual changes that were effective during the previous quarter January – March 2019.

Chorley and South Ribble CCG Primary Care Commissioning Committee: • Noted the contractual changes

7 Summary of the Changes to the Policy Guidance Manual 2019/2020 Mrs Donna Roberts presented the changes which NHS England have made to the Primary Medical Care Policy and Guidance Manual for 2019/20.

The Policy Book was published in January 2016 to provide commissioners with guidance on the process of primary care contractual management and changes.

In 2017, NHS England released the Primary Medical Care Policy and Guidance Manual (PGM) which expanded the Policy Book guidance and included templates for commissioners to use when considering a range of contractual changes.

NHS England committed to review the Primary Medical Care Policy and Guidance Manual each year to include its use, application and taking into account any feedback received.

Chorley and South Ribble CCG Primary Care Commissioning Committee: • Noted the changes.

8 Proposals to develop a Lancashire & South Cumbria wide approach to Practice Relocations Ms Lysa Hasler presented to the committee a proposed template business case for use in all future GP practice relocation applications for all CCG areas across Lancashire and South Cumbria.

The template has been developed with the intention of ensuring commissioners are provided with the robust information required in considering the implications of a proposed relocation and to ensure a standard approach across Lancashire and South Cumbria.

Chorley and South Ribble CCG Primary Care Commissioning Committee: • Approved the final draft template business case for use in all future GP practice relocation applications.

9 Template Business Case for Practice Merger applications Ms Lysa Hasler presented the final version of the template business case for use in all future GP practice merger applications for all CCG areas across Lancashire and South Cumbria.

The initial version was presented at the February 2019 Primary Care Commissioning

Minutes of Chorley and South Ribble CCG Primary Care Commissioning Committee 5 June 2019 Page 471 Committee and has been revised following the recommendations made by the Committee.

Chorley and South Ribble CCG Primary Care Commissioning Committee resolved: • Approved the final draft template business case for use in all future GP practice merger applications.

10 Whittle surgery portakabin Mrs Donna Roberts presented the paper which informed the Committee of the request by Whittle Surgery to continue to use their temporary portakabin premises which provide additional clinical space and to also request the required notional rent for the portakabin.

The Committee was also advised that the surgery originally applied for permission for alternative premises as a contingency should planning permission for the portakabin not be extended by Chorley Borough Council. At the Delegated Commissioning Committee in December 2018, the practice received permission for alternative / contingency premises should planning permission for their temporary portakabin not be extended by Chorley Borough Council. The premises identified as the contingency were the former Chorley Medics building at 114 Wigan Road, Euxton.

The Committee also approved the associated notional rental contributions for the Chorley Medics Building; this meant that the notional rent contributions payable to the practice for both buildings would increase from £29,100pa (current surgery rent) to £50,850pa (an increase of £21,750pa).

Planning permission has now been extended for the portakabin. The current rental value of the portacabin is £33,696 per annum (£40,435 inclusive of VAT). The supplier has also quoted for reduced price of £26,957 per annum (£32,348 inclusive of VAT) effective after signing a 12 month lease.

The Committee was also advised that the development of the practices new premises had been delayed due to land acquisition issues and clarification on the use of ETTF funding for new premises under the new Premises Cost Directions (PCD). The practice supported by the CCG has worked directly with Chorley Council who have now purchased the land, removing any land issues and Chorley Council will now lease the land to the practice for a nominal sum, supporting progress with the build. Clarification on the use of ETTF under PCD is still awaited.

Dr Bangi also gave a brief summary of the background to this application. He confirmed that the surgery was looking at the longer term plan and that the portakabin was part of an interim solution that would also require the administration functions of the practice to be moved off site to create further space at the main practice premises.

Following further discussion it was agreed that approval be given to the practice to continue to operate from their temporary portakabin premises and to utilise the former Chorley Medics building to facilitate the practices administrative functions moving off site.

'It was agreed that, in order to avoid any unnecessary delay in facilitating this move, Chair's action would be taken, in consultation with CO & CFO, in respect of approving the move of the administration services to the former Chorley Medics building. Any such Chair's action taken would be reported at the first subsequent PCCC meeting.

Mr Gaunt requested that any future funding was taken into consideration for inclusion in the 2020/21 budget.

Minutes of Chorley and South Ribble CCG Primary Care Commissioning Committee 5 June 2019 Page 472

Chorley and South Ribble CCG Primary Care Commissioning Committee agreed: • To support the request from the practice to continue to operate from their temporary portakabin premises until their new premises were completed and to support the request for the additional notional rent contributions for the portakabin. • Chairs action to be taken for the practices administration functions to move off site to the former Chorley Medics building.

11 Vice Chair arrangements Mr Paul Richardson raised the issue of vice chair arrangements for the PCC committee. It was agreed that in the absence of the Chair, then either the Secondary Care Doctor or Governing Body Nurse as lay members would take on the role.

12 Any other business There was no further business.

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

Minutes of Chorley and South Ribble CCG Primary Care Commissioning Committee 5 June 2019 Page 473

This page is intentionally left blank Agenda Item 20

Governing Body Meeting

Date of meeting 25 September 2019 Title of paper Remuneration Committee Update Presented by Mr Paul Richardson, Remuneration Committee Chair Author Mr Paul Richardson, Remuneration Committee Chair Clinical lead N/A Confidential No

Purpose of the paper The purpose of this paper is to provide an update of recent activities of the Remuneration Committee since last reported to the Governing Body in March 2019.

Executive summary The Remuneration Committee meets on an ad-hoc basis and will normally meet a minimum of twice per year in accordance with the Terms of Reference.

The key decisions made at the meetings held on 16 May and 12 June 2019 are presented in this report. The full details of the papers and minutes cannot be shared with the Governing Body meeting as the Remuneration Committee is a private meeting not held in public.

Recommendations The Governing Body is asked to note the contents 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 their voices are heard SO5 Be seen as a well-run clinical commissioning group and the system ☒ leader

Remuneration Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 475 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 The Remuneration Committee consists of lay members only to ensure that decisions are fair and impartial.

Remuneration Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 476 1.0 Introduction

1.1 The Remuneration Committee is responsible for making recommendation on the remuneration, fees and other allowances for employees and for other persons providing services on behalf of the Clinical Commissioning Group (CCG). All recommendations regarding remuneration will be submitted to the Governing Body for approval.

1.2 The Committee meets with Greater Preston CCG Remuneration Committee as a meeting in common. Meetings are chaired by the Chorley and South Ribble CCG Vice Chair as staff are employed by Chorley and South Ribble CCG and seconded to Greater Preston CCG.

1.3 Since the last Remuneration Committee update report to the Governing Body on 27 March 2019, two meetings have taken place on 16 May and 12 June 2019. The outcomes of the meetings held on 16 May and 12 June are provided in this report. The next meeting of the Remuneration Committee is being scheduled in September 2019.

2.0 Pay and Contractual Issues

2.1 The Committee dealt with a number of pay and contractual issues (excluding those relating to Remuneration Committee members due to conflicts of interest).

3.0 Health and Safety Policies

3.1 The committee received a revised health and safety policy and two health and safety related procedures following a review by the MLCSU Health and Safety Team and the CCG Lead for Health and Safety. The committee approved the revised health and safety policy and recommends this to the Governing Body for approval. The procedures relate to Fire Safety and Managing Challenging Behaviour and do not require Governing Body approval.

4.0 HR Policy Review

4.1 The committee received a suite of HR policies which were reviewed by the MLCSU People Services Team. The review was undertaken to identify any changes in legislation and align them to those policies within the Lancashire and South Cumbria footprint. The committee acknowledged that further amendments from staff side at the CCG would be provided in a briefing paper to the Remuneration Committee.

Mr Paul Richardson Remuneration Committee Chair September 2019

Remuneration Committee Update NHS Chorley and South Ribble CCG Governing Body Meeting 25 September 2019 Page 477

This page is intentionally left blank Agenda Item 21

Governing Body Meeting

Date of meeting 25 September 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 Ann Robinson, GP Director Confidential No

Purpose of the paper This report provides an update from the Clinical Effectiveness Committee held on 7 August 2019.

Executive summary Individual Funding Requests (IFR) Annual Report 2018/2019 inclusive of Q4

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.

For Chorley and South Ribble CCG 104 applications were completed for 2018/19 from which 32 were not approved, 41 were approved and 31 were rejected or redirected. 42% of applications were for restricted procedures. Greater Preston received 150 applications of which 51 were approved, 46 not approved and 53 rejected or redirected. 46% were for restricted procedures.

RightCare / CART update

CART (Clinical Analysis and Review Team) is a forum that has linked across the ICP and aims to engage with other organisations and has been working toward functioning on the ICP footprint. A workshop is to be planned to review what intelligence is available within each partner organisation and how best to utilise this for ICP future development. Links have been developed with Lancashire Teaching Hospital (LTH) to link Getting It Right First Time (GIRFT) and RightCare intelligence together and this will be developed over the coming months. A fact-finding meeting with Pennine CCG’s BILT (Business Intelligence Leadership Team) is to be arranged to look at how they use intelligence.

RightCare packs continue to be received. The most recent were for vision,

Clinical Effectiveness Committee NHS Chorley and South Ribble CCG Governing Body Meeting Page 479 7 August 2019 Cardiovascular Disease, gastrointestinal, mental health and dementia, neurological problems, frailty, genitourinary and respiratory. Further packs are due to be received towards the end of the year which will focus on practice level information and hopefully primary care network level packs. The process for sharing RightCare intelligence across the organisation is currently being reviewed.

Clinical Policy update

An update was provided to the Committee on the work of the Commissioning Policy Development and Implementation Group (CPDIG).

All ratification has now been carried out. Feedback will be given at a future date regarding progress and implementation since policies have been introduced. There is no further update regarding the Assisted Conception Policy.

CQUIN Q4 reconciliation

The CCG monitors the achievements against the agreed contractual CQUIN schemes for Lancashire Care NHS Foundation Trust (LCFT), Lancashire Teaching Hospitals (LTH), Ramsay Health Care (RHC).

Confirmation of CQUIN position at quarter four: Lancashire Teaching Hospitals Trust (LTHTR) achieved 10 indicators, one partially achieved and three not achieved. Lancashire Care Foundation Trust (LCFT) achieved 10 indicators and did not achieve one. Ramsay Health Care achieved both their indicators.

Medicine Management

Audit work has been completed regarding high dose opioids. In total 74 practices and over 1000 patients were included in the audit. Data was gathered and analysed and a training package developed and delivered by the CCGs Medicines Optimisation Team in line with national and local best practice guidance. A reduction in high dose opioid prescriptions has been reported and further work is required to support adherence to best practice guidelines.

Avastin update

Mrs Clare Moss was linking with colleagues regarding financial impact on the delay of introduction Avastin as a treatment option for age related macular degeneration. More information will be available after JEM (12th September) and the extraordinary CEC meeting on the 19th September.

Clinical Effectiveness Committee NHS Chorley and South Ribble CCG Governing Body Meeting Page 489 7 August 2019

CEC Terms of Reference

The CEC TOR will require further review from the committee and will be discussed at the next CEC meeting in October.

CEC Annual Report

The annual report has received sign off by members of the CEC.

CHC Choice and Equity Policy

The CHC Choice and Equity Policy was received by members of the CEC where a number of comments were made and subsequently forwarded onto East Lancashire CCG as the policy author to be considered when the policy is reviewed. The Governing Body is asked to ratify the CHC Choice and Equity policy attached.

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

Clinical Effectiveness Committee NHS Chorley and South Ribble CCG Governing Body Meeting Page 481 7 August 2019 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 Assurance will continue to be provided to the Governing Body from the Clinical Effectiveness Group.

Clinical Effectiveness Committee NHS Chorley and South Ribble CCG Governing Body Meeting Page 482 7 August 2019 Clinical Effectiveness Committee Annual Report 2018/19

1.0 Introduction

1.1 The Clinical Effectiveness Committee (the committee) has prepared this report to the Governing Body. It provides information about actions taken by the committee to satisfy its Terms of Reference (TOR) in the financial year 1 April 2018 to 31 March 2019.

1.2 Evidence contained in this report will be shared with the Clinical Commissioning Group Governing Body and will be used to support the content of the CCG Annual Governance Statement.

1.3 The committee meets jointly (with NHS Greater Preston CCG) and met four times during the period 1 April 2018 to 31 March 2019. Attendance at these meetings is enclosed at Appendix 1 for Information.

2.0 Background

2.1 The constitution outlines that the Governing Body has established a Clinical Effectiveness Committee, and provided that committee with delegated responsibility in the following areas:

• Providing assurance that the CCG is developing clinical policies in line with the organisations strategic direction and in accordance with national / local priorities • Overseeing effective use of resources for clinical purposes • Providing oversight of the implementation of prescribing policies • Advise the Governing Body on latest clinical evidence in decision making • Prioritising clinical policy implementation • Providing advice on evidence and effectiveness when setting quality standards including CQUIN • Promoting research and innovation

3.0 Governance, Establishment and Duties

3.1 Members of the committee are appointed by the Governing Body from amongst the Lay Members, GP Directors and Officers of the CCG. The TOR were reviewed and updated by the committee in May 2018 and this resulted in the Head of Strategy and Corporate Services to be removed from the membership list as this role was no longer in place. To achieve quoracy at least four core members must be present, including at least one GP Director and one Lay member six members must be present, which must include two clinicians and one lay member.

3.2 The committee receives support from the Quality and Performance Team. The team take formal minutes of the committee which are provided to all members of the Governing Body. A summary report is also provided to the Governing Body at each meeting, this is prepared by the committee chair. The report draws to the attention of the Governing Body any issues that require disclosure to the full Governing Body, or issues that require further discussion or executive action.

Clinical Effectiveness Committee Annual Report Clinical Effectiveness Committee 1 May 2019 Page 483 3.3 Duties

• Provide assurance to the CCG’s Governing Body that clinical policy and guidance are being developed and implemented.

• Approve clinical policies where the updates do not result in any changes in commissioning decisions and do not change any thresholds that impact on treatment for patients. Where the policy change does change commissioning decisions and/or thresholds for treatment for patients these should be approved by the Governing Body, following recommendation from the CEC. All polices that impact on the de-commissioning of services will be approved by the Governing Body.

• Receive assurance on the appropriateness of prescribing policies.

• To seek assurances that clinical recommendations on investment and disinvestment in services are based on rigorous assessment of clinical effectiveness, affordability and health benefit.

• Ensure that effective evaluation systems and processes are in place to assess the appropriateness of the CCGs priorities. Measure the impact and outcomes of commissioning decisions in line with Right Care priorities.

• To receive assurances that clinical business cases are sound and are complied with ensuring appropriate clinical policies are in place.

• To be assured that best practice in relation to NICE and other clinical guidance, high level inquiries and confidential inquiries are considered and clinical decisions are made in line with resources available.

4.0 Committee Effectiveness

4.1 There were four committee meetings during the year. All meetings were quorate.

4.2 The committee has a cycle of business, which is ordered around its TOR. The cycle of business ensures that the committee receives the reports and assurance it needs to report to the Governing Body in a timely manner. The cycle of business allows for planning for standing items alongside flexibility to deal with emerging risks.

5.0 Achievements

5.1 Throughout the year the Clinical Effectiveness Committee has received reports on the current status on clinical policies and the work underway to develop policies that were under review. In year the committee considered the risks to the organisation of clinical policies being outside of their review date, whilst work was on-going across Lancashire to develop a harmonised set of policies for the county.

Clinical Effectiveness Committee Annual Report Clinical Effectiveness Committee 1 May 2019 Page 484 5.2 The committee had oversight of the development of Commissioning for Quality and Innovation (CQuINs) Schemes for providers and received quarterly updates on progress.

5.4 There is a wealth of information available that offers a picture of how well services are delivered. The committee received information outlining the different datasets available to the CCG. By comparing reports the committee had oversight of some of the issues and was provided with information on initiatives within the Operational Plan to address area where outcomes are less favourable.

5.5 The committee had oversight of the development of Rightcare evaluation plans that had been requested by NHS England. Assurance was provided that the RightCare programme is embedded into the CCG’s operational plan, with the view to mobilise the change initiatives and programmes of work via clinical works streams.

5.6 The committee received information on the work carried out by the Medicine Optimisation Team against their plan for 2018/2019. The Committee where informed of initiatives in place to promote medicines optimisation.

6.0 Priorities 2019/20

6.1 The key priorities for 2019/20 will include: • Rightcare becoming business as usual and developing a clinical analysis and review function across the organisation. • Receiving regular intelligence on the clinical outcomes for the local population • Ensuring there is a comprehensive set of up to date clinical policies and receiving monitoring information on implementation • Review the requests and outcomes following Individual funding request • Receive assurance on progress against provider CQUIN schemes

7.0 Summary

7.1 In summary the committee has satisfied itself that the CCG has met its terms of reference, but recognises that opportunity exists in 2019/20 to progress further particularly in view of the shared approach to the development of clinical policies across all Lancashire CCGs.

Clinical Effectiveness Committee Annual Report Clinical Effectiveness Committee 1 May 2019 Page 485 Appendix 1:

Attendance

09/08/18 11/07/18 10/10/18 09/01/19

Members

Mrs Debbie Corcoran    

Mrs Helen Curtis   

Mrs Tricia Hamilton    

Mr Glenn Mather    

Dr Eamonn McKiernan   

Ms Clare Moss   

Mr Geoffrey O’Donoghue    

Dr Sandeep Prakash  Absent Absent Absent

Ms Stephanie Purcell   

Dr Ann Robinson   

Mrs Ruth Bond    

Apologies sent  Attended

Clinical Effectiveness Committee Annual Report Clinical Effectiveness Committee 1 May 2019 Page 486

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

CONTINUING HEALTHCARE (CHC) CHOICE & EQUITY POLICY

Ref: ELCCG_ Version: V3 Supersedes: Author (inc Job Title): Judith Johnston Ratified by: (Name of responsible Committee) Date ratified: Review date: Target audience: CCG Wide

This policy can only be considered valid when viewed via the East Lancashire CCG or Blackburn with Darwen CCG websites. If this document is printed into hard copy or saved to another location, you must check that the version number on your copy matches that of the one online.

1 Page 487 REVIEW AND AMENDMENT LOG

Version Description of Change or reason for Number Date Author update V3 22/08/2018 Judith Johnston Revised national framework for NHS funded continuing health care

1

Page 488 Contents

1. Introduction Page 3

2. Purpose Page 3

3. Policy Statement Page 3

4. Equality Impact Assessment Page 3

5. Dissemination and Implementation Page 3

Appendix 1 – Lancashire Clinical Commissioning Groups’ Continuing Healthcare Choice and Equity Policy

2

Page 488 1. Introduction

1.1 This policy has been developed as a part of the governance framework in relation to the CCG’s duties relating to NHS fully funded Continuing Health Care (CHC) and has been updated in line with the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care October 2018 (Revised).

1.2 It has been produced following the decision of Clinical Commissioning Groups in Lancashire to develop and agree a consistent approach in the allocation of resources when an individual has met the eligibility criteria for CHC.

2. Purpose

2.1 This policy describes the way in which the CSU Continuing Healthcare Team (CHC) on behalf of the CCGs will implement this policy to provide care for people who have been assessed as eligible for NHS Continuing Healthcare. The policy describes the way in which the CHC team will commission care in a manner which reflects the choice and preferences of individuals but balances the need for the CCGs to commission care that is safe and effective and makes the best use of available resources.

3. Policy Statement

3.1 The policy is outlined in Appendix 1

4. Equality Impact Assessment

4.1 An equality impact assessment has been undertaken and engagement

5. Dissemination and Implementation

5.1 The Corporate Business Manager will arrange for all ratified policies to be added to the CCG Website and staff will be notified of all policy activity through the CCG’s internal email communication system.

5.2 The CCG website will be the only point of access for up to date, version controlled CCG Policies. A full record of all dissemination activity will be managed by Corporate Affairs.

5.3 CCG commissioners will arrange for the updated policy to be rolled out across relevant services.

3

Page 488 APPENDIX 1

CONTINUING HEALTHCARE (CHC)

CHOICE & EQUITY POLICY

Version 3 October 2018

4

Page 488

Subject and version number Continuing Healthcare (CHC) and Funded Nursing of document: Care (FNC) Choice and Equity Policy

Serial number:

Operative date: 1 October 2018

Author: Judith Johnston East Lancashire CCG Iain Fletcher Blackburn with Darwen CCG On behalf of Lancashire CCGs’ Individual Patient Activity Board Review date: 30 September 2020

For action by: The Choice and Equity Policy is aimed at all CCG, CSU and NHS provider services staff involved in continuing health care Policy statement: This policy describes the way in which the Midlands and Lancashire Commissioning Support Unit Continuing Healthcare teams (CHC) on behalf of CCGs will provide care for people who have been assessed as eligible for fully funded NHS Continuing Healthcare. The policy describes the way in which the CHC team will commission care in a manner which reflects the choice and preferences of individuals but balances the need for the Clinical Commissioning Groups (CCGs) to commission care that is safe and effective and makes the best use of available resources.

This should be read in conjunction with the Statement of Principles for commissioning of health care

Responsibility for Line managers within the CHC / Funded Nursing Care dissemination to new staff: team. Methods for dissemination: All new and updated policies are published on the CCG website.

Training implications: Reference to this policy should be included in induction and refresher training for relevant staff Resource implications: There are no resource implications in relation to implementation of this policy.

5

Page 492 Equality Analysis Yes Completed?

Consultation Process The content of the policy has been reviewed by lawyers and has been made available on CCGs’ websites. It has been brought to the attention of all services commissioned for individuals meeting CHC eligibility criteria in Lancashire

Approved by:

Date approved:

20180822 version 3 P6age 493 TABLE OF CONTENTS Page

Foreword

1. Introduction

2. National Framework For NHS Continuing Healthcare And NHS Funded Nursing Care November 2012 (Revised)

3. Context

4. The Provision Of Services For People Who Are Eligible For NHS Continuing Healthcare

5. Continuing Healthcare Funded Care Home Placements

6. Continuing Healthcare Funded Packages Of Care At Home

7. Risk Assessment Of Packages Of Care At Home

8. Exceptional Circumstances

9. 10. Personal Health Budgets

11. Memorandum Of Understanding For Care At Home And Personal Health Budgets

12. Capacity

13. Review

14 Guidance

20180822 version 3 P7age 493 FOREWORD

Clinical Commissioning Groups (CCGs) assumed statutory responsibility for NHS Continuing Healthcare from 1 April 2013. The Continuing Healthcare teams (CHC) for the CCGs are subcontracted to the Midlands and Lancashire Commissioning Support Unit CSU. This policy will be ratified by the following CCGs:

Blackburn with Darwen Greater Preston Chorley and South Ribble Morecambe Bay East Lancashire West Lancashire Fylde and Wyre

1. INTRODUCTION

1.1 This policy describes the way in which the CSU Continuing Healthcare Team (CHC) on behalf of the CCGs will implement this policy to provide care for people who have been assessed as eligible for NHS Continuing Healthcare. The policy describes the way in which the CHC team will commission care in a manner which reflects the choice and preferences of individuals but balances the need for the CCGs to commission care that is safe and effective and makes the best use of available resources.

2. NATIONAL FRAMEWORK FOR NHS CONTINUING HEALTHCARE AND NHS FUNDED NURSING CARE OCTOBER 2018 (REVISED)

2.1 The National Framework says:

“Where an individual is eligible for NHS Continuing Healthcare, the CCG is responsible for care planning, commissioning services, and for case management. It is the responsibility of the CCG to plan strategically, specify outcomes and procure services, to manage demand and provider performance for all services that are required to meet the needs of all individuals who qualify for NHS Continuing Healthcare The services commissioned must include ongoing case management for all those eligible for NHS Continuing Healthcare, including review and/or reassessment of the individual’s needs..” (Paragraph 165)

‘Where a person qualifies for NHS Continuing Healthcare, the package to be provided is that which the CCG assesses is appropriate to meet all of the individual’s assessed health and associated care and support needs. The CCG has responsibility for ensuring this is the case, and determining what the appropriate package should be. In doing so, the CCG should have due regard to the individual’s wishes and preferred outcomes. Although the CCG is not bound by the views of the local authority on what services the individual requires, any local authority assessment under the Care Act 2014 will be important in identifying the individual’s needs and in some cases the options for meeting them. Whichever mechanism is used for meeting an individual’s assessed needs, the approach taken should be in line with the principles of personalisation” (Paragraph 172)

20180822 version 3 P8age 493 3. CONTEXT

3.1 “NHS Continuing Healthcare” means a package of continuing care arranged and funded solely by the NHS where the individual has been found to have a ‘primary health need’ as set out in the National Framework. The actual services provided as part of that package should be seen in the wider context of best practice and service development for each client group. Eligibility places no limits on the settings in which the package of support can be offered or on the type of service delivery.

3.2 The Secretary of State has developed the concept of a ‘primary health need’. Where a person’s primary need is a health need, the NHS is regarded as responsible for providing for all their needs, including accommodation, if that is part of the overall assessed need, and so they are eligible for NHS Continuing Healthcare.

4. THE PROVISION OF SERVICES FOR PEOPLE WHO ARE ELIGIBLE FOR NHS CONTINUING HEALTHCARE

4.1 This policy has been developed in light of the need to balance personal choice alongside safety, clinical effectiveness and appropriate use of finite resources. It is also necessary to have a policy which supports decisions that are consistent, equitable and compliant with the CCG’s obligations under equality legislation. These decisions need to provide transparency and fairness in the allocation of resources.

4.2 Application of this policy will ensure that decisions about care will: • Be person centered • Be robust, fair, consistent and transparent • Be based on the assessment of the person’s clinical need, safety and (where a person lacks mental capacity to make decisions about their care) their best interests • Have regard for the safety and appropriateness of care to the individual and staff involved in the delivery • Involve the person and their family/representative wherever possible • Take into account the need for the CCG to allocate its financial

resources in the most cost effective way; • Support individual choice and preference to the greatest extent possible in view of the above factors.

• comply with the relevant legal duties

The CCG has a duty to provide care to a person with continuing healthcare 4.3 4 needs in order to meet those assessed needs. An individual or their . family/representative cannot make a financial contribution to the cost of the 3 care identified by the CCG as required to meet the individual’s needs. An individual however, has the right to decline NHS services and make their own private arrangements. The level of need is determined upon a comprehensive, multi-disciplinary assessment of the totality of health and social care needs that contribute to the decision-making process of eligibility for NHS funded healthcare.

20180822 version 3 P9age 493 4.4 Access to NHS services depends upon clinical need, not ability to pay. The CCG will not charge a fee or require a co-payment from any NHS patient in relation to the assessed needs. The principle that NHS services remain free at the point of delivery has not changed and remains the statutory position under the NHS Act 2006. The CCG is not able to allow personal ‘top up’ payments into the package of health care services, where the additional payment relates to core services assessed as meeting the needs of the individual and covered by the fee negotiated with the service provider (for example, the care home) as part of its contract with the CCG.

4.5 However, where service providers offer additional services which are unrelated to the person’s needs as assessed under the NHS CHC framework, the person may choose to use personal funds to take advantage of these services.

4.6 Examples of such services which will in most cases fall outside NHS provision as they are unrelated to the person’s primary healthcare needs include hairdressing, a bigger room or a better view. Any such additional services will not be funded by the CCG as these are services over and above those which the service user has been assessed as requiring, and the NHS could not therefore reasonably be expected to fund those elements.

4.7 In instances where more than one suitable care option is available (such as a nursing home placement and a domiciliary care package) the total cost of each package will be identified and assessed for the overall cost effectiveness as part of the decision making process.

4.8 4.8Any assessment of a care option will include consideration of the wishes of the individual, their psychological and social care needs and the impact on the home and family life as well as the individual’s health needs.

4.9 4.9The setting in which CHC is commissioned is ultimately a decision for the CCG. The CCG must take into consideration its wider resources and an equitable allocation of the same. The CCG will carefully consider the views of the individual, their family or others as appropriate and act on all reasonable requests to the best of their ability, including working with the relevant Local Authority to keep couples together where practically possible.

4.10 CHC decisions will be made by the case manager with support from their team leader. In certain circumstances, funding decisions will be made by the Commissioning Decision Panel. These circumstances include:

When there is a disagreement between the case manager and the service user about the care required Where the annual cost of the package exceeds £100 000 Where there is a significant cost difference between a package of care preferred by a service user and that proposed by the case manager. Where, for any other reason, the case manager requires the assistance or input of the Panel.

5. CONTINUING HEALTHCARE FUNDED CARE HOME PLACEMENTS

20180822 version 3 1P0age 497 5.1 Where a person has been assessed as needing a placement within a care home, the CHC team operates a provider framework list and the expectation is that individuals requiring placement will have their needs met in one of these homes. Within this policy the term “care home” includes care home, nursing home and specialist setting.

5.2 The person may wish to move into a home outside of the provider framework list or their family/representative may wish to place the individual in a home outside of the provider framework list. The CCG will consider this in line with the factors set out at paragraph 4.2.

5.3 If the fee for the requested home is higher than the fee charged by a care home on the provider framework list the CHC team would require clarification as to whether the extra fees are for services or facilities unrelated to the person’s primary health care need. The provider will only be able to invoice the CCG for the care and reasonable accommodation costs associated with the person’s assessed health needs and will have to invoice the client separately for any services unrelated to those needs. The invoices will detail what the CCG and client is being charged for.

5.4 5.4If the provider refuses to provide appropriate clarification as to the basis upon which their fees are charged, the CCG are unlikely to purchase the care at this home and the client or their family as appropriate will be advised that they will need to consider other homes, including those on the CCG’s framework.

5.5 5.5If an individual is already resident in a care home, that is not on the framework, when they become CHC eligible or where the costs exceed framework price, the CCG will take due consideration of all relevant factors prior to a decision being made, including the wishes of the individual and the likely effect of any move upon the individual’s physical and mental well-being.

6 CONTINUING HEALTHCARE FUNDED PACKAGES OF CARE AT HOME

6.1 People who are eligible for continuing healthcare funding have a complexity, intensity, frequency and unpredictability of health needs which can present challenges to the safe delivery of care in their own homes.

6.2 The CCG will take account of the following issues when considering whether or not to commission a care package at home:

• The wishes of the individual • The psychological, social and physical impact on the person • Whether care can be delivered safely and without undue risk to the person, the staff or other members of the household (including children) • Safety will be determined by a written assessment of risk undertaken by an appropriately qualified professional in consultation with the person or their family. The risk assessment will include the availability of equipment, the appropriateness of the physical environment and the availability of appropriately trained care staff and/or other staff to deliver the care at the intensity and frequency required • The acceptance by the CCG and each person involved in the person’s care of any identified risks in providing care and the person’s acceptance

20180822 version 3 1P1age 498

6.9 6.9

6.10

6.3 6 . 3

6.4 6 . 4

6.5 6 . 5

6.6 6 . 6

6.7 6 . 7

6.8 6 . 8 20180822 version 3 1P2age 498 o re at home f • Where an identified risk to the care providers or the person can be minimised through actions by the person or their family and carers, those t individuals agree to comply and confirm in writing their agreement with the h steps required to minimise such identified risk. e • The person’s GP agrees to provide primary care medical support • The suitability and availability of alternative care options r • The cost of providing the care at home in the context of cost effectiveness i • The relative costs of providing the package of choice considered against s the relative benefit to the person k • The willingness and ability of family, friends or informal carers to provide s elements of care where this is part of the care plan and the agreement of those persons to the care plan. a n Many people wish to be cared for in their own homes rather than in a care d home, especially people who are in the terminal stages of illness. The CCG will carefully consider a person’s preference about their care setting but it p cannot be guaranteed that the CCG will commission a package of care at o home. Any request for a package of care at home will be considered, even if t discounted, with documented reasons. e n Home care packages in excess of eight hours per day would indicate a high t level of need which may be more appropriately met within a care home i placement. These cases would be carefully considered and a full risk a assessment undertaken. l c It is likely to be easier to provide waking night care to a person in a care home o placement. The need for waking night care indicates a high level of support n day and night. s e Care home placements may be more appropriate for persons who have q complex and high levels of need. Care home placements benefit from direct u oversight by registered professionals and the 24 hour monitoring of residents. e n If the individual’s clinical need is for direct supervision or intervention fromof a c registered nurse throughout 24 hours, the care would often be expected to be e provided within a home placement. This would include the requirement for 1-2 s hourly intervention/monitoring for turning, continence management, medication, feeding, manual handling or for the management of significant o cognitive impairment. f There are specific conditions or interventions that it would not generally be r appropriate to manage in a home care setting. These would include but not e restricted to: the requirement for sub-cutaneous fluids, continual invasive or c non-invasive ventilation or the management of grade 4 pressure areas. e i Safety of the package will be determined by a formal assessment of risk v undertaken by appropriately qualified professionals. The risk assessment will i include the availability of equipment, the appropriateness of the physical n environment and availability of appropriately trained carers and/or staff to g deliver care whenever it is required. c The resilience of the package will be assessed and contingency arrangements a

20180822 version 3 1P3age 498 will need to be put in place for each component of the package in case any component of the package fails.

7. RISK ASSESSMENT OF PACKAGES OF CARE AT HOME 7.1 Environmental Risk Assessment The risk assessment must consider all risks that could potentially cause harm to the individual and their representatives and the staff. Where an identified risk to the care providers or the individual can be minimised through actions by the individual or their representatives, they must agree to comply with the steps required to minimise such identified risk. Where the individual requires any particular equipment then this must be able to be suitably accommodated within the home. 7.2 The CCG is not responsible for any alterations required to a property to enable a home care package to be provided. For the avoidance of doubt, where an individual or their representatives has made alterations to the home but the CCG has declined to fund the package, the CCG will not provide any compensation for those alterations. Included in the risk assessment will be a robust Safeguarding Adult Assessment in order to assess whether there are any actual or potential risks to the individual. Funding for adaptions to the home environment may be available from the local authority subject to their local criteria. 7.3 Clinical Assessment When considering whether a package of care is suitable, the CCG will request support and involvement from the District Nurse to undertake a clinical assessment of the individual's needs and the extent to which that clinician considers that the proposed domiciliary care package meets those needs. The clinical assessment will consider the benefits of a ‘Care at Home’ package against the benefits of a care home placement. 7.4 A nurse and the individual's GP will be asked to consider the proposed arrangements in order to determine whether it is the most appropriate care package. This will include current and likely future clinical needs and psychological needs. Where part of the package is based on care being provided by the individual’s representatives it will also include consideration of how needs will be met in the event that the carer is temporarily unable to provide the care. 7.5 Staffing Assessment The CCG will assess the care need and the input required by the individual to meet those needs. The CCG shall consider the qualification of any required staff and the sustainable availability of appropriately qualified staff including appropriate contingency arrangements. 7.6 The CCG has a duty to its staff to assess any potential harm and take steps to prevent it. This covers both physical risks and any potential psychological risks that may arise. The commissioned provider is responsible for assessing the environment and the care required in line with their organisation’s Health and Safety policies and procedures will apply. This includes Manual Handling

20180822 version 3 1P4age 498 policies and Lone Worker policies. 7.7 The individual and their representatives are responsible for ensuring that the environment is safe for the provision of the care package. Where the safety assessment identifies a potential risk associated with the home, the individual is responsible for remedying that. The individual and their representatives are also responsible for ensuring that the environment is appropriate for the provision of the care package by staff. This includes ensuring staff are able to have access to toilet, bathroom and kitchen areas and such areas are kept in a clean state and ensuring that staff are treated with dignity and respect. 7.8 When working within an individual’s own home, staff do not have access to the full range of support services that are available within a hospital or nursing home environment, and in most cases staff will be working in isolation. This issue needs to be acknowledged and the implications of not having such support services needs to be identified, fully understood and Contingency plans put in place. It needs to be understood that it is not possible to replicate support services that are available within the NHS and nursing home facilities and if this level of support is required it may not be possible to care for the patient at home.

7.9 Due to the nature of the individual’s condition, their high health needs and the care necessary, the NHS is required to ensure only appropriately trained staff are employed to care for patients and that those staff have the specialist skills they need to meet the patient’s individual needs. The CCG is responsible for commissioning care staff from a preferred provider in the first instances in accordance with agreed care specification in relation to the skill level of the staff required. Community Health Services are responsible for liaising and agreeing with the commissioned domiciliary provider . 7.10 The Provider will ensure that any necessary specialist training is given to staff and that staff employed on the package of care are confident at working without the support services normally available in hospital or nursing home environments. Training must also be given by the provider in the use of all necessary equipment. Where the individual’s representatives wish to assist in the care of the patient, they will have to be trained and deemed competent to carry out agreed tasks safely.

7.11 In any circumstance where the CCG considers that the safety of its staff or its agents/contractors are at risk it shall take such action as it considers appropriate in order to remove that risk. Where this relates to the conduct of the individual or the home environment it shall request that the individual and their representatives take the necessary action to remove the risk.

7.12 Where a review identifies, or the CCG otherwise becomes aware that an action to reduce an identified risk to either the people involved providing care to the individual or to the individual has not been observed and such failure may put those individuals providing care at risk or may significantly increase the cost of the package then the CCG will take the necessary steps to protect the individual and their representatives and staff involved with a view to ensuring the safety of all concerned. Harassment or bullying of care workers by the individual and their representatives will not be accepted and the CCG will take any action considered necessary to protect their staff and contractors

20180822 version 3 1P5age 498 in line with the NHS stand on Zero Tolerance.

7.13 Where safety of the individual and/or those people involved in providing care is likely to be compromised without such action and the individual or representative does not take the required action then the CCG may write formally to the individual. Where there is a threat to the safety of CCG Staff or agents then the CCG retains the right to take any action it considers necessary to remove the threat including the immediate withdrawal of the care provision.

7.14 Where the individual is in receipt of a Home Care Package and an assessment determines that this is no longer appropriate for any reason (including increase in care needs, inability for the individual’s representatives to provide agreed care or identified risk) then an alternative package will be discussed and agreed. 8. EXCEPTIONAL CIRCUMSTANCES

8.1 The CCG will seek to take account of the wishes expressed by individuals and their families when making decisions as to the location of care packages and care home placements to be offered to satisfy the obligations of the CCG to provide continuing healthcare. The CCG accepts that many people with complex medical conditions wish to remain in their own homes and to continue to live with their families, with a package of support provided. Where an individual or their family expresses such a desire the CCG will investigate to determine whether it is clinically feasible, safe and cost effective to provide a sustainable package of continuing care for a person in their own home or whether a care home is the only safe and realistic option.

8.2 Packages of care in an individual’s own home are bespoke in nature and thus can often be considerably more expensive for the CCG than delivery of an equivalent package of services for a person in a care home. Such packages have the benefit of keeping the individual in familiar surroundings and/or enabling a family to stay together. However, the CCG needs to act fairly to balance the resources spent on an individual with those available to fund services to the population it serves.

8.3 8.3. By way of guidance, the CCG will generally not fund a home care package where its costs are [more than 10% higher/significantly more] than care in an alternative appropriate location such as a care home. However, in exceptional circumstances the CCG will pay a higher cost for a preferred package.

8.4 Exceptionality will be determined on a case by case basis. Decisions will be made by the CCG’s Commissioning Decision Group and be documented with reasons.

8.5 The Commissioning Decision Group will make their decision in line with its Terms of Reference and the factors outlined in this policy.

9. IMPORTANT LEGAL CONSIDERATIONS

20180822 version 3 1P6age 498 9.1 The UN Convention of the Rights of Person with Disabilities reaffirms that all persons with all types of disabilities must enjoy all human rights and fundamental freedoms.

9.2 Article 8 of the European Convention on Human Rights requires a respect for an individual’s private and family life, home and correspondence. Refusing an individual’s request for a package of care at home is an interference with this right and will be unlawful unless there are clear reasons why their wishes cannot be followed. The cost of such a package can justify a refusal to fund care at home but each case will require careful analysis in line with the criteria set out in this policy.

9.3 Under the Equality Act 2010, assessment and decision-making should be fair and consistent without discrimination.

10. PERSONAL HEALTH BUDGETS

10.1 The authorisation for the commissioning and funding of packages of care at home lies with the CCG. There will be a process for the authorisation of eligibility and the authorisation of care packages and placements.

10.2 From October 2014, individuals who are eligible for NHS Continuing Healthcare have the right to ask for a personal health budget.

10.3 Personal health budgets will be calculated on the basis of what the CCG would usually pay to commission the package and will reflect the principles in paragraph 7.3. This money will then be offered to the patient/their representative.

10.4 A personal health budget is an amount of money to support a person’s identified health and wellbeing needs, planned and agreed between the individual and their local NHS team. CCGs are encouraged to use personal health budgets where appropriate. A personal health budget helps people to get the services they need to achieve their health outcomes, by allowing them control over how money is spent on their care/support as is appropriate.

10.5 Personal health budgets can work in a number of ways, including: • a notional budget held by the CCG commissioner • a budget managed on the individual’s behalf by a third party, and • a cash payment to the individual (a ‘healthcare direct payment’).

10.6 Further information is available from the CHC assessor and

www.personalhealthbudgets.england.nhs.uk

10.7 Decisions in respect of the award of a Personal Health Budget will be made in accordance with the CCG PHB Policy

10.8 The CCG will work closely together with the relevant Local Authority with regard to the personalisation of care and support in order to share expertise and develop arrangements that provide for smooth transfers of care where

20180822 version 3 1P7age 498 necessary

11. MEMORANDUM OF UNDERSTANDING FOR CARE AT HOME AND PERSONAL HEALTH BUDGETS

11.1 Where the CCG agrees to fund a ‘care at home’ package or meet assessed need by way of a personal health budget, the individual (if appropriate) and/or representatives may be required to enter into a Memorandum of Understanding ("Memorandum") confirming that they accept the terms on which any care is provided.

11.2 This Memorandum will set out what the CCG will provide and what the individual and representatives have agreed to provide.

11.3 This Memorandum will also confirm that the individual and representatives understand that the care package or Personal Health Budget is agreed on the basis of the assessed health and personal care needs and the required input as at the date of the Memorandum. Where the cost of meeting the assessed care needs increases for any reason, or the assessed needs change such that the individual is no longer eligible for CHC, or care can no longer safely be delivered at home, the individual and representatives acknowledge that existing arrangements may no longer be appropriate and they will work with the CCG, and where relevant the Local Authority, to agree an alternative care package.

11.4 The Memorandum will set out the agreed alternative arrangements should the care package breakdown.

12. CAPACITY

12.1 If a person does not have the mental capacity to make a decision about the location of their commissioned care package and suitable placement, the CCG will commission the most cost effective, safe care available based on an assessment of the person’s best interests. This will be carried out in consultation with the following so far as is reasonably practicable:-

(i) The individual themselves (ii) Any appointed advocate (iii) Any attorney under a Lasting Power of Attorney which does not authorise the attorney to make a decision by themselves as to where the person should live (see further 12.3 below) (iv) A Court Appointed Deputy whose terms of appointment do not authorise them to make a decision by themselves as to where the person should live (see further 12.3 below) (iv) Family members (v) Any other person who must / may be consulted under the terms of the Mental Capacity Act 2005.

12.2 If there is a significant dispute between any of those referred to in the preceding paragraph about where the person should live, the CCG shall take advice as to whether the matter must/may be referred to the Court of

20180822 version 3 1P8age 498 Protection.

12.3 Alternatively, if the terms of a Lasting Power of Attorney or Deputyship grant authority for the Attorney/Deputy to make decisions about where a person lives, the CCG will advise the Attorney/Deputy as to what they consider to be the most appropriate placement. The Attorney/Deputy will then decide whether to accept that placement as being in the person’s best interests.

13. REVIEW

13.1 Individuals and their families need to be aware that there may be times where it will no longer be appropriate to provide care at home. For example, deterioration in the person’s condition may result in the need for clinical oversight and 24 hour monitoring that can only be provided in a care home setting.

13.2 The care package will be reviewed after the first three months and then annually as a minimum requirement alongside the continuing healthcare eligibility review to ensure that it is still meeting the person’s needs at that time. The package will also be reviewed if the person’s needs change significantly at any point.

13.3 If the weekly cost of the care increases, apart from a single period of up to two weeks to cover either an acute episode or for end of life care, the care package will be reviewed and other options (for example a nursing home placement) will be explored following consideration of the issues outlined in paragraph 6.2.

13.4 Any decision to withdraw CHC from an individual will not normally be a unilateral decision. If there is a possibility the CCG will be withdrawing funding it will consult with the individual and local authority before removing any package Following a review, as described in section 11, the individual’s condition may have improved to an extent that they are no longer eligible for CHC funding. In these circumstances, the CCG is obliged to cease funding. In these cases the CCG will carry out a joint review with the local authority.

13.5 The individual will be notified they may no longer be eligible for CHC; at this point the local authority has 28 days to review the individual’s requirements. In suitable cases, CCG funding for an individual’s care may be continued for 28 days where a local authority is undertaking such a review. The CCG may contribute to further packages of care according to need.

13.6 Should the individual or their family/representative on their behalf be unhappy with a decision about eligibility for NHC Continuing Healthcare then they may request a local review of that decision in line with the CCGs Continuing Healthcare Local Review Policy.

13.7 Where there are disputes between the CCG and the Local Authority on care provision, the CCG will follow the Dispute Resolution protocol agreed with the Local Authority.

20180822 version 3 1P9age 498 13.8 It may be appropriate for the CCG to remove CHC services where the situation presents a risk of danger, violence to or harassment of care staff who are delivering the package. In these circumstances urgent discussions shall be held with the local authority to arrange for interim care arrangements to ensure that there is not a shortfall in the individual’s care package.

13.9 The CCG may also withdraw CHC where the clinical risks become too high; this can be identified through, or independently of the review process. Where CHC clinical risk has become too high in a home care setting, the CCG will offer CHC in a care home or specialist setting. 14. GUIDANCE

The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care – October 2018 (revised) The NHS Continuing Healthcare (Responsibilities) Directions 2012 Human Rights Act 1998 Who Pays? Establishing the Responsible Commissioner (revised 2013) Care Act 2014 Statutory guidance to support Local Authorities to implement the Care Act 2014 The Care and Support and After Care (Choice of Accommodation) Regulations 2014

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Appendix 2

Responses to consultation on draft CHC choice and equity policy

CCG Responder Response Blackburn with Advocacy Focus “I have viewed the draft policy and feel that it is well written. It ensures that the Darwen CHC process is fair and transparent whilst ensuring that individual needs are met. I in particularly liked the part which states that you will make all attempts to keep couples together if it is safe and appropriate to do so. I feel that this is an important aspect when commissioning care as these individuals have chosen to live together and keeping them together (where possible) would ensure a person centred approach is taken.” Age UK Blackburn with Darwen the policy is very fair and does the job. My only specific comment on the actual policy is whether there is any conflict with the End of Life pathway and advance planning support - as in, if advance planning has been done with someone and there choice is to stay at home, but this is not supported by this policy, how is this managed?

I would also like to be clear what protocols or guidance will sit behind the policy for those involved in assessing/decision making. The policy is by its nature, based on individual needs and wishes, which is absolutely right, but this does leave room for inconsistency in decision making? Blackburn with Darwen Council Having reviewed the contents, we note that the majority of the draft policy reflects wording already in use in CHC Choice and Equity policies elsewhere in the country - and that the sections which differ relate in the main to recent CHC case law and are thus useful for inclusion.

Given the above, we are satisfied that the draft circulated provides a reasonable and transparent framework for future cooperation on CHC regionally. Child action North West How will transition care work for children with complex needs or disability who have reached the age of 18 and previously have remained at home, but the assessment of care costs is above the 10% highlighted for cost differential. What weighting will be put on the social value of individuals remaining in their own homes? Page 507 Page

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CCG Responder Response Child action North West cont How will this be considered within the SEND provision for young people aged 18- 25 years, should there be additional mention of transition situations?

Has the policy considered within its economic criteria challenges in relation to ‘right to family life’ if individuals express wish to remain at home, is there a framework that allows balance of various considerations if challenged?

Chorley South No feedback received from CCG Ribble East Lancashire Scope UK Summary: Is AAC included in Continuing Healthcare plans – or can it be, if communication is chronically affected and therefore a primary health need?

Do you allow people who are eligible for Continuing Healthcare to buy equipment with their budget? Who identifies what they need?

Would this equipment include Communication Aids (which could include iPads or more expensive bespoke Computers costing up to £5000)?

If so would the Healthcare support needed to set up this equipment and ongoing maintenance be paid for in a CHC package? The Fed My main comment is in relation to individual’s cultural and religious needs which are often intertwined with their clinical and care needs.

Provision is made in hospital for religious dietary and treatment needs and these clearly come at a higher cost. There is no reference whatsoever to cultural and religious needs within the policy which rather undermines the title in terms of choice and equity.

Provision of culturally and religiously appropriate care is more expensive than “mainstream” care but if it is integral to effectively meeting the clinical needs of people it cannot be charged for separately and should be met by under the guidance in line with principle that NHS services remain free at the point of delivery under the NHS Act 2006. Page 508 Page

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CCG Responder Response I believe that the policy should more fully explore the issues in relation to religiously appropriate care Fylde and Wyre No response received from CCG Greater Preston No response received from CCG Lancashire No responses received by CCG Request from CCG: “Are there any plans to consult/engage with different North methods, don’t think this approach has been effective” West No response received from CCG Lancashire

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This page is intentionally left blank Agenda Item 22

Governing Body Meeting

Date of meeting 25 September 2019 Title of paper Joint Patient Voice Committee update Presented by Mr Geoffrey O’Donoghue, Lay Member for Patient and Public Involvement Author Ms Rebecca Stafford, Customer care and Patient experience officer, NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Clinical lead N/A Confidential No

Purpose of the paper This paper provides an overview and summary of the themes discussed and areas scrutinised at the Joint Patient Voice Committee (PVC) meeting held on 4 September 2019. The ratified minutes for the meeting held on 3 July 2019 are also attached. The minutes of the 4 September 2019 meeting will be ratified at the 6 November 2019 Committee meeting and brought to the Governing Body meeting that follows.

Executive summary The Joint Patient Voice Committee on 4 September 2019 was updated on the IPSOS MORI 360o Stakeholder Survey, the Our Health, Our Care programme and the deep-dive topic presented to the Committee was in respect of personalised care.

Members also reviewed and noted updates on standing items for the meeting including, the quarterly patient involvement and assurance report and the customer care activity – quarter 1 2019/20 report.

What follows is a summary of key topics covered during the 4 September 2019 meeting.

Customer care activity – quarter 1 2019/20 report

Members were presented with an overview of the CCGs’ customer care activity for quarter 1 2019/20 and heard that there had been a 5% decrease of overall contacts, compared to the previous quarter.

MP enquiries had also decreased, with the 89% of enquiries received being for Chorley and South Ribble CCG.

Freedom of Information requests had increased by 15% compared to the previous quarter. The Committee questioned if there was any kind of theme or trends to the FOI requests and although no specific trends had been identified, members were

Joint Patient Voice Committee update NHS Chorley and South Ribble CCG Governing Body Meeting Page 511 25 September 2019 pleased to hear that the CCGs’ online FOI publication scheme and the use of appropriate exemptions was being utilised.

The Committee was informed that although the number of complaints received had decreased in quarter 1, the type of complaints are extremely complex which requires the customer care team to have lengthy complex conversations with patients, internal colleagues and external colleagues.

Patient and Public Involvement Assurance Report

The Committee members were presented with an overview of the Patient and Public Involvement Assurance Report, summarising involvement activities that had taken place since the last PVC meeting and provided details of future planned activity.

Members were particularly pleased to hear that the Patient Advisory Group had been extremely happy with the OHOC update that they had received from Mr Jason Pawluk, commenting that the information received had been very clear, understandable and informative.

The Committee also welcomed the newly appointed PAG vice chair, Mrs Sheila Seal.

IPSOS MORI 360o Stakeholder Survey

The Committee received an overview of the content of the survey and was reminded that this was a piece of work that also linked in with the Involvement and Assurance Assessment Framework (IAF), and that NHS England (NHSE) commissions IPSOS MORI to run the survey on a national level. Members heard that the survey was sent to a limited, prescribed target invite list, including patient representatives and all member representatives for the CCGs.

Results showed an overall response rate of 52% for Chorley and South Ribble CCG which is the same as 2018. However, there had been an increase on the overall response for Greater Preston to 51%.

55% of responders commented that they thought Chorley and South Ribble CCG demonstrated that it had considered the views of the public and patients when commissioning. This figure was significantly higher, with 71% for Greater Preston CCG.

Committee members were pleased to hear that the CCGs will be exploring alternative ways of gathering stakeholder feedback, given that last year was the final year that NHS England were commissioning Ipsos Mori.

Our Health Our Care The Committee received an update on the outcome of the OHOC Joint Committee meeting that took place on 28 August 2019 and heard that it had been agreed that all 13 options would be further explored from a clinical perspective. In addition, it was agreed that an investigation in whether there is significant capital investment in central Lancashire to develop a new single site hospital.

Joint Patient Voice Committee update NHS Chorley and South Ribble CCG Governing Body Meeting Page 512 25 September 2019 Members discussed the update and heard what the next stages of the programme entailed from a service user perspective.

It was agreed that once the shortlisted options had been agreed, the PVC would be updated, with this expected to be at the January 2020 PVC meeting.

Deep Dive – NHS Long Term Plan – Personalised Care The Committee was presented with an update in relation to personalised care and its wider context, as this is a specific theme that runs throughout the NHS 10 Year plan.

Members were informed that personalised care was one of the five major, practical changes to the NHS and heard that it was a ‘whole system’ approach that integrates services including health, social care, public health and wider services around individual patients. It is an all-age approach beginning with maternity, through to childhood and up to the end of life, which also recognises the role and voice of carers, the contribution of communities and the voluntary, community social enterprise sector.

The Committee heard that: • The model of personalised care will enable 2.5 million people to have choice and control over support for their physical and mental health. • 200,000 patients will benefit from a personal health budget by 2023/24 • By the end of 2020/21 over one thousand social prescribing line workers will have been put in place, with numbers increasing further by 2023/24. The aim being that over 900,000 patients can improve health and wellbeing by accessing wider community services. • Training will be provided to help staff identify and support patients in the last year of their life, enabling them to jointly develop a personalised and proactive care plan, which reduces any avoidable admissions to hospital. And, enabling more patients to die in a place of their choosing

Members were presented with a ‘plan on a page’ developed by the CCGs, partners, and the Integrated Care System’s personalisation team, that was specific to the central Lancashire footprint. The plan outlined each area of work to be delivered throughout 2019/20 and included information of how the success of the work would be measured.

The ‘plan on a page’ also provided an overview of the social prescribing element of the plan and Committee members heard that social prescribers had been appointed to nine of the primary care networks, and the remainder should be in place within the next four to five weeks. A ‘world café’ style event is scheduled to take place on Tuesday, 29 October 2019, to bring together colleagues from across the Voluntary Community and Social Enterprise sector and Health, to understand how we can work together to support people living in Central Lancashire to achieve better health and wellbeing outcomes through social prescribing.

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

Joint Patient Voice Committee update NHS Chorley and South Ribble CCG Governing Body Meeting Page 513 25 September 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 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 ☐ ☒ ☐ 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 Assurances on delivery in this area will continue to be provided by the Patient Voice Committee to the Governing Body.

Joint Patient Voice Committee update NHS Chorley and South Ribble CCG Governing Body Meeting Page 514 25 September 2019

Patient Voice Committee Minutes 12.45pm – 2.45pm Wednesday 3 July 2019 Boardroom 2, Chorley House, Leyland PR26 6TT

Present Mrs Lynsey Beniston, Projects Manager – Healthwatch Lancashire Mr Jonathan Bridge, Communications and Stakeholder Relations Manager – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mrs Kate Burgess, Commissioning Delivery Manager – Urgent Care, NHS Chorley & South Ribble CCG and NHS Greater Preston CCG Mrs Dawn Clarke, Equality and Diversity Lead – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mrs Debbie Corcoran, Patient and Public Involvement Lay Member – NHS Greater Preston CCG (Chair) Mrs Dedrah Moss, Patient Advisory Group representative Mr Usman Nawaz, Engagement Consultant – NHS Transformation Unit Mr Geoffrey O’Donoghue, Patient and Public Involvement Lay Member – NHS Chorley & South Ribble CCG (Vice Chair) Mrs Sheila Seal, Patient Advisory Group representative Mrs Glenis Tansey, Engagement and Patient Experience Lead – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG

In Attendance Mr Dominic Carlin, Medicines Optimisation Pharmacist, Midlands and Lancashire Commissioning Support Unit Mrs Samantha Loughlin, Receptionist and Administrator – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG Mr Usman Nawaz, Engagement Consultant – NHS Transformation Unit Mr Jason Pawluk, Delivery Director – NHS Transformation Unit Mrs Donna Roberts, Head of Primary Care/Deputy Head of Planning and Delivery, NHS Chorley and South Ribble CCG and NHS Greater Preston CCG

1 Welcome and apologies for absence Mrs Corcoran opened the Patient Voice Committee (PVC) by welcoming everyone to the meeting and introductions were made.

Apologies were received from Mrs Helen Curtis, Director of Quality and Performance – NHS Chorley and South Ribble CCG and NHS Greater Preston CCG and Ms Samantha Riding, Quality and Effectiveness Specialist (Clinical) – Midlands and Lancashire Commissioning Support Unit

Mrs Loughlin informed the Committee that Ms Riding is covering the position of Ms Stephanie Purcell who is now on maternity leave, but due to other commitments Ms Riding was unable to attend the meeting.

2 Declarations and register of interests

Final minutes V1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 3 July 2019 Page 515 Mrs Corcoran informed the Committee that as the PVC is an assurance committee, a register of interests is not required.

Mrs Corcoran asked if any members of the PVC had anything to declare.

There were no declarations made in relation to the Committee agenda.

3 Minutes of previous meeting – 1 May 2019 Mrs Corcoran requested that the findings of the Healthwatch Social Care engagement work be fed back to the Committee.

ACTION POINT • Mrs Beniston to provide feedback to the Committee in respect of the findings of Healthwatch’s Social Care engagement work.

The Committee reviewed the minutes of the 1 May 2019 meeting and agreed that the minutes were an accurate reflection of the discussions.

4 Matters arising The Committee appraised the matters arising log and agreed to the closure of the items identified as complete.

Updates were provided for the below matters arising and it was noted that they were completed, with an update in the meeting against the following 2 actions:

• PVC190306-06c – Mrs Clarke and Mrs Tansey to explore ideas of how to communicate the PVC’s achievements in a more interactive way.

• PVC190501-08a – Mr Bridge to check that all clinical policies have an Equality Impact Assessment (EIA) completed and considered. Feedback will be provided at the 3 July 2019 PVC meeting.

PVC190606-06c Mrs Clarke and Mrs Tansey informed the meeting that in order to highlight the achievements of the PVC in a more interactive way they would like to provide a pre- recorded update to the Patient Advisory Group (PAG) following the Committee meetings. The logistics for this will be discussed further with Mrs Corcoran and Mr O’Donoghue.

PVC190501-08a Mr Bridge confirmed that all clinical policies have got an EIA attached to them.

The remaining outstanding matters arising were noted as “ongoing” and on track for completion.

Chair’s summary The Committee welcomed the updates, noted the updates and agreed to the closure of those items that were now complete.

Items related to duties and assurance 5 Patient Voice Committee – Ratified Terms of Reference Mrs Tansey advised the Committee members that Committee’s Terms of Reference (TOR), are reviewed on an annual basis. Mrs Tansey confirmed that following discussion at a previous PVC Committee meeting, the refreshed TOR’s had now been approved and ratified at the following CCG Governing Body meetings:

Final minutes V1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 3 July 2019 Page 516

• 22 May 2019 – NHS Chorley and South Ribble CCG • 23 May 2019 – NHS Greater Preston CCG

6 Patient and Public Involvement Assurance Report Mrs Clarke introduced Mrs Seal and Mrs Moss who were representing the PAG on behalf of the Chair and Vice Chair. Mrs Clarke informed the Committee members that Mrs Culshaw had stepped into the role of Vice Chair representing both NHS Chorley and South Ribble and Greater Preston CCGs and that Ms Stirling was now the Chair representing NHS Chorley and South Ribble CCG. The position of Chair representing NHS Greater Preston CCG was still vacant. The Chair congratulated Mrs Culshaw and Ms Stirling on their appointment and recognised the critical role PAG plays in relation to the CCG and the work of this Committee.

Mrs Clarke presented the Committee members with the report and provided an overview of a number of involvement activities.

Members heard that she and Mrs Loughlin had recently attended a meeting relating to the Culturally Deaf and the difficulties they face when attempting to access different services. She explained that case studies had been presented at the meeting and that this had highlighted a range of issues.

Mrs Corcoran requested further information on the Community Restart programme referenced in the report. Mrs Clarke advised that a Community Restart workshop had been held at the CCG offices in respect of Lancashire Council Council’s (LCC) redesigned service. She explained that Community Restart is a jointly commissioned service between the CCGs and LCC, and it is part of a whole systems approach to supporting people with mental health problems in the community based on the MoSCow (Must, Should, Could, Would) project model. Mrs Clarke advised members that feedback from the workshop will lead into the redesign of the Community Restart Service.

As part of the Integrated Care System (ICS) targeted engagement work in respect of the NHS 10-year plan, the Committee members were updated on a project taking place between the CCG and Healthwatch. Mrs Clarke advised that the following groups had been identified and targeted for engagement due to possible gaps in services:

• Older transgender • Military Veterans • CCG long-term priorities • Preston Pride/LGBT

Mrs Seal provided the members with an update of the main points of discussion and any concerns raised at the PAG meeting held on the 23 April 2019. She explained that at this recent meeting PAG had taken the opportunity to share information and experience. This had highlighted the huge wealth of knowledge within the PAG membership.

Mrs Seal informed the Committee members that the PAG had requested a contracts workshop or sub-group be set up to monitor feedback for the services that they had been involved with such as Ophthalmology and Ear, Nose and Throat (ENT). She also advised that some PAG members had raised concerns in respect of gtd (Go to Doc) Healthcare and the re-referral of patients back to their GPs instead of to a hospital consultant. Committee members explored this and were assured that this concern is to be addressed in future PAG meetings within the gtd healthcare agenda item, and there will be feedback to PVC as appropriate.

Final minutes V1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 3 July 2019 Page 517 Mrs Tansey provided an update to the Committee members in respect of the Maternity Voices Partnership (MVP) group. She explained that there had been changes to the chairing arrangements and that Kate Ismail had stepped down from the co-chair role due to other increasing commitments. Mrs Tansey confirmed that the MVP group had agreed for a Vice Chair to be appointed and that following an expression of interest being issued to the core service user group a new Vice Chair has been successfully appointed.

Mrs Tansey informed the PVC meeting that new Head of Midwifery at Lancashire Teaching Hospital, Janet Cotton, has now joined the MVP group following the retirement of Cathy Atherton and had expressed how impressed she is with the co-production work occurring.

Mrs Tansey gave a brief overview of key activity the MVP had participated in, which included presentations by the MVP Chairs at both CCG Governing Body meetings and also at the recently held National Midwifery Forum event.

Mrs Tansey provided Committee members with an update regarding the long-term future of Station Surgery following the sad death of Dr Ahad. Mrs Tansey advised the Committee that an interim contract had been awarded to another GP provider to ensure continuity of care to patients over the next six months.

Mrs Corcoran asked for assurance on the longer term plans for provision of services to patients and how patients were being informed and also involved in decision-making. Mrs Tansey informed the PVC Committee that long-term future of Station Surgery is undecided and this will be considered by the CCGs’ Primary Care Commissioning Committee in September and that the two options for consideration are listed below:

• Close the surgery and request patients register with another nearby practice. • Procure and award a long-term contract to another GP Practice to continue providing services for the existing Station Surgery premises.

Mr Bridge informed the meeting that an initial patient engagement information event had been held at the surgery on the 19 June 2019 and that 64 patients had attended. Mr Bridge explained that further engagement was being undertaken using a range of methods and will consist of:

• Four face-to-face engagement drop-in sessions at the surgery. • Question cards. • Online survey. • Hard copy survey for hard to reach patients registered at the surgery.

The Committee members were advised that a wide range of tactics were in place to ensure promotion of the patient engagement being undertaken.

Chair’s summary The Committee members welcomed the report and the assurance it provides, whilst also reflecting a full range of activities.

Mrs Corcoran wished to formally record congratulations and thanks to Mrs Culshaw and Ms Stirling for stepping into the PAG roles, and also expressed thanks to Mrs Dedrah Moss and Mrs Sheila Seal for representing PAG today.

7 Committee Effectiveness Annual Report 2018/19

Final minutes V1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 3 July 2019 Page 518 Mrs Tansey presented the Committee Effectiveness annual report for 2018/2019 to the Committee for comments and approval.

Mrs Tansey informed the Committee members that a survey had been undertaken to understand member’s views on the Committee’s effectiveness and identify any areas for improvement. Mrs Tansey explained that eighteen people had been invited to participate and that seven Committee members had responded. As the questions had been slightly updated from the previous year’s survey, Mrs Tansey advised the Committee that as a result it had not been possible to do a ‘like for like’ comparison of results and feedback. Mrs Tansey informed the Committee members that the findings of the survey confirmed the Committee’s effectiveness and that the Terms of Reference have been fulfilled.

Mrs Corcoran thanked Mrs Tansey for the presentation and that the information provided was very helpful. However, she was disappointed with the low response rate. Mr O’Donoghue expressed concerns that as the survey had been sent to everyone that had attended the Committee during the period, either as a presenter or representative, this may have impacted on the response rate. Mrs Tansey was asked to reword section 5.7 to allow an explanation for the distribution and impact this may have had on the response rate. Mrs Tansey will also consider this feedback in the approach taken to next year’s survey, and there will be pro-active follow-up and reminders to encourage a full response rate.

ACTION POINT • Mrs Tansey to reword section 5.7 of the Committee Effectiveness annual report 2018/2019 on membership, distribution of the survey and the possible impact this has had on the response rate to the survey.

Chair’s summary The Committee welcomed and agreed the PVC Committee Effectiveness annual report for 2018/19, subject to the rewording of section 5.7

8 Equality Delivery System – Update and Proposal The Committee received a report in respect of the new draft of the Equality Delivery System (EDS3) national framework, presented by Mrs Clarke.

Mrs Clarke highlighted the differences between the previous EDS2 and the new EDS3 and the CCGs proposal for undertaking EDS3 in 2019. The Committee members were informed that in the new approach, NHS England had attempted to simplify the outcomes within each goal by reducing the outcomes required from eighteen to nine.

Mrs Clarke updated the Committee in respect of the changes in the EDS2 to EDS3 outcomes and provided a proposal to deliver EDS in our CCGs over the next two years. The amended EDS3 national framework removes the following outcomes: person centred care (1.2), patient safety (1.4), patient access (2.1), patient experience (2.3), recruitment and representation (3.1), equal opportunities (3.2), discrimination (3.4), staff experience (3.6), leadership commitment to EDI (4.1), and equality impact assessments (4.2).

Mrs Clarke informed the meeting that the PAG had agreed to repeat the 2018 process of grading with refresher training sessions now diarised. Members were informed that as feedback on the world café style delivery on EDS2 last year had agreed this as an effective process to engage with key contributors to the assessment process; it was proposed to repeat this approach for the delivery of EDS3 in 2019.

Final minutes V1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 3 July 2019 Page 519 The Committee members approved the following recommendations presented to the PVC by Mrs Clarke:

• The adoption of EDS3 and approach to embedding the process to deliver EDS for the CCGs as part of the EDI strategic work plan. • To take this process forward on an ICP and ICS footprint.

Chair’s summary The Committee thanked Mrs Clarke for the helpful paper. The Committee noted and agreed that consultation of the PAG was crucial in the implementation of the Equality Delivery System within the CCG.

9 Integrated Care System (ICS) Engaging on the Long Term Plan – update Mr Bridge provided PVC members with a brief update of the Integrated Care System (ICS) and the commissioned engagement around preventative measures targeting “people of working age”, who have historically been a hard to reach group. Mrs Beniston confirmed that the planned focus groups for this group is due to begin in July. Mr Bridge advised that the engagement would revolve around how people would like to access preventative services and explore their views on what kind of offers they would like to see.

Communications and Engagement steering group – update Mr Bridge advised the Committee that the Lancashire and South Cumbria ICS have a Communications and Engagement steering group who meet on a monthly basis, where updates about current communications and engagement within the CCGs are fed into and monitored. Mrs Tansey commented that it had been recognised that the steering group meetings were very communications focussed and they were hoping to set up a Community of Practice to bring colleagues together to share engagement insights.

Mr Bridge left the meeting at this point.

Chair’s summary The Committee welcomed the update and members agreed the information provided was helpful.

10 Healthwatch Digital Report – Mini Audit Mrs Clarke advised the Committee that the CCG had completed a mini audit of our CCG’s approach and practice against the recommendations and best practice set out in Healthwatch’s Digital Report 2019. Five key themes were identified for action in Healthwatch’s report:

• NHS Orb/NHS App • IPLATO • Digital Patient Engagement Plan • GP Contract • Finance

The Committee reviewed the report and were assured that the CCG was progressing all areas of good practice identified in Healthwatch’s report. Mrs Beniston confirmed that Healthwatch welcomed the CCG’s audit as excellent practice. She explained that Healthwatch had found the report extremely useful to understand local approaches and implementation and as a result had included the work as good practice in their annual report and were encouraging other CCGs to follow suit.

Final minutes V1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 3 July 2019 Page 520 Mrs Clarke advised the Committee that going forward, the Integrated Care Partnership (ICP) Finance Lead leading key areas of local implementation was seeking guidance on the following:

• How the Committee would like to be engaged and receive assurance for the digital work stream– The Committee discussed and agreed that six-monthly updates would be beneficial.

• The possibility of one of the Lay Members joining the ICS Digital Group.

• The possibility of the ICP Finance Lead and Equality and Diversity Lead to provide a Central Lancashire ICP update to the PVC at the next meeting – Members agreed that this should be done either as a “Deep dive” topic or by means of a return paper at the next six-monthly update by the Central Lancashire ICP Digital Group.

ACTION POINT • Mrs Corcoran and Mr O’Donoghue to identify the possibility of a Lay Member joining the ICS Digital Group.

Mrs Clarke provided the meeting with assurance that the CCGs had addressed all the points raised in the Healthwatch Digital Report.

Chair’s summary The Committee thanked Mrs Clarke for the report commenting that it was very thorough and members would welcome future updates from the Central Lancashire ICP Digital Group.

11 Integrated Care Partnership Updates Mr Bridge re-entered the meeting.

Mrs Corcoran welcomed Mr Pawluk and Mr Nawaz from the Transformation Unit (TU) to the meeting and thanked them for attending. Mr Pawluk presented an update of the ‘Our Health Our Care’ (OHOC) Programme to the Committee. Committee members were updated on the progress and development of the OHOC options. The presentation illustrated a high level overview of the key differences between the emerging options, and the process to-date and moving forward. Information was shared and assurance given of patient and public involvement in the work and approach.

Committee members were informed that Mr Pawluk and Mr Nawaz would be presenting a programme update to the PAG at their next meeting on the 30 July 2019.

Mrs Corcoran commented that it would be useful if Mr Pawluk and Mr Nawaz could submit updates prior to PVC meetings to enable Committee members to digest and understand the information prior to future presentations. Committee members agreed that moving forward all reports and presentations will be submitted and published one week prior to PVC meetings taking place.

Chair’s summary Committee members welcomed the update and thanked Mr Pawluk and Mr Nawaz for attending the meeting and providing the presentation.

Mr Pawluk, Mr Nawaz and Mrs Clarke left the meeting at this point.

Final minutes V1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 3 July 2019 Page 521 Items for Information 12 Deep dive: Primary Care Networks Mrs Corcoran welcomed Mrs Roberts, Head of Primary Care to the meeting. Mrs Roberts provided the Committee members with an overview of the emerging Primary Care Networks within the context of the Integrated Care Partnership (ICP) across central Lancashire.

Mrs Roberts outlined to the Committee the six strategic platforms within the ICP informing the members that Primary Care Networks sits within platform three, Wellbeing and Health in Integrated Neighbourhoods (WHINs). She explained that the ethos of the WHINs platform is the way we reshape the systems and processes of care delivery that distributes resources and care delivery into the out of hospital (community) sector, with a focus on supporting wellbeing and prevention.

Mrs Roberts briefed the Committee members on the terminology used within the central Lancashire ICP in reference to the Networks;

• Neighbourhood – The geography covered by a Neighbourhood Network, typically with populations of 30,000 – 50,000.

• Neighbourhood Network – The group of providers and other stakeholders within a Neighbourhood that jointly co-ordinate, manage and deliver services and supports.

• Primary Care Network – The group of GP practices that cover the registered population within each Neighbourhood.

Mrs Roberts outlined to the Committee members the roles and functions of a network explaining that these are groups of practices who have come together locally in partnership with community services, social care, Voluntary Community Social Enterprise (VCES) and other providers of health care services. She explained that one of the core elements of the Networks is to build on the core of current primary care and enable greater provision of proactive, personalised, co-ordinated and more integrated healthcare.

Mrs Roberts informed the Committee members that a toolkit has been developed across Lancashire and South Cumbria to support and assist development of the networks. She then identified the key achievements to date and provided an explanation of how patient engagement within the networks will be conducted going forward.

ACTION POINT • Mrs Roberts to provide the Committee with further clarification of the deep-dive topic, prior to the Committee providing assurance to the Governing Bodies in relation to the approach of patient engagement and involvement within the Primary Care Networks.

Chair’s summary The Committee welcomed the update and insight into the development of the Primary Care Networks. Further clarification was requested in relation to patient involvement in regards of the Primary Care Networks and in particular the Patient Participation Groups (PPGs).

13 Healthwatch Lancashire Mrs Beniston informed the Committee that Healthwatch has primarily been focussing on engagement in respect of the NHS Long Term Plan. Mrs Beniston advised the Committee that 969 people had responded to surveys that have been conducted to gather information and views on the Long Term Plan and its implementation. She outlined key

Final minutes V1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 3 July 2019 Page 522 points which have been flagged and that feedback had indicated disconnect between the health and social care systems. Mrs Beniston advised the Committee that the report was with the ICS awaiting sign off. Mrs Beniston apologised that a summary report had not been submitted to the PVC in advance, and looked forward to offering this for future meetings.

Chair’s summary The members thanked Mrs Beniston for the helpful update on Healthwatch’s approach and key work, and look forward to further updates around the Healthwatch 2019/20 work plan.

14 Any other business The committee members noted the change of time to the PVC Meeting on the 4 September (12:30pm – 2:30pm).

15 Reflections of the meeting Mrs Corcoran welcomed any comments or thoughts from the Committee. Members agreed it had been a productive meeting. It was agreed that the balance of time given to items on the agenda had worked well, but that given the significance of OHOC moving forward we must ensure materials are received before and there is sufficient time on the agenda. It was agreed to revise the timings of agenda items to enable a bigger focus on key items as necessary.

Date of next meeting: Wednesday 4 September 2019, 12.30pm – 2.30pm Boardroom 2, Chorley House, Lancashire PR26 6TT

Final minutes V1.0 NHS Chorley and South Ribble CCG / NHS Greater Preston CCG, Patient Voice Committee 3 July 2019 Page 523

This page is intentionally left blank Agenda Item 23

Lancashire Health and Wellbeing Board

Minutes of the Meeting held on Tuesday, 23rd July, 2019 at 2.00 pm 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 Geoff Driver CBE, Lancashire County Council County Councillor Phillippa Williamson, Lancashire County Council Dr Sakthi Karunanithi, Public Health, Lancashire County Council Louise Taylor, Adult Services and Health and Wellbeing, Lancashire County Council Edwina Grant OBE, Education and Children's Services, Lancashire County Council Tim Almond, Morecambe Bay CCG Kirsty Hollis, East Lancashire CCG Joanne Platt, Lancashire Teaching Hospitals Foundation Trust Jane Booth, Lancashire Safeguarding Adults Board Stephen Ashley, Lancashire Safeguarding Children's Board Councillor Bridget Hilton, Central District Council Councillor Sue Brennan, Rossendale Borough Council Cllr Viv Willder, Fylde Coast District Council Councillor Margaret France, Central Health and Wellbeing Partnership Tammy Bradley, Housing Providers David Russel, Lancashire Fire and Rescue Service Peter Tinson, Fylde and Wyre CCG Sue Stevenson, Healthwatch Clare Platt, Health, Equity, Welfare and Partnership, Lancashire County Council Sam Gorton, Democratic Services, Lancashire County Council

Apologies

Dr John Caine West Lancashire CCG Dr Geoff Jolliffe Morecambe Bay CCG Suzanne Lodge North Lancashire Health & Wellbeing Partnership Gary Hall Lancashire Chief Executive Group Adrian Leather Third Sector Denis Gizzi Chorley and South Ribble CCG and Greater Preston CCG

1. Appointment of Chair

Resolved: That in accordance with the Terms of Reference, County Councillor Shaun Turner, as the Cabinet Member for Health and Wellbeing, was appointed as Chair for the remainder of the 2019/2020 municipal year. 1

Page 525 2. Appointment of Deputy Chair

Resolved: That the Board agreed that Denis Gizzi, Chorley, South Ribble and Greater Preston Clinical Commissioning Groups (CCGs) be reappointed as Deputy Chair for the municipal year 2019/2020.

3. Membership and Terms of Reference of the Lancashire Health and Wellbeing Board

Resolved: That the Board noted the current membership and Terms of Reference for the 2019/2020 municipal year, as set out in the agenda pack.

Future collaboration with Lancashire, Blackburn with Darwen and Blackpool Health and Wellbeing Boards will require Terms of Reference to be developed agreed.

4. Welcome, introductions and apologies

The Chair welcomed all to the meeting.

Apologies were noted as above.

New members of the Board were as follows:

Caroline Donovan replacing Professor Heather Tierney-Moore, Lancashire Care Foundation Trust. County Councillor Phillippa Williamson replacing County Councillor Susie Charles. Stephen Ashley, Lancashire Safeguarding Children's Board (Jane Booth returns to Lancashire Adult Safeguarding Board only). Councillor Steve Hughes replacing Councillor Barbara Ashworth (East Lancashire District).

Replacements for the meeting were as follows:

Kirsty Hollis for Dr Julie Higgins, East Lancashire Clinical Commissioning Group. Joanne Platt for Karen Partington, Lancashire Teaching Hospitals Foundation Trust. Tim Almond for Dr Geoff Jolliffe, Morecambe Bay Clinical Commissioning Group.

Also in attendance from Blackpool Council and Blackburn with Darwen Council Health and Wellbeing Boards were:

Dominic Harrison, Director of Public Health, Blackburn with Darwen Council. Councillor Mohammed Khan, Chair of Blackburn with Darwen Council's Health and Wellbeing Board. Nicky Dennison, Senior Public Health Practitioner, Blackpool Council.

Apologies were received from Councillor Graham Cain, Chair of Blackpool Council's Health and Wellbeing Board.

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Page 526 5. Disclosure of Pecuniary and Non-Pecuniary Interests

There were no disclosures of interest in relation to items appearing on the agenda.

6. Minutes of the Last Meeting

Resolved: That the Board agreed the minutes of the last meeting.

7. Action Sheet and Forward Plan

There was an update on the development of the Advancing.

Following the circulation via email on 19 June 2019, of the final versions of the Joint Strategic Needs Assessment reports, the Board were asked to nominate two project sponsors for each thematic at this meeting.

Resolved: i) That the Board noted the actions from the last meeting that had been included on the forward plan, along with other items for the Board's consideration at future meetings also detailed on the plan. ii) The Board nominated County Councillor Phillippa Williamson for the children and young people Joint Strategic Needs Assessment project and Dr Sakthi Karunanithi for the health inequalities Joint Strategic Needs Assessment project.

8. Lancashire Special Educational Needs and Disabilities (SEND) Partnership- SEND Improvement Plan (updated Written Statement of Action)

Sian Rees, Special Educational Needs and Disabilities Consultant, Lancashire County Council, reported on the progress following the inspection by Ofsted and Care Quality Commission in November 2017 to judge how effectively the special educational needs and disability reforms had been implemented, as set out in the Children and Families Act 2014. The inspection identified two fundamental failings and twelve areas of significant concern.

Partners in Lancashire were required to produce a Written Statement of Action, setting out the immediate priorities for action. Progress on the implementation of these actions had been monitored by the Department for Education (DfE) and NHS England. Formal review visits by the Department for Education and NHS England had taken place since April 2018 to consider the progress being made in line with the Written Statement of Action. The Statement had been updated and any ongoing actions included in the Special Educational Needs and Disabilities Partnership Improvement Plan for the period April 2019 to December 2020.

The progress report for July will have details of review dates where timescales have been missed. The report will be presented to the Special Educational Needs Partnership Board and will then come to the next meeting of the Health and Wellbeing Board.

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Page 527 Resolved: That the Health and Wellbeing Board:

i) Received and considered the Special Educational Needs Improvement Plan, noting that this would continue to drive forward improvement over the next two years. ii) Considered the first assessment of progress on the newly implemented plan and would expect to receive regular updates at future meetings.

9. Integrated Care System

Gary Raphael, Executive Director of Finance and Investment, Lancashire & South Cumbria Integrated Care System, informed the Board of a proposed that regular updates on both the development of the plans (operational and strategic) during the year be provided.

The paper was intended to support the development of a strategic narrative for the Lancashire and South Cumbria Integrated Care System by Clinical Commissioning Group Governing Bodies, Provider Trust Board and Local Authority leadership teams. The paper also outlined the process of engagement on that narrative that is being undertaken.

The presentation in the agenda pack proposed that the Lancashire and South Cumbria Integrated Care System endorses eight partnership priorities for changing the way we work as a system – priorities which enable explanation of our vision for future system working to our staff, patients, citizens and stakeholders and to set out how working in partnership will enable our most significant challenges to be tackled.

The plans were not only for the NHS to lead on however, they were to ensure a partnership approach when formulating and delivering them. During the engagement process, comments, advice and recommendations were being sought from Councils and the public.

The Board welcomed the document and felt that this identified a role for the Local Authority as well as committing joint working teams across the Integrated Care System, Integrated Care Partnerships and at neighbourhood levels and going forward they would monitor the plan collectively. The plan also needed to be aligned with the six principles that the Local Government Association, Directors of Adult Social Services, NHS Clinical Commissioners, NHS Providers, NHS Confederation and the Association of Directors of Public Health had recently signed up to. The six principles were:

• Collaborative leadership • Subsidiarity – decision-making as close to communities as possible • Building on existing, successful local arrangements • A person-centred and co-productive approach • A preventative, assets-based and population-health management approach • Achieving best value

Deadlines for the plan was for completion by the end of September with the Board signing it off following that.

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Page 528 With a deficit of £112 million, £20.5 billion had been put aside for the NHS over the next five years with £4.5 billion set aside for improving Primary and Community Care Services which was a big financial challenge for acute trusts. Significant change will be required and Trusts have been looking to improve joint working and also take the same approach when working in specialisms. There was still a significant amount of work to do.

It was anticipated that the Health and Wellbeing Board would come together as a system to challenge and form a high level of scrutiny of the proposals going forward.

Resolved: That the Health and Wellbeing Board:

i) Commented on the strategic narrative which had been developed by the Lancashire and South Cumbria Integrated Care System. ii) Endorsed the strategic narrative document as the basis for the development of the Lancashire and South Cumbria Integrated Care System five year plan. iii) Endorsed in principle the eight priorities within the document, subject to the outcomes of a proposed engagement process. iv) Endorsed the proposed engagement process with patients, citizens, staff and wider partners and support the actions required to deliver it effectively. v) Supported the further system development work now being arranged in respect of provider collaboration, commissioning and partnership between local authorities and the NHS.

9. Review of Intermediate Care in Lancashire

Tony Pounder, Director of Adult Services, Lancashire County Council provided an update on the review intermediate care in Lancashire.

Work started towards the end of 2019 and was now drawing to a conclusion with an expected end date in July 2019. A presentation drew out the main findings from the final report, its key recommendations and the implications for the Health and Social Care system across Lancashire and South Cumbria.

It was recognised that serious effort would be needed to deliver the changes outlined and this could take 3-4 years. The Advancing Integration Board would take ownership as it requires delivery by the whole health and social care system.

Resolved: That the Health and Wellbeing Board:

i) Noted the key findings of the report. ii) Approved the next steps for implementation. iii) Agreed that the Advancing Integration Board (formerly Better Care Fund Steering Group) to hold the accountability for driving implementation reporting at regular intervals to be determined to the Health and Wellbeing Board.

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Page 529 9. Better Care Fund Progress

Louise Taylor, Executive Director for Adult Services and Health and Wellbeing, Lancashire County Council gave an update to the Board on:

Better Care Fund Metrics

• Residential and nursing home admissions continued to fall but at a much lower rate than previously. They remained much higher than the national average. • Reablement continued to be successful with increasing take up and consistently high success. • Non elective admissions continued to exceed target and have seen a year on year increase for the last three years. • Delayed Transfers of Care were considerably lower for 2018/19 than 2017/18 but performance had deteriorated over recent quarters.

BCF planning and Finances

Despite the delay in publication of Better Care Fund planning guidance partners were making progress in confirming local plans across health and social care.

Confirmation of the level of contributions to the fund was also delayed. An additional element of the Better Care Fund for 2019/20 would be the Winter Pressures Grant of £5.5m for Lancashire. Partners had discussed and agreed the spending plan for this.

Advancing Integration

A high level of joint working had resulted in significant progress in designing a model for making integration across health and social care happen. The model provides the structure to manage the Better Care Fund, the Intermediate Care Review and integration as a whole. It was proposed that the Better Care Fund steering group was replaced by the Advancing Integration Board, to take on this wider responsibility while remaining accountable to the Health and Wellbeing Board.

Resolved: That the Health and Wellbeing Board:

(i) Noted the Better Care Fund performance against the required metrics. (ii) Noted the planning and financial arrangements for the Better Care fund in 2019/2020. (iii) Noted the work to date on Advancing Integration across health and social care using the Better Care Fund as an enabler. (iv) Approved the development of the Advancing Integration Board. (v) Approved the creation of the Advancing Integration transformation team. (vi) Approved the approach to Advancing Integration based around levels of neighbourhoods, districts, Integrated Care Partnerships and the Integrated Care System.

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Page 530 9. Collaboration - Health and Wellbeing Boards

Clare Platt, Head of Service Health, Equity, Welfare and Partnerships, Lancashire County Council presented the report where over recent months there had been a number of discussions highlighting the opportunity for the Health and Wellbeing Boards to work with, and influence, the Lancashire and South Cumbria Integrated Care System to promote integration and improve population health outcomes. Recently the Integrated Care System had been reviewing its governance arrangements, and so it was timely to consider the opportunities for a system-wide approach to integrated health and social care, prevention, and tackling health inequalities.

There were a number of examples of such arrangements across the Country, with the Local Government Association (LGA) supporting Health and Wellbeing Boards in developing this approach, and publishing associated case studies. The Local Government Association had offered support in delivering joint arrangements for Lancashire and South Cumbria.

The report identified learning and best practice in relation to joint working, progress and the governance options available for consideration.

The Board agreed that there was a need for collaboration to deliver one strategy and ensure more health and social integration and that there should be one collaborative arrangement under the Integrated Care System, with five Integrated Care Partnerships.

Following this meeting there would need to be discussions between the three chairs of the Health and Wellbeing Boards in Lancashire, Blackburn with Darwen and Blackpool so that each understood what each Board could bring to the collaboration and how to ensure it worked including holding the Integrated Care System to account. This was a real opportunity to look at a broader agenda.

Resolved: That the Health and Wellbeing Board:

i) Noted the report and agreed to progress joint arrangements. ii) Agreed that the offer of support from the Local Government Association be accepted. iii) Required an update on progress to the next meeting of the Board.

Prevention and Population Health Services

Clare Platt also gave an update on discussions that had taken place with East Lancashire, Fylde and Wyre, Greater Preston, Chorley and South Ribble and Morecambe Bay Clinical Commissioning Groups about alignment of public health services. A further conversation with West Lancashire was to be held shortly. Discussions revealed that there were different interpretations of the Lancashire County Council offer across each Clinical Commissioning Group footprint. This posed a significant challenge for Lancashire County Council in terms of planning, consistency and risk management.

Clinical Commissioning Groups are keen to understand the degree of devolution whether it was involvement in decision making or devolution of public health grant monies with an associated performance framework or something between the two.

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Page 531 There needed to be more clarity re development of a Memorandum of Understanding, governance and the opportunity for oversight by the Health and Wellbeing Board.

A paper had also been requested that could be shared with all Clinical Commissioning Group Boards outlining the proposal, followed up by more detail on governance at a later state.

Resolved: That the Health and Wellbeing Board welcomed the update.

10. Urgent Business

Motor Neurone Disease Association

The Chair reminded the Board of the Motor Neurone Disease event taking place on 31 July 2019 and to confirm attendance.

11. Date of Next Meeting

The next scheduled meeting will be held at 2pm on 10 September 2019 in the Duke of Lancaster Room – Committee Room 'C' at County Hall, Preston.

12. Exclusion of Press and Public

This item was not required as the Part II report at agenda item 13 was discussed under Part I.

13. Health and Social Care Integration - Advancing Information Systems Interoperability

Tony Pounder, Director Adult Services, Lancashire County Council and Declan Hadley, Digital Lead, Healthier Lancashire and South Cumbria informed the Board about the progress on the Advancing Information Systems Interoperability.

NHS organisations and local authority social care organisations within the Lancashire and South Cumbria Integrated Care System need to share information with one another about individuals they treat or support so they can be effective and efficient in delivering joined up care and ensuring timely transfer of responsibilities between agencies. Given the number of different information systems in operation across these organisations the Integrated Care System had been committed through its Digital Strategy to ensuring these systems could talk to one another by devising solutions that advance interoperability.

The report and presentation to the Board sets out the recent success Lancashire County Council and Lancashire Teaching Hospitals have had in establishing the information governance, technical and operational arrangements to allow for the smooth and timely flow of information about those people waiting for discharge from hospital. It will further outline the provisional Grant Award recently communicated by NHS England to Lancashire County Council as part of the Social Care Digital Pathfinders programme to plan for these arrangements to be widened out to all hospitals and local authorities within the Integrated Care System.

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Page 532 Resolved: That the Health and Wellbeing Board:

i) Noted and commended the progress on advancing information systems interoperability between Lancashire County Council and Lancashire Teaching Hospitals in relation to hospital discharge

ii) Noted and welcomed the provisional award of a Grant from NHS England from its Social Care Digital Pathfinder fund to enable planning for advancing system interoperability between all councils and NHS hospital trusts within the Integrated Care System in relation to hospital discharge.

L Sales Director of Corporate Services

County Hall Preston

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